Laparoscopic management of persistent vaginal discharge remote from sacrocolpopexy

Abstract

Demonstrate surgical management of sinus tract formation from infected suture material. Sacrocolpopexy is considered the "gold standard" by many for the management of advanced pelvic organ prolapse. Adverse outcomes, such as anatomic failure and mesh or suture exposure, have been shown to occur over increased length of time from the index surgery. Given permanent foreign body placement with this reconstructive technique, inflammatory reaction due to infection may result in complication. We present a 60-year-old gravida 4 para 4 with a two-year history of persistent vaginal discharge. Her surgical history is notable for laparoscopic hysterectomy, sacrocolpopexy, midurethral sling, and posterior colporrhaphy 12 years ago, as well as ventral and right inguinal hernias repaired with abdominal mesh 2 years ago. The patient did not have recurrence of prolapse on exam. This case demonstrates management of sinus tract formation from an inflammatory response to infected tissue from permanent polyester braided suture material. The case was begun with intraabdominal survey. The peritonealized mesh was identified, and the distal end was noted to be edematous. Culture results showed a polymicrobial infection. Dissection was performed over the apical mesh. Suture material and involved mesh were identified and resected. Minimal tissue integration into the macropores of the mesh was observed. A vaginotomy was created due to the sinus tract and was repaired with Monocryl suture after bladder dissection. The overlying peritoneum was dissected superiorly, and the mesh was excised until healthy tissue with mesh integration was identified. The peritoneum was reapproximated using barbed suture, and the patient was discharged with a 7-day course of antibiotics. To avoid infectious complications, surgeons may consider avoiding braided polyester suture for vaginal mesh attachment when performing sacrocolpopexy.