Vaginal Sacral Colpopexy: A Pictorial Explanation of Surgical Technique

Abstract

The vaginal sacral colpopexy (VSC) has been presented as a video at the 2014 SGS meeting. The technique has been proven to be safe, but the general perception is that it is fraught with risk, extremely difficult, and performed blindly in the retroperitoneal space. Photographs of each step of the VSC supported with clear explantions will enable the viewer to clearly understand the concept, technique, safety and potential advantages of the procedure. A prospective cohort study of VSC cases initiated in November, 2013 was designed to collect data on a series of cases for a minimum of one year following surgery. To date, 13 cases have been completed. Photographs from these cases accompanied by clear explanations are used to record and explain each step of the VSC. These steps are: hydrodissection of and transverse incisions in the distal anterior and posterior vagina, creation of vesicovaginal and rectovaginal spaces, joining these spaces above the vaginal apex, identifying and opening the enterocele, visualization of the sacral promontory through the open enterocele, retroperitoneal dissection to the presacral space with simultaneous monitoring of this dissection by indirect viewing through the enterocele, placement of retractors in the retroperitoneal space, visualization of the anterior longitudinal ligament at S-1, fixation of a “sacral” strip of mesh to the ligament, fixation of a second “vaginal” strip of mesh to the vagina extending from the anterior surface continuing around the apex and down as far as desired toward the perineum on the posterior surface, reduction and support of the vagina into its desired position, joining the “sacral” strip to the “vaginal” strip at the apex, irrigation and closure. One critical step differentiates the VSC from the various abdominal sacral colpopexy procedures. This is the transvaginal, retroperitoneal access to the anterior longitudinal ligament at the sacral promontory. This step is safely performed using the technique demonstrated. All other steps are the same albeit with one clear advantage to the VSC. The entire extent of the anterior and posterior defects is visualized and can be supported with synthetic mesh as deemed necessary. All steps are clearly shown and supported with photographs. There have been no mesh related complications to date. The perception that transvaginal access to the sacral promontory is dangerous and offers no advantage over existing transabdominal techniques is based on conjecture. In fact, the risk is no different from that of the abdominal sacral colpopexy. The technique is simple and straight forward, the progress of the dissection within the retroperitoneal space is continuously monitored by indirect intraperitoneal viewing through the open enterocele, and there are distinct advantages.