Abdominal sacrocolpopexy (ASC) using graft material is a widely accepted transabdominal prolapse operation, and many consider it the preferred procedure to correct advanced apical prolapse. Grafts of autologous, cadaveric, or synthetic materials may be used, but permanent (synthetic) mesh has the best success rate and is selected unless otherwise contraindicated (Culligan, 2005). The graft augments native tissue and suspends the upper third of the vagina to the anterior longitudinal ligament of the sacrum. In addition to correcting apical prolapse, the graft also covers proximal portions of the anterior and posterior vaginal walls. As such, ASC also corrects apical segment prolapse of the anterior vagina wall (“apical” or “transverse” cystoceles) and of the posterior vaginal wall (enteroceles and “high” rectoceles). A modification of the procedure, sacrocolpoperineopexy, is used if concomitant perineal descent is present and believed to contribute to patient symptoms (Cundiff, 1997).
One advantage to ASC is its durability, and long-term success rates for apical suspension approximate 90 percent. It may be used as a primary procedure or alternatively as a repeat surgery for patients with recurrences after other prolapse repair failures. In addition, ASC is often chosen for women believed to be at high risk for recurrence and for whom mesh would augment their own tissue. Examples include those with connective tissue disease, history of recurrent hernia, obesity, or chronically increased intraabdominal pressure such as chronic obstructive pulmonary disease or chronic constipation. Abdominal synthetic mesh aids durability, but its use is balanced against the potential for complications, as discussed later.
Although the vaginal apex can also be successfully suspended with vaginal approach procedures such as sacrospinous ligament fixation and uterosacral ligament suspension, ASC offers distinct advantages. First, ASC maintains or lengthens the vagina, in contrast to vaginal approaches, which may shorten it. Second, the use of synthetic “permanent” mesh with multiple attachment sites to the vagina has a very low risk of apical failure. Finally, unlike vaginal approaches, in which the vaginal apex is directly affixed to a structure such as the uterosacral or sacrospinous ligament, ASC repositions the vaginal apex to its nearly normal anatomic position using intervening graft material. Thus, the apex typically remains mobile, which possibly lowers dyspareunia rates.
Sacrocolpopexy can be performed by laparotomy, by conventional laparoscopy, and with robotic assistance. If minimally invasive surgery (MIS) is performed in the same manner as the open operation, similar results can be expected. However, only limited data are currently available on long-term success rates with these MIS approaches (Freeman, 2013; Maher, 2013; Paraiso, 2011).
Prolapse of the vaginal apex often coexists with other prolapse sites along the vagina. Accordingly, a careful preoperative search is performed for other prolapse sites. If necessary, ASC can be completed concurrently with paravaginal defect repair, posterior repair, or other prolapse surgeries. Beer and Kuhn (2005) found that approximately 70 percent of ASC procedures were performed with other pelvic reconstructive operations. With the technique we describe, a concurrent enterocele will be repaired by the colpopexy, and other enterocele repairs are thus unnecessary.
Prior to ASC, patients with symptoms of urinary incontinence undergo simple or complex urodynamic testing to clarify the type of incontinence and determine if an antiincontinence procedure will be beneficial. For those with SUI, a concurrent antiincontinence operation is generally performed. Because prolapse correction can unmask occult SUI in some women, clinicians also test those without incontinence while manually reducing the prolapse. Last, apical suspension can predispose to later development of anterior vaginal wall prolapse and SUI. Thus, stress-continent women undergoing ASC may elect a prophylactic SUI procedure. To evaluate this practice, the CARE (Colpopexy After Reduction Efforts) trial found that continent women undergoing ASC plus a prophylactic urethropexy had a 2-year postoperative SUI incidence of 32 percent. Without preventive urethropexy, SUI rates following ASC were 45 percent (Brubaker, 2006, 2008). Importantly, adding an antiincontinence procedure decreases, but does not eliminate, the risk of later de novo SUI. At this time, it is unclear how best to extrapolate these findings to women who elect to have sacrocolpopexy and midurethral sling procedures.
Recurrent prolapse is common following any corrective surgery. Thus, a surgeon should be aware of recurrence rates quoted in the literature and his or her own personal rates. Although apical prolapse recurrence is infrequent, later prolapse of the anterior and posterior vaginal walls is more common. An extension of the CARE trial used a clinically based definition of anatomic failure. It showed that by 5 years, nearly one third of women met the composite definition of failure (Nygaard, 2013). However, 95 percent had no retreatment for their prolapse.
Mesh erosion develops in 2 to 10 percent of cases. It is generally found at the apex and occurs more often if hysterectomy is performed concurrent with ASC. Erosion may arise soon after surgery or years later (Beer, 2005; Nygaard, 2004, 2013). Many technical points described in the following steps aim to prevent this complication.
Bowel preparation will vary depending on surgeon preference. Patients can be instructed to take only clear liquids the day prior to surgery and complete one or two enemas that night or the morning of surgery. Alternatively, a mechanical bowel preparation using agents listed in Chapter 39 may be preferred. Ballard and associates (2014), however, noted no distinct advantage to this for urogynecologic operations. Antibiotics and thromboprophylaxis are given as outlined in Tables 39-6 and 39-8.
For postmenopausal women, vaginal estrogen cream use during the 6 to 8 weeks prior to surgery has been routinely recommended. Estrogen treatment is thought to enhance vascularity and thereby increase tissue strength and promote healing. Although this is logical and commonly practiced, no data suggest that preoperative vaginal estrogen cream decreases mesh erosion or prolapse recurrence rates.
Instruments and Materials
The upper vagina must be elevated and distended by a vaginal manipulator to allow adequate dissection and delineation of the vaginal wall fibromuscular layers for mesh placement. The manipulator may be a cylindrical Lucite rod or a large EEA (end-to-end anastomosis) sizer, which is present in most operating rooms and shown in Figure 46-21.4.
The ideal bridging material for this procedure is permanent, nonantigenic, easily cut or customized, and readily available. The ideal mesh has a large pore size to allow host tissue ingrowth, is monofilament to decrease bacterial adherence, and is flexible. Currently, polypropylene mesh is the most common synthetic graft used (American Urogynecologic Society, 2013, 2014b).
Anesthesia and Patient Positioning
Following administration of general anesthesia, the patient is positioned in a modified supine position with thighs parallel to the ground and legs in booted support stirrups. Correct positioning prevents nerve injury and allows access to the vagina for manipulation and examination, to the bladder for cystoscopy, and to the abdomen for proper self-retaining retractor placement. The buttocks are positioned at the table edge or slightly distal to allow full range of vaginal manipulator motion. The vagina and abdomen are surgically prepared, and a Foley catheter is inserted.
A vertical or transverse abdominal incision may be used, and selection is directed by a woman’s body habitus and by planned concurrent procedures. A Pfannenstiel incision generally provides adequate access to the sacrum and deep pelvis. If a Burch colposuspension, paravaginal defect repair, or other surgery in the space of Retzius is planned, then a low transverse incision that is positioned closer to the symphysis may be preferred.
A self-retaining retractor, preferably a Balfour type, is placed, and the bowel is packed up and out of the pelvis with moist laparotomy sponges. Bowel packing attempts to shift the sigmoid colon farther to the patient’s left, thereby permitting access to the midline and right aspects of the sacrum.
Some data suggest that hysterectomy at the time of ASC leads to higher mesh erosion rates (Culligan, 2002; Griffis, 2006). To reduce erosion risks at the cuff, some surgeons advocate supracervical hysterectomy, theorizing that the cervical stump may act as a barrier to prevent ascending infection and erosion (McDermott, 2009). If a total abdominal hysterectomy is performed, the vaginal apex is closed with absorbable suture such as 0-gauge polyglactin 910 (Vicryl) in a running or interrupted fashion. A second imbricating layer using the same suture may be placed to reduce potential mesh erosion. Another preventive measure is avoiding mesh fixation near the cuff suture line. Specifically, a 1-cm margin from this suture line may avert early mesh erosion during the cuff’s healing phase.
Identification of Pelvic Anatomy
Important boundaries during presacral space dissection are identified beneath the peritoneum prior to the posterior peritoneal incision. These include the aortic bifurcation, iliac vessels, right ureter, right uterosacral ligament, medial border of the rectosigmoid colon, and sacral promontory, which is the upper anterior surface of the S1 vertebra. An understanding that the right ureter, right common iliac artery, and left common iliac vein all lie within 3 cm of the sacral promontory’s midline may lower rates of their injury during surgery in the presacral space (Good, 2013b; Wieslander, 2006). Moreover, both ureters are threatened during dissection of the bladder off the anterior vaginal wall and during suturing of the anterior mesh strip.
The rectosigmoid colon is gently retracted to the left with a malleable ribbon or similar retractor. The peritoneum overlying the sacral promontory, between the rectosigmoid colon’s medial border and the right ureter, is elevated with tissue forceps and incised sharply. The incision is extended caudally into the posterior cul-de-sac of Douglas. As the incision approaches the deeper portion of the cul-de-sac, it is kept between the medial border of the rectum and the right uterosacral ligament. A vaginal manipulator directed ventrally to create tension aids dissection. The incision may then be continued to the posterior vaginal wall and toward the vaginal apex.
Maintaining proper orientation is critical during this step as inadvertent deviation can cause ureteral or iliac vessel injury on the right, or colon injury on the left. Similarly, if the initial peritoneal incision is extended above the sacral promontory, the left common iliac vein should be identified and avoided. This vessel can lie less than 1 cm from the promontory and is generally difficult to visualize or palpate due to its absent pulsatility and decreased tone. Final closure of this peritoneal incision allows the mesh to lie retroperitoneally. This may lower the risk of bowel-to-mesh adhesions and of bowel obstruction from small-bowel loops entrapped below the bridging mesh strip.
Identification of Anterior Longitudinal Ligament
Following peritoneal incision, the loose connective tissue between the peritoneum and the sacrum is sharply and bluntly dissected to expose the anterior longitudinal ligament lying along the sacrum’s vertical midsection. Generally, this presacral space dissection is started at the promontory and continued 3 to 4 cm inferiorly to the upper extent of the S2 vertebra. Within the connective tissue of the presacral space, fibers of the superior hypogastric nerve plexus, right and left hypogastric nerves, and the inferior mesenteric and superior rectal artery and vein are embedded (Fig. 38-23). Of these, the right hypogastric nerve is the most common structure identified during dissection. Below the aortic bifurcation, this midline cordlike nerve courses laterally and at the lower sacral levels, reaches the right pelvic sidewall. Transection of this nerve is ideally avoided.
Also of seminal importance, the middle sacral vessels typically adhere to the anterior surface of the ligament. Once found in the area exposed for mesh attachment, middle sacral vessels can be avoided, ligated, or coagulated depending on surgeon’s preference and operative findings. The middle sacral vein also forms anastomoses with the lateral sacral veins that contribute to the sacral venous plexus. Vessels of this plexus can be extensive, especially in the lower part of the sacrum.
Presacral Space Hemorrhage
Careful exposure of the anterior longitudinal ligament and overlying vessels helps prevent bleeding during suture placement. Despite these efforts, laceration of the sacral venous plexus can lead to rapid and substantial blood loss, and several steps are critical to its control. First, pressure is applied immediately and held for several minutes. This may be particularly effective for venous bleeding. Sutures and clips may be useful, but tearing of small veins frequently worsens with suturing. Additionally, as vessels retract into the bone, isolation and ligation becomes difficult. Sterile thumbtacks directed through lacerated vessels and pushed into the sacrum can effectively compress such vessels. Unfortunately, these tacks are not routinely found in many operating rooms.
Alternatively, various topical hemostatic agents have been used to control bleeding refractory to these initial steps (Table 40-5). Of these, the fibrin sealant family allows conformation to irregular wounds, which is a distinct advantage for presacral space hemorrhage. In refractory cases, vascular surgery consultation may be prudent. Also, injury to the iliac vessels or aorta necessitates immediate consultation.
Sacral Suture Site Selection
To anchor the suspending mesh strips proximally, a surgeon must decide whether to place sutures through the anterior longitudinal ligament at higher or lower sacral levels. Suture placement at the S3 or S4 vertebral bodies increases the risk of sacral venous plexus laceration, and this practice has largely been abandoned. Suture placement above the sacral promontory risks left common iliac vein injury and penetration of the L5-S1 disc, which may lead to painful discitis or osteomyelitis (Good, 2013a; Wieslander, 2006). However, this disc is the most protuberant structure in the presacral space, and mesh is commonly affixed here, especially during the learning phase of ASC (Abernathy, 2012).
For correct sacral promontory identification, the steep angle of descent between L5 and S1 can be used. That said, even correct suture placement at S1 and the sacral promontory still risks middle sacral vessel laceration. However, at S1, the middle sacral vessels are visible and can be easily isolated and avoided or when necessary, clipped or coagulated. Additionally at S1, the anterior longitudinal ligament is thicker and stronger than at lower sacral levels (White, 2009). Affixing sutures here minimizes suture avulsion risks. Finally, attachment of the mesh at S1 may result in a more anatomic suspension of the vaginal apex (Balgobin, 2013).
For these reasons, we prefer to affix mesh to the anterior surface of S1, with the most cephalad suture placed at or just below the sacral promontory. If safe suture placement over the S1 vertebra is prohibited, then the level of the L5-S1 disc is an alternative. Shallow tissue “bites” are needed here to avoid the disc as the anterior longitudinal ligament is only 1 to 2 mm thick.
Typically, three or four serial permanent sutures are used to affix the sacral portion of mesh to the anterior longitudinal ligament. These stitches can be placed first, as described here, or later after vaginal mesh attachment. Needle passage moves from right to left with each stitch, and sutures are aligned vertically. Starting with the lowest suture, they are spaced approximately 0.5 to 1 cm apart. With suturing, 2-0 gauge permanent material, each double-armed with SH needles, is passed through the full thickness of the anterior longitudinal ligament (Fig. 45-17.1). During this, based on findings, suture “bites” either encompass or avoid vessels. Once completed, sutures are held by a hemostat and not tied. Their needles are covered with a surgical towel to avoid stick injuries.
Placement of sacral sutures.