Laparoscopic Hysterectomy with Sacrocolpopexy for Uterine Prolapse in Elderly Women

Aaradhya Sharma

https://www.laparoscopyhospital.com/SERV01.HTM  This video demonstrate Laparoscopic Hysterectomy with Sacrocolpopexy for Uterine Prolapse performed by Dr R K Mishra at World Laparoscopy Hospital. Total Laparoscopic Hysterectomy with Sacrocolpopexy is performed in order to correct prolapse and/or herniation of the vagina, uterus, and bladder. In this procedure, which is done in conjunction with a laparoscopic hysterectomy, mesh is used to anchor the cervix to the anterior longitudinal ligament of sacrum, thereby lifting the vagina and bladder into their normal anatomic positions. Laparoscopic sacrocolpopexy can also be performed in women who have suffered a prolapse of the vagina and sometimes the intestines as well—a condition known as enterocele. Traditional open abdominal sacrocolpopexy has been shown to be a durable and successful method of repairing symptomatic prolapse while maintaining natural vaginal depth and length. We have now adapted the techniques utilized in open surgery to laparoscopic sacrocolpopexy. Laparoscopic surgery offers a minimally invasive approach with several technical advantages for the surgeon, including enhanced visualization with magnification, reduced blood loss, improved suturing techniques. Laparoscopic sacrocolpopexy avoids the need for a large abdominal incision, women undergoing this procedure are able to experience a less painful recovery with a significantly quicker return to normal activities than would be possible with open surgery.  In this procedure, the patient is placed under general anesthesia and five small incisions are made in the lower abdomen, allowing the introduction of a camera, three robotic instrument arms, and one accessory port for passage of sutures and mesh materials. In cases of advanced uterine prolapse, a hysterectomy will then be performed with preservation of the cervix. Following this, a small piece of polypropylene mesh is used to anchor the cervix, vagina, and bladder to the anterior longitudinal ligament of sacral bone. In some cases, the uterus can be preserved and suspended in a similar manner—a procedure known as sacrohysteropexy. Finally, tissues are sewn over the mesh to form a barrier between the mesh and surrounding pelvic organs.  For more information please contact:  World Laparoscopy Hospital  Cyber City, Gurugram, NCR DELHI  INDIA 122002  Phone & WhatsApp: +919811416838, + 91 9999677788

Transcript

00:00Hello friends, this is a case of total laparoscopic histectomy with sacrocobopexy.

00:09Here this patient has grade 2 uterine prolapse, so uterus was pushed up and now uterine manipulator

00:16is taking the uterus and pushing it towards the opposite shoulder.

00:21We will start TLH from the right side and this is the right round ligament and with the ligature,

00:32round ligament is getting dissected.

00:37Now this is fallopian tube followed by ovarian ligament, here we go 2.5 cm over the broad

00:50ligament.

00:55Now fundus will be pushed towards the opposite shoulder that means tip of the right shoulder.

01:04So that now you can do easily the left side of the adnexal structure.

01:16Now this is left side round ligament followed by fallopian tube and here it is ovarian ligament.

01:35This is 2.5 cm over the broad ligament.

01:43After that uterus will be retroverted at 5 o'clock position and with the left hand you can stretch

01:49the plutonium and you can separate the anterior leaf of the broad ligament.

02:01slowly slowly uterus will go at 6 o'clock position and eventually it turns over the 7 o'clock position,

02:13so that you can reach to the right side.

02:20Now the bladder should be separated with the blunt dissection.

02:39Criss cross pattern of the capillaries of the vagina should be identified and bladder should

02:57be pushed up.

03:10Now the entire bladder should be separated.

03:23Entire bladder should be separated.

03:33So this entire anterior leaf of the broad ligament is separated that separation is very important

04:02and to prevent the injury of bladder as well as urator.

04:16Now this is the posterior peritonium.

04:18Now this is the posterior peritonium.

04:42Now the anterior peritonium.

04:43Then you can reach up to the arc of uterus circle ligament.

04:45Then you can reach up to the arc of uterus circle ligament.

05:19And the posterior petroleum is separated.

05:27Now you can deal with the uterine artery.

05:32This is the right side of uterine artery with the ligature.

05:40You can cook it couple of times and then it can be cut in between.

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06:21So this is the final coagulation of the uterine.

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07:16And now it is cut, cervical vaginal fascia junction is visible and now this is the harmonic

07:35which is doing colpotomy and assistant will rotate the entire vault with the colpotomizer

07:41and with the tip of the harmonic, colpotomy is being performed and entire uterus will be

07:48separated from vagina.

08:01This is posterior remaining colpotomy and our uterus will be free.

08:12So this is total laparoscopic chistectomy is complete.

08:21After that this is vault closure, this is the utero-shackle ligament of the right side.

08:26We are using No.1 Vicryl with the curved needle, 35 mm needle and then vault closure is started

08:36from right side with the continuous switch ring from right to the left.

08:50It is important that when you close the vault, you should must include the epithelium to prevent

08:58the granulation tissue formation.

09:05For vault closure many things can be used.

09:09You can use extracorporeal square knot, you can use western knot.

09:14You may use the interrupted switch ring also with the surgeon's knot.

09:19But here we are using continuous double layer switch ring, full thickness.

09:27And then from the right it is reached to the left.

09:34Now we see the left utero-shackle ligament.

09:48And it is reached to the left corner.

09:51Once you reach to the corner suture, you should ideally interlock.

09:59Interlocking is very useful so that the corners also will get included.

10:08This is interlocking.

10:12And then we will return back.

10:37Once again reaching to the right corner, again it will be interlocked.

10:44And now with the remaining tail, it will be closed.

11:07I hope you will.

11:18Hi, God.

11:19Hi, God.

11:31So now the vault is closed and then you can cut the suture and take the needle out.

11:58Now we will use a 15 cm x 3 cm mesh and we will cut the mesh, split the mesh, make it Y shaped.

12:11And then we can start cutting it.

12:16But before that this is the tunnel from the sacral pulmonary up to the vagina, right side

12:22to the rectum i.e. peitoneal window has to be formed for sacrocopopexy to hide the mesh.

12:29So now let's take a look at this.

12:36So now let's take a look at this.

12:44Slowly the mesh is going on.

12:59Tunnel is going on and you have to cut the peitoneum only.

13:11It is very important to stretch it anteriorly to prevent any injury of the ligaments and the vessels.

13:18Especially middle rectal artery which is branch, second branch of intranial ear comes and you

13:25should also avoid any injury to the rectum.

13:38So it is almost reached at this point to the pararectal space and it is reached up to the utero

13:47sacral ligament on the right side.

13:52And now you will take, you see the anterior longitudinal ligament, you can make it shiny.

13:58Here this is pearly white color and it is made shiny.

14:05After that this is the mesh.

14:07One leaf of the mesh is fixed with the posterior vagina and another leaf will be fixed with the anterior vagina.

14:21So through the mesh and then anterior vagina and again through the mesh.

14:28So this way vagina will be sandwiched in between the two layers of the mesh.

14:34This we have first used with the silk and after that reinforcing with the dark round, that is polyester.

14:44You can fix the mesh with the polyester.

14:56You can fix the mesh with the polyester.

15:14This is surgery's knot.

15:31Fixing the mesh with the anterior vagina.

15:34Approximately 3 cm of the vagina should be included.

15:40And it will be fixed with the mesh.

16:09Polyster is very strong and that is better than the silk for fixation.

16:39So, now this is again final closure with the corners, message once more fix.

17:08This fixation should be strong enough so that it should not cut through.

17:20That's why multiple bite is taken, interrupted is better.

17:25All continuous bite can be taken but if one is loose, all will be loose.

17:30That's why it is better to close it nicely.

17:35And now the long limb of the mesh is pulled up over the sacral pulmonary.

17:42You can keep it there.

17:44And we are using here titanium tacker, protac from Covidian to fix the mesh to the sacral pulmonary.

17:53So, this is double layer protac and here it is.

17:57Left hand will stabilize it and on the right corner of the interior longitudinal ligament you can fire it.

18:05So, one tacker is fired.

18:08Now, this is another one that also securely and this is the third one.

18:15Three tacker is fired to fix the mesh.

18:19And now excess of the mesh is trimmed out.

18:23Sometime we use suture also.

18:26But here it is the, only the mesh was fixed with the tacker.

18:31And now entire plutonium of the anterior leaf together with the posterior plutonium will cut out.

18:41So that nicely you can close the, and you can hide the mesh.

18:46So, this is a continuous suturing to cover the mesh.

18:52Any portion of the mesh should not be visible.

18:58So, either end, this is the lower end and here it is the round ligament.

19:06And that was the IP ligament.

19:18Slowly plutonium closure is started.

19:27Many people, they don't close the vault.

19:30But plutonium closure, especially after sacroculopexy is good practice.

19:35So, there it will hide the mesh completely.

19:39And there will not be any chance of internal hurliation.

19:43And there will be no chances of

19:46Mesh doing the

19:49Infection

19:51Or adhesion to the small bubble.

19:55Now this tunnel will be closed.

19:58This is the

20:00Rectal side of the plutonium.

20:03And this is the anterior flap.

20:06All is taken and this corner was closed.

20:10And then with the same suture,

20:15Continuously you can close the

20:19Pararectal defect of the plutonium.

20:21This is on the right side.

20:24So, continuous suture is very good for plutonium.

20:30Peritonium tolerates continuous suturing very nicely.

20:33And there will be no cut through.

20:36Interrupted will be time taking and there is no need of interrupted suture for plutonium.

20:42So, now slowly it is coming towards the cycle permanently.

20:55This is the final closure.

20:57And again you can return back to go to the junction.

21:01The entire mesh is hidden now.

21:16Again you can go back and with this extra plutonium.

21:20You can take the final bite and terminate the knot.

21:25So, that way entire mesh is nicely covered.

21:32And this is now final termination.

21:36Slowly the mesh will go to its own position and the

21:46This plutonium will get reorganized.

21:51And once it will get nicely reorganized.

21:57After that,

21:59It will regenerate and the remaining defect will be also closed.

22:05So, this is important that

22:09The mesh should not be directly come into the contact with the

22:14Bowel or rectum.

22:16And plutonium should cover it.

22:25So, now this is over.

22:27And this is the final view.

22:28As you can see.

22:30That entire plutonization is there.

22:33So, thank you very much for watching this video.

22:37Have a nice day.

22:39Thank you very much.

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