Technique
The presented operation is performed in two steps, consisting of an initial vaginal surgery followed by a laparoscopic approach. The procedure begins by placing the patient in the dorsal lithotomy position to permit access to both the vagina and abdomen, and is conducted under general anesthesia with broad-spectrum prophylactic antibiotics. The cervix is grasped with a tenaculum and downward traction is applied. An anterior 2-cm long transverse incision to the anterior cervix is made. The bladder is dissected through blunt and sharp dissection to the level of the isthmus. Posteriorly, a 2-cm long colpotomy is performed, and the peritoneum over the pouch of Douglas is opened at the level of the cervix. A type 1 macroporous monofilament is used to create a light mid-urethral polypropylene sling (40 cm length, 1 cm width; Figure 1). The mesh is inserted through the cervix from 8 to 10 way in right and from 2 to 4 way in left with the help of a clamp (Figure 2). The midpoint of the tape is fixed to the cervix with a 2/0 polypropylene suture. The free ends of the tape are inserted into the peritoneal cavity with the aid of ring forceps. Vaginal incisions are closed with a polyglactin 910 2/0 suture. A uterine sound is placed to allow gentle manipulation of the uterus and gloves are changed before starting the laparoscopic phase of the procedure. The vaginal approach is concluded with a low posterior colporrhaphy/perineoplasty and the placement of a mid-urethral sling.
After abdominal preparation and induction of pneumoperitoneum, a 30° telescope is inserted through a 10-mm umbilical port. Two 5-mm ports are inserted at the right upper quadrant and one 5-mm port is inserted suprapubically. For better visualization, the bilateral ovaries can be fixed to the anterior abdominal wall with the aid of sutures and a straight needle, representing another novel technique used in the current procedure (optional). The bilateral ureters, sacrouterine ligament lines, L5-S1 and promontorium anatomies are carefully identified. For the right sacrouterine ligament tape simulation, the prevertebral parietal peritoneum is vertically incised over the sacral promontory with a harmonic scalpel and the anterior longitudinal ligament of the sacrum is revealed. A tunneler, modified by manually bending disposable clinched grasping forceps (Covidien, Mansfield, MA, USA) to form a 15-cm diameter semicircle (Figure 3), is used to make a tunnel parallel and medial to the sacrouterine fold. This modified grasping tunneler is inserted suprapubically after removing the suprapubic port. The free end of the tape is grasped and pulled, then it is fixed to the anterior longitudinal ligament with three 5-mm titanium helical tacks (Tacker™ Fixation Device, Covidien, Mansfield, MA, USA) avoiding excessive tension. After medialization of the sigmoid colon, a 2-cm incision of the peritoneum over the sacrum is made. The same technique for tunneling and passing of tape is then used. Alternatively, a 10-cm diameter semicircular mid-urethral sling applicator can be passed from the cervix to the sacrum medial to sacrouterine fold. Both techniques are shown in the accompanying video. The free end of the mesh is transfixed to the anterior longitudinal ligament, similar to that done on the right side. Excess mesh is cut with scissors and the peritoneum over the sacrum is closed with 2/0 polyglactin sutures and tied with an extracorporeal knot.