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 (Tackerâ„¢ 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.