Laparoscopic Sacrocolpopexy

Overview

The symptomatic fall of at least two portions of the vaginal wall—the anterior/posterior walls and the apex—is referred to as pelvic organ prolapse. Following hysterectomy, collapse of these wall components can lead to later prolapse of the cervix and/or uterus—or the vaginal cuff. Pelvic organ prolapse, like abdominal hernias, is a protrusion of either pelvic or abdominal contents caused by a structural weakness in the pelvic floor.

The International Urogynecological Association and International Continence Society describe pelvic organ prolapse symptoms as "a deviation from normal feeling, structure, or function perceived by the woman in connection to the location of her pelvic organs."

Sacrocolpopexy (sacral colpopexy) is a surgical procedure used to correct pelvic organ prolapse. Reconstruction is performed using either an open abdominal approach or less invasive methods. The treatment technique is determined by the kind and degree of pelvic organ prolapse, as well as the intensity of symptoms.

As with any surgical operation, there are dangers associated, including: damage to a vein or artery, which might result in substantial bleeding bladder or rectum perforation, difficulty with full bladder evacuation, rectum (rectocele) or bladder (cystocele) bulging, hip discomfort, and leg numbness.

Structures & Function of Pelvic floor

The pelvic floor is structured like a funnel. It connects to the smaller pelvic walls, dividing the pelvic cavity from the perineum inferiorly (region which includes the genitalia and anus).

Within the pelvic cavity are the pelvic viscera (bladder, rectum, pelvic genital organs, and the terminal end of the urethra) (or the true pelvis). This cavity is found beneath the pelvic brim in the lower region of the pelvis.

A variety of muscles contribute to the cavity's walls, including the obturator internus and the pirformis, the latter of which also forms the posterior wall.

The roles of the pelvic floor muscles are:

Support of abdominopelvic viscera (bladder, intestines, uterus etc.) through their tonic contraction.
Resistance to increases in intra-pelvic/abdominal pressure during activities such as coughing or lifting heavy objects.
Urinary continence. The muscle fibres have a sphincter action on the rectum and urethra. They relax to allow urination and defecation.

What is Laparoscopic Sacrocolpopexy?

Laparoscopic sacrocolpopexy is a minimally invasive surgery that uses a laparoscope to treat pelvic organ prolapse (a thin, long, flexible instrument with a camera and light source at one end).

The pelvic organs include the vagina, uterus, cervix, bladder, urethra (the tube through which urine travels), intestines, and rectum (the part of the body between the hip bones). A set of muscles and other support tissue holds these organs in place. When this support system is strained, damaged, or torn, pelvic organs might fall out of their regular positions or droop down (prolapse).

Prolapse can be classified according to the organ or organs implicated, such as uterine prolapse.

Causes of Pelvic Organ Prolapse Requiring the Procedure

The most common causes of pelvic organ prolapse are the following:

Childbirth: Vaginal delivery is more likely to result in prolapse than cesarean section (when the baby is delivered through a surgical opening in the wall of the abdomen).
Surgery, such as a hysterectomy
Aging
Extreme physical activity or lifting of heavy objects
Any condition related with high abdominal pressure, such as being overweight, straining to urinate frequently, or having a persistent cough
Factors of genetic (hereditary) origin: The pelvic support system of one person may be inherently weaker than that of another.
Vaginal vault prolapse: It occurs when the top of the vagina (the "vaginal vault") falls down the vaginal canal. This occurs in women who have undergone a hysterectomy in the past (removal of the uterus).
Cystocele: The bladder bulges into the vagina.
Rectocele: The rectum bulges into the vagina.
Enterocele: The small intestine bulges against the vaginal wall. An enterocele and vaginal vault prolapse can occur together.

Before Surgery

Discuss how to prepare for your operation with your healthcare practitioner.
Inform your doctor about all of the medications you are taking. This covers both over-the-counter and prescription medications such as aspirin. Herbs, vitamins, and other supplements are also included. Some medications, such as blood thinners, may need to be discontinued prior to surgery.
If you smoke, you must quit before your operation. Smoking can impede healing. If you need assistance quitting smoking, speak with your physician.
The night before your procedure, don't eat or drink anything after midnight.
Inform your healthcare practitioner of any recent changes in your health, such as a fever.
Follow any further instructions provided by your physician.
You may need to have tests before your surgery, such as:
Electrocardiogram, to evaluate your heart rhythm
Chest X-ray, to assess your heart and lungs
Urine sample, to test for infection and other factors
Blood tests, to check for infection, anemia, and kidney function

What Happens During Laparoscopic Sacrocolpopexy?

The pelvic floor is strengthened during a laparoscopic sacrocolpopexy operation. During the procedure, a surgical mesh is connected from the vagina to the tailbone (sacrum). If necessary, the uterus can be removed with or without the cervix. The fallopian tubes and/or ovaries may also be removed depending on the patient's age, permission, and family history.

During a laparoscopic sacrocolpopexy:

The IV line is set up by the anesthesiologist.
The patient is given general anesthesia (the patient sleeps during the procedure).
The surgeon cleans the surgical site and makes four or five tiny incisions in the abdomen.
The abdomen is inflated with carbon dioxide gas to provide a better vision and room for the procedure.
A laparoscope (a thin, flexible tube-like tool with a camera and a light source) was passed through one of the incisions by the surgeon. Other devices are introduced into the remaining incisions.
A piece of surgical mesh is attached to the front and back walls of the vagina and subsequently to the sacrum by the surgeon. This returns the top of the vagina or cervix to its usual position.
If necessary, the bladder and/or rectum supports can be reinforced.
A tiny portion of the mesh may be inserted beneath the urethra (the tube that delivers pee) to provide support when the patient laughs, sneezes, or coughs in individuals who are unable to control their urine (urinary incontinence).
The surgeon uses a tiny camera to inspect the interior of the bladder to verify that there are no injuries at the conclusion of the procedure.

What Happens After Sacrocolpopexy?

The patient will remain in the PACU until the anesthetic has worn off. If the caregivers have any worries regarding the procedure, the patient may be required to spend the night in the hospital for observation.

Before the patient is released home, a voiding experiment will be undertaken to check if the catheter in the bladder can be withdrawn. The catheter will be withdrawn and the bladder will be filled with saline (salt water). If the patient can empty (pass or urine) two-thirds of the volume placed in the bladder, she will be released without a catheter.

If she is unable to completely empty her bladder, the catheter will be changed and she will be taught how to care for it by a nurse. A follow-up appointment will be scheduled in 3-5 days for another voiding trial.

What should the patient do after a sacrocolpopexy?

The patient's abdomen will have 3-5 incisions that will be closed with glue or tape. She should maintain the incisions clean, dry, and airy. Stitches put beneath the skin disintegrate on their own and do not need to be removed.

The patient should wash her hands often, particularly before handling her wounds, changing dressings, using the toilet, and eating.

Other options for recovery include:

After the surgery, the patient should obtain plenty of rest. The first one or two nights after surgery, a responsible adult should stay at home.
Anesthesia can cause tiredness and disorientation, which can last for up to 24 hours following surgery.
Because of the gas used to inflate the abdomen, the patient may experience gas discomfort, abdominal swelling, or shoulder pain for 24 to 72 hours following surgery. A warm shower, heating pad, and/or walking may alleviate any pain.
The patient should take ibuprofen every 6 hours for the first 24 hours, then the narcotic prescription as needed. She can take ibuprofen as required for discomfort after the first day after surgery.
Narcotic pain relievers can occasionally induce constipation. The patient will be given a prescription for drugs to assist lessen the likelihood of constipation.
At home, she should drink plenty of fluids and consume bland, low-fat meals like crackers, Jell-O, and chicken broth at first. She should avoid fatty meals, which might trigger nausea, and then gradually increase her calorie intake as tolerated.
To train her calf muscles and avoid blood clots in her legs, the patient should take gentle walks about the home.
To avoid infection of the lungs, the patient will be given a breathing equipment known as an incentive spirometer. For the first several days after her operation, she should use this gadget every hour to take deep breaths.
If the patient is sent home with a catheter, she should empty the bag before it becomes too full, keep the catheter tubing free of kinks, keep the Foley bag below the level of the bladder, and keep her pubic region and catheter tubing clean.
It is typical to experience some vaginal discharge or bleeding following surgery. This might persist up to six weeks.
Surgery recovery normally takes two to four weeks, although it might take longer if more vigorous exercise is anticipated. It is natural to feel exhausted during this period.
A patient can shower 48 hours after surgery, but she cannot swim or soak in water for 6 weeks.
The patient should go slowly on stairs and use the railing, especially the first day after surgery.

The patient should NOT:

Do any cleaning or hefty door or supermarket cart pushing.
For 4-6 weeks, do any strong lifting, pushing, or tugging.
Lift anything weighing more than 5 pounds, including laundry, groceries, children, and pets.
Unless the doctor instructs her otherwise, she should not put anything in her vagina for 6 weeks following surgery. Tampons, douching, and sexual intercourse are all examples of this.
Drive for two weeks following surgery, while using narcotic pain medication, or until she feels ready.

Cost

The cost of RA-sacrocolpopexy was higher than that of laparoscopic or abdominal sacrocolpopexy. When the robotic operation time is decreased to 149 minutes and the disposable expenditures are cut from $3293 to $2132, robotic and laparoscopic sacrocolpopexy become cost-equivalent.

If the duration of stay following the abdominal procedure exceeds 5 days or the disposables used cost less than $668, laparoscopic sacrocolpopexy becomes as costly as abdominal sacrocolpopexy. The results of cost-cutting studies cannot be extended to other hospitals or health systems, and they do not consider the consequences or advantages to patients of varied access ways.

Complications

Failure to correct prolapse in 10%
Urinary urgency or urge incontinence in 5%
Urinary tract or wound infections in 2-5% of patients.
Voiding difficulty that necessitates the use of prolonged catheter use <1% of patients
Blood loss requiring transfusion < 1%
Clotting in the legs(DVT) or lungs(PE) < 1%
Damage to the urinary system (bladder or ureter) or bowel occur in approximately 1% and are usually corrected at time of surgery. Very occassionally further surgery may be required to adress these complications.
Conversion to open surgery in <1%
Mesh exposure or rejection in 2-3%.
Painful intercourse can occur in 2-4% especially if a posterior vaginal repair is performed. Confidence and comfort during coitus is likely to be increased as a result of the prolapse being repaired.
Surgery will be covered with antibiotics to decrease the risk of infection and blood thinning agents (Clexan self injected for 5 days) will be used to decrease the risk of clots forming in the postoperative phase.
For the first 24 hours postoperatively a vaginal pack is often inserted into the vagina to decrease the risk of bleeding and a catheter is used to drain the bladder.

Is There any Way to Minimise The Risk of Complications?

Sacrocolpopexy is a difficult surgical treatment with inherent dangers (mentioned above). In general, the risk of problems is reduced when the surgery is performed by surgeons with proper training, acceptable surgical abilities, and extensive experience. According to the American Urogynecologic Society (AUGS), 'excellent experience' involves an annual surgical volume of at least 30 prolapse operations, at least 5 of which are sacrocolpopexy.

When To Call Your Doctor?

A patient should call her doctor if any of the following happen:

She is unable to urinate for 3 to 5 hours and can only urinate in little amounts.
She has a fever of more than 100.4°F (38.0°C) or chills.
Her incisions are causing her issues, such as redness, warmth, swelling, and foul-smelling discharge.
She suffers from acute nausea or recurrent vomiting.
She is soaking more than one pad every hour and has vivid red vaginal bleeding.
She has odorous vaginal leakage.
She is in excruciating agony that is not alleviated by the pain meds she was given.
She suffers discomfort and swelling in her legs, particularly on one side.
If urination becomes uncomfortable, or if the urine becomes hazy or odorous.

Conclusion

The pelvic organs include the vagina, uterus, cervix, bladder, urethra (the tube through which urine passes), intestines, and rectum (the part of the body between the hip bones). A set of muscles and other support tissue holds these organs in place. When this support system is strained, damaged, or torn, pelvic organs might fall out of their regular positions or droop down (prolapse).

Sacrocolpopexy is a significant surgical treatment that fixes the vault (top) of the vagina to the sacrum using a graft or mesh in women who have undergone a prior hysterectomy. Sacrocolpopexy, which was first reported in the late 1950s, is highly acclaimed for its efficiency and durability in the treatment of vault prolapse.

With advancements in minimally invasive surgery, sacrocolpopexy can now be performed by 'keyhole' surgery employing laparoscopic or robotic surgery, resulting in less discomfort and faster recovery than laparotomy.

Patients are often admitted to the hospital for 24-48 hours following surgery. The catheter and drip are usually removed the first morning after the procedure. The patient can eat, drink, and walk around.

The length of recovery varies from woman to woman. It's vital to remember that everyone's experience is unique, so don't compare your personal recovery to that of others on the ward.

Because the body will be utilizing additional energy to produce new cells and mend itself, patients may feel fatigued for 4-6 weeks following surgery. Within 2-4 weeks, most women will be able to resume driving and working.

Sacrocolpopexy outperforms transvaginal surgeries such as sacrospinous ligament, uterosacral ligament, and mesh suspension. The reported long-term success rate varies per surgeon and ranges from 80 to 100 percent. Long-term follow-up demonstrates that repair of uterine and vault prolapse is successful in over 95% of cases.