Surgical Treatments of Uterine Procidentia

Aug 19, 2006

As presented under the auspices of the AAGL 33rd Annual Meeting, November 2004

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Hello, I am Dr. Daniel Tsin and today I am going to present a mini-laparoscopic technique called Sacralpromontory Cervical Colpoplexy, with one alteration of the posterior cul-de-sac in an abridged procedure.

There are many operative procedures for the treatment of uterine procidentia. The abdominal sacrocolpoplexy is the most commonly used.

There are several surgical approaches, it is my opinion that minilaparotomy must be considered as another alternative.

Repairs have been done with or without hysterectomy and with supracervical hysterectomy. Doing supracervical hysterectomy may have some advantage. It is possible that opening the vaginal bowl could increase the risk of infection. This procedure does not remove the cervix. And placing the sling in the cervical stump instead of the vagina could reduce the incidence of erosions.

Minilaparotomy is not a new procedure. Obstetrician-gynecologists have performed post-partum tubal ligations for a long time. These procedures have several benefits.

This patient’s uterine procidentia was selected for minilaparotomy. She had previous laparotomies, and also small fibroids.

To aid in minilaparotomy I use this elastic retractor. The retractor consists of two flexible rings connected with a sleeve of plastic material. The internal ring is blue and it is squeezed through the abdominal incision and it is allowed to open against the parietal peritoneum. The finger assessment is made to assure the viscera are not trapped between the ring and the anterior abdominal wall.

The external ring is pulled upwards, placing the sleeve on tension and then rolled towards the abdominal wall. Usually two or three full rolls are required until it sits firmly against the skin.

In this way the elastic retractor creates an area that firmly holds the full thickness of the abdominal wall. Working in small incisions the metallic retractor loses the grip, mostly at the peritoneum layer. This will not happen with an elastic retractor.

The view of the field is not obstructed; abdominal packing and a small metallic retractor could be used as in laparotomy.

The exposure of the sacral peritoneum is easy, due to the uterine prolapse. So there is no uterus blocking your way, the sigmoid is pushed to the left side, a longitudinal incision is done from the promontory to the corner of the sacral, and it is held with long forceps.

This creates enough space in the area to place either two sutures or tucks. In this particular case I use a tuperine suture.

A suture is placed in the sacral fascia and tested for its holding strength. When in doubt, I put in a second suture.

After both uterine arteries are cut, identified and secure and prior to the amputation of the corpus of the uterus, the fundus of the uterus is held upward with the anterior and caudal tractions. This helps to identify the uterosacrals and the pouch of Douglas.

A suture is placed into the right uterosacral and into the middle of the cul-de-sac and both left uterosacral ligaments. We begin near the cervix and then progress posteriorly with other sutures as needed.

A Marlex sling in this case is threading both ends, the cephalic in the sacral fascia, and the caudal in the posterior aspect of the cervix, near the uterosacral ligaments. We then proceed with a supracervical hysterectomy and ablation of the endocervical canal.

This link is tied into position with the lower end at the posterior apex of the cervix and the upper end in the sacral fascia.

The entire area will be covered with the peritoneum, and mesh will lie behind the cover. The elastic retractor was then removed, and the parietal peritoneum was closed. The incision gave enough exposure to do a proper procedure.

Sacralpromontory fixation remains the most common treatment for uterine procidentia, and the benchmark for which many other procedures are compared.

This approach has been traditionally done via laparotomy, but could be done with minilaparotomy. Keeping the uterine cervix was done for previously mentioned reasons. This technique addressed the treatment of the anterior, posterior and apical defect in a minimal access manner.

Thank you very much for your attention.