Laparoscopic monolateral suspension for vaginal vault prolapse: a report of an exit surgical strategy during sacralcolpopexy

Abstract

Background Vaginal vault prolapse is the most frequent long-term complication in patients undergoing hysterectomy and sacralcolpopexy is considered the gold standard. We report our surgical strategy maintaining single-arm mesh when the sacral promontory is not accessible to fix the mesh for an unknown sacral osteophytosis during a laparoscopic sacralcolpopexy. This is significant because, to our knowledge, the bone variant as a procedure limiting factor has never been described before. This opens new horizons for the sacralcolpopexy surgery, because it becomes necessary to know of a valid surgical alternative with mesh maintenance if this complication occurs again or to perform an assessment of the accessibility of the sacral promontory immediately after its dissection. Case presentation We present a case of a 75-year-old woman with recurrence of vaginal vault prolapse. A laparoscopic sacralcolpopexy was recommended. During surgery, we found that the procedure was not feasible due to the presence of an unknown osteophytosis of the sacrum which prevented the fixing of the mesh to the sacral promontory. We decided to proceed with a single-arm lateral suspension by using a modified approach of the original technique, maintaining the mesh originally shaped for the sacral colpopexy. At follow-up, the vaginal vault is well suspended. Conclusion This exit strategy may represent a valid surgical alternative when laparoscopic sacral colpopexy is not possible for anatomical variants, allowing to keep the laparoscopic approach using mesh. To our knowledge, cases in which the anatomical bone variant prevented access to the sacral promontory have never been described in the literature, as bone evaluation has never been considered a limiting element of this procedure.

Spondylodiscitis After Surgery for Pelvic Organ Prolapse: Description of a Rare Complication and Systematic Review of the Literature

“…However, surgeons are able to minimize the risk of spondylodiscitis by carefully placing the presacral fixation, putting stitches or tacks into the anterior longitudinal ligament avoiding the disc space (49). The surgeon has to keep in mind that the anterior longitudinal ligament is only 1-2 mm thick and this could lead to an easy perforation of it (50). Furthermore, mesh suture load into the vaginal wall should be minimized in order to decrease the risk of organism migration between the mucocutaneous layer and the mesh (51).…”