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13: Laparoscopic cerclage sacrohysteropexy: A novel simplified technique

      Objective

      The purpose of this video is to demonstrate a novel technique for surgical management of uterovaginal prolapse that reduces operating time and minimizes the advanced suturing skills typically involved with the traditional method. It leverages the experience with the Shirodkar cerclage with sacral fixation in order to perform sacrohysteropexy. Laparoscopic cerclage sacrohysteropexy differs from traditional sacrocolpopexy in that absolutely no endoscopic suturing of the mesh onto the vagina or cervix is required.

      Description

      The procedure is begun laparoscopically, where the peritoneum overlying the sacral promontory is incised and dissection is performed to expose the anterior longitudinal ligament of the sacrum. The incision is continued along the right pelvic sidewall, lateral to the rectum and medial to the right ureter, and the rectovaginal space is dissected allowing the rectum to be displaced posteriorly. The surgery is continued vaginally, where an incision is made at the cervico-vaginal junction from 10:00 o'clock to 2:00 o'clock and the bladder is advanced off the cervix. A posterior incision is then made between 4:00 o'clock to 8:00 o'clock, and the posterior cul-de-sac is entered. An Emmett needle is passed bilaterally from the posterior to anterior cervix and a polypropylene mesh sling is drawn through the lateral cervix and placed flat anteriorly on the cervix. The two tails existing posteriorly are sutured side-by-side and this sacral extension is placed into the pelvis through the cul-de-sac incision. The two vaginal incisions are closed with absorbable suture. Laparoscopically, the mesh is fixed to the sacrum (S1) with permanent sutures and the peritoneum is closed over the mesh.

      Conclusion

      The steps shown for placement of a cervical mesh are familiar and easily reproducible, and can greatly simplify what is classically a complex surgical procedure.