Nerve preserving vs standard laparoscopic sacropexy: Postoperative bowel function

Abstract

Aim: To compare our developed nerve preserving technique with the non-nerve preserving one in terms of de novo bowel symptoms.

Methods: Patients affected by symptomatic apical prolapse, admitted to our department and treated by nerve preserving laparoscopic sacropexy (LSP) between October, 2010 and April, 2013 (Group A or "interventional group") were compared to those treated with the standard LSP, between September, 2007 and December, 2009 (Group B or "control group"). Functional and anatomical data were recorded prospectively at the first clinical review, at 1, 6 mo, and every postsurgical year. Questionnaires were filled in by the patients at each follow-up clinical evaluation.

Results: Forty-three women were enrolled, 25/43 were treated by our nerve preserving technique and 18/43 by the standard one. The data from the interventional group were collected at a similar follow-up (> 18 mo) as those collected for the control group. No cases of de novo bowel dysfunction were observed in group A against 4 cases in group B (P = 0.02). Obstructed defecation syndrome (ODS) was highlighted by an increase in specific questionnaires scores and documented by the anorectal manometry. There were no cases of de novo constipation in the two groups. No major intraoperative complications were reported for our technique and it took no longer than the standard procedure. Apical recurrence and late complications were comparable in the two groups.

Conclusion: Our nerve preserving technique seems superior in terms of prevention of de novo bowel dysfunction compared to the standard one and had no major intraoperative complications.

Keywords: Apical prolapse; Bowel dysfunction; Laparoscopic sacrocolpopexy; Nerve sparing; Vaginal vault prolapse.

Figure 1

Step 1: Opening the peritoneum. A: Schematic drawing of the “dissection triangle” on the right lumbosacral spine with the safe area (X) for opening the peritoneum; B: Laparoscopic view of the peritoneal opening point (X). rCIA: Right common iliac artery; SP: Sacral promontory; AB: Aortic bifurcation; SHP: Superior hypogastric plexus; rHN: Right hypogastric nerve; lHN: Left hypogastric nerve; InfVC: Inferior vena cava; lCIV: Left common iliac vein.

Figure 2

Step 1: Presacral fascia displacement, prevertebral fascia opening. A: The imaginary outline of the “dissection triangle” on the right lumbosacral spine between the four anatomical landmarks; B: Presacral fascia displacement not beyond the middle sacral vein (msv); C: Presacral fascia and prevertebral fascia; D: Denuded periosteum after prevertebral fascia opening. rCIA: Right common iliac artery; SP: Sacral promontory; AB: Aortic bifurcation.

Figure 3

Step 2: Opening of the peritoneum on the right pelvic sidewall. A: Schematic drawing of the dissection line (green arrow) and the autonomic pelvic nerves; B: Dissection line (dotted green line) at the cross of the caudal proximal third of the uterosacral ligament. Modified from Ceccaroni M, Fanfani F, Ercoli A, Scambia G (2006). Innervazione viscerale e somatica della pelvi femminile. CIC Edizioni Internazionali, Roma. rHN: Right hypogastric nerve.