Vaginal-Assisted Laparoscopic Sacrocolpopexy (VALS) With Advanced Pelvic Organ Prolapse

Abstract

Objective: To review advances of the sacrocolpopexy procedure and demonstrate the Vaginal-Assisted Laparoscopic Sacrocolpopexy approach.

Design: Participants who underwent the Vaginal-Assisted Laparoscopic Sacrocolpopexy approach and consented to intra-operative video documentation were included.

Setting: This research was conducted at a single academic institution.

Interventions: Sacrocolpopexy is an abdominal apical suspension that involves placement of mesh between the vaginal apex and anterior longitudinal ligament overlying the S1-S2 vertebrae. Vaginal Assisted Laparoscopic Sacrocolpopexy (VALS), is a modified approach to sacrocolpopexy. After the hysterectomy, the mesh is attached vaginally to the anterior and posterior vaginal walls. Vaginal dissection of the vesicovaginal and rectovaginal spaces by hand is quick and efficient and allows for palpation of needle depth, which can prevent suture tearing and inadequate mesh attachment with non-tactile placement. The surgeon then transitions back to laparoscopy to complete the remainder of the procedure. Recent literature demonstrates similar rates of mesh complications and reoperation for prolapse with concurrent total hysterectomy versus supracervical hysterectomy given the transition to type I polypropylene mesh and reduction in permanent suture use for vaginal mesh attachment. We anticipate an increase in utilization of the VALS technique given multiple benefits of total hysterectomy, including reduced risk of postoperative menses in premenopausal patients, less postoperative pain and better cosmetic outcomes without need for mini-laparotomy or port-site extension for uterine morcellation, and decreased cervical and endometrial cancer risk. Surgical benefits of the VALS technique include shorter anesthesia and operative time and reduces the need for higher level assistance intraoperatively. VALS is also more ergonomic for the surgeon, promoting use of different muscles throughout the case, thus decreasing muscle fatigue and risk of repetitive motion injury.

Conclusion: Laparoscopic sacrocolpopexy utilizing transvaginal mesh attachment is another tool in the myriad of techniques to treat advanced pelvic organ prolapse. This technique reduces operative and anesthesia time, minimizes mesh complications while maintaining successful outcomes for patients. VIDEO ABSTRACT.

Keywords: Laparoscopy; Patient centered outcomes; Prolapse; Sacrocolpopexy; Surgical technique; Vaginal surgery.