Pelvic organ prolapse (POP) is a common problem in women with around 40 % developing POP in their lifetime1. Surgical management of POP, if desired by the woman, can be offered abdominally or vaginally. This requires extensive counselling and consent as a synthetic mesh is typically used in abdominal surgeries. 

It has been demonstrated that many women with POP wish to retain their uterus2,3. When a woman with apical prolapse, wishes her uterus to be preserved and chooses to have an abdominal procedure, a sacrohysteropexy is the preferred technique. While abdominal sacrocolpopexy has demonstrated durability and effectiveness4, uterine preservation can have advantages of maintaining fertility, maintaining sexual satisfaction, reducing surgical time and blood loss, as well as a quicker recovery5. It is also associated with less mesh exposure due to avoidance of mesh on the colpotomy site6. There is some evidence that sacrohysteropexy may not be as effective for simultaneous correction of anterior vaginal wall prolapse when compared to a sacrocolpopexy7 but is an accepted technique of correcting combined apical and posterior vaginal wall prolapse.

This video demonstrates the technique of performing a laparoscopic sacrohysteropexy to treat combined apical and posterior vaginal wall prolapse in a woman who wished to preserve her uterus. We demonstrate extensive dissection of the rectovaginal septum and fixation of the mesh to the cervix and posterior vaginal wall to correct the concomitant posterior vaginal wall prolapse.

Laparoscopic Entry is achieved through the umbilical port. The uterovesical fold of peritoneum is opened and the bladder is pushed down to clear the cervix. Dissection is carried out laterally to open the anterior leaf of the broad ligament. A window is created in an avascular area of the broad ligament on either side. The uterosacral ligaments and the posterior peritoneum are identified, and the Pouch of Douglas is opened reflecting the rectum down.

The right ureter is identified and kept in vision throughout the dissection. The sacral promontory is identified. The overlying peritoneum is lifted and opened and a nerve sparing dissection is performed from the promontory extending down to the pelvis, staying medial to the right uterosacral ligament. Further dissection of the rectovaginal septum into the pelvic floor is carried out.

A Y mesh is used with the anterior leaf cut in the middle to form two arms. These are then passed through the broad ligament on either side of the uterus to encircle the cervix. This is stitched onto the anterior surface of the cervix using a double breasting technique. The posterior leaf of the Y mesh is placed on the posterior vaginal wall and is anchored there. Both anteriorly and posteriorly, a combination of absorbable and non-absorbable sutures is used and tied using intra and extra-corporeal knots. 

The mesh is then adjusted and attached to the sacral promontory and the uterosacral ligament is closed, covering the mesh.

This video demonstrates the technique of retaining the uterus and treating apical and posterior vaginal wall prolapse with extensive dissection of the rectovaginal septum and placement of the mesh on the posterior vaginal wall.

Olsen A, Smith V, Bergstrom J, Colling J, Clark A. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstetrics & Gynecology. 1997;89:501–506. doi:10.1016/ s0029-7844(97)00058-6
Korbly N, Kassis N, Good M, Richardson M, Book N. Patient preferences for uterine preservation and hysterectomy in women with pelvic organ prolapse. American Journal of Obstetrics and Gynecology. 2013;209(470):e1-6. doi:10.1016/j.ajog.2013.08.003
Frick A, Barber M, Paraiso M, Ridgeway B, Jelovsek J, Walters M. Attitudes toward hysterectomy in women undergoing evaluation for uterovaginal prolapse. Female Pelvic Medicine & Reconstructive Surgery. 2013;19:103–109. doi:10.1097/SPV.0b013e31827d8667