LAPAROSCOPIC UTEROSACRAL VAGINAL VAULT SUSPENSION 5. Case Presentation
With the advent of the Endo-Stitch™ (United States Surgical Corporation, a division of the Tyco Healthcare Group LP) in the late 1990’s, endoscopic surgeons have been able to perform suturing and intra-corporeal knot tying with this ingenious device. Endoscopic upper-abdominal surgeons have been using this device with SurgiDac (Dacron) sutures to perform Nissen Fundoplications for hiatus hernia and reflux. In 1999 I performed my first laparoscopic pelvic floor repair using this device. I perform a McCall type culdoplasty similar to the technique described by CY Liu (2005)1, dissecting and mobilizing the ureters from below. Liu uses Gore-Tex sutures as opposed to a suturing device. I have now performed 108 procedures with none requiring conversion to either abdominal or vaginal procedure. Two thirds were performed with laparoscopic hysterectomy. There were no direct ureteric or large bowel injuries or obstructions and one inadvertent cystotomy.
Originally I did not obliterate the enterocele sac as was the recommendation of Harry Reich (1999)2. Subsequently a patient required a laparotomy and bowel resection for obstruction secondary to incarceration in the enterocele sac a few months after the original surgery. Now I include large ‘bites’ of the para- rectal tissues below the uterosacral ligaments and incorporate them into the repair. I believe these add important support to the repair. One patient early in the series required a vaginal repair of rectocele three months after the original procedure. One patient developed a port site herniation of small bowel requiring an open reduction three days after original surgery (no bowel resection required). Two patients have required a repeat procedure that I will describe in detail.
Thank you Pelvic floor repairs for vaginal vault prolapse can be adequately performed laparoscopically using the Endo-Stitch device.