V2-01: TRANSABDOMINAL SACROCOLPOPEXY WITH RECTUS FASCIA GRAFT
VideoIntroductions and Objectives
Extrusion is a known risk of abdominal sacral colpopexy performed with synthetic mesh. Long-term follow-up in the CARE trial revealed 23 cases or an estimated 9.9% risk of mesh extrusion. Infection is also a risk when using synthetic mesh. There are 26 reports of spondylodiscitis after sacral colpopexy with synthetic mesh. The risk of infection is likely increased when concomitant gastrointestinal or genitourinary surgery is performed. There are few reports on use of autologous rectus fascia graft for abdominal sacral colpopexy. The objective of the video is to demonstrate a transabdominal sacrocolpopexy using rectus fascia graft.
A midline laparotomy incision had already been made by the colorectal service. The fat overlying the rectus fascia was dissected off. The desired segment of rectus fascia was marked and divided. The graft measured approximately 2 cm wide by 12 cm long. The peritoneum overlying the sacral promontory was divided thus exposing the anterior longitudinal ligament. An EEA sizer was placed in the vagina. The bladder was distended with irrigation thus defining its borders. The bladder was gently grasped with a Babcock clamp and retracted anteriorly exposing the area of the vaginal cuff. The bladder was carefully dissected off the vaginal cuff using sharp dissection. Appropriate length of the graft was estimated. Vaginal exam confirmed adequate reduction of the prolapse. The rectus fascia graft is secured to the vaginal cuff caudally and to the anterior longitudinal ligament cranially. The peritoneum over the sacral promontory was closed with interrupted sutures.
This patient was last seen at 4 months for follow-up. She reports resolution of the vaginal pressure, improvement in voiding, and rare stress urinary incontinence. Renal ultrasound demonstrated no hydroureteronephrosis on the side of her re-implantation. On exam, her POPQ measurements were significant for Ba point of -2, a C point of -9 and a Bp point of -2.
Abdominal sacral colpopexy using autologous rectus fascia graft is a feasible option, especially in cases where infection and synthetic mesh extrusion risks are high.