Laparoscopic Surgical Techniques
Uterovaginal & Vaginal Prolapse
The patient is placed under general anesthesia. The laparoscope is placed into the abdominal cavity through a small, .5-inch incision inside the navel. An additional 3 to 4 ¼-inch incisions may be needed in the lower abdomen to place other laparoscopic instruments during the operation.
The laparoscope is connected to a small, sophisticated and sensitive video camera that greatly magnifies the deep pelvic structures onto three high-resolution video monitors positioned in front of the surgeon, the surgical assistant and the scrub technician. This allows the entire surgical team to have a superb view of the operative field.
As the individual supporting defects are visualized and reconfirmed by digital vaginal palpation under the view of the laparoscope, defects are repaired with the placement of permanent, non-absorbable sutures. Precise placement is possible due to laparoscopic instruments.
Frequent digital vaginal examinations are performed throughout the surgery to ensure that all defects are repaired. Because of excellent visibility of the operative field through the laparoscope, the blood vessels in the pelvic area can be either avoided or sealed by electrocautery or suture ligation, thus minimizing blood loss.
There are several laparoscopic surgical techniques that can be used to repair the uterovaginal and vaginal prolapse. Dr. Liu prefers to use presacral uterosacral ligaments to resuspend the apex of the vagina and cervix (if the patient still has a uterus) to restore the depth and axis of the vagina.
The presacral uterosacral ligament is a very strong fibromuscular tissue that can withstand great strain. To demonstrate the strength of presacral uterosacral ligaments to a group of physicians attending an anatomy meeting, Dr. Liu once placed a large suture through the ligament and hooked the suture to a 30-pound weight. The ligament held the weight with out any problem.
For patients with marked prolapse, a paravaginal repair usually will be necessary at the same time of the surgery to reattach the midvagina to the pelvic side walls.
Unlike traditional vaginal surgical repair, there is little to no cutting or trimming of the vagina, therefore, there is absolutely no risk of making the vagina too narrow or too short, both of which are the major long-term complications of vaginal surgical repair of prolapse.
When the bladder drops from its normal place into the vagina, it is called a cystocele. Small cystoceles are common. They usually do not interfere with urination and do not need surgery. Some cystoceles cause urine leakage when a woman coughs, sneezes, lift objects, or even walks. However, large cystoceles may kink the urethra and interfere with the passing of urine.
Support for the bladder and urethra (the tube between the bladder and the opening of vagina) is provided by a strong fibromuscular layer that covers the linings of the anterior vaginal wall. This is the pubocervical fascia.
Superiorly, it attaches to the upper part of the vagina and cervix of the uterus. Laterally, it attaches on each side to the pelvic side wall.
The pubocervical fascia supports the bladder and the urethra by forming a shelf, allowing the bladder neck and the proximal part of urethra to be compressed in an anteroposterior fashion during periods of stress, such as coughing, sneezing, laughing or lifting heavy objects.
When this supporting mechanism loosens due to the trauma of childbirth, or for other reasons, the stability of this once-supportive layer of fascia diminishes and may ultimately fail, leading to the formation of a cystocele. If the fascial defect involves the support of the bladder neck and proximal urethra, stress urinary incontinence may also develop.
A Widely Accepted Concept
In 1976, after careful clinical observations and cadaver dissections, Dr. Richardson, of Atlanta, Georgia, emphatically proposed that the vast majority of cystocele is not caused by stretching or attenuation of the pubocervical fascia, but that it is a result of a break of the pubocervical fascia from its attachments to the pelvic side walls.
He called this condition paravaginal defect, and he strongly advocated the use of paravaginal repair -- instead of traditional vaginal anterior repair (anterior colporrhaphy) -- for the treatment of cystocele.
His concept and proposed treatment of cystocele have been accepted and endorsed by virtually all of the leading urogynecologists in the country.
Laparoscopic Paravaginal Repair for Cystocele
Under general anesthesia, a laparoscope is inserted into the abdominal cavity through a small ½-inch umbilical incision.
The peritoneum (the lining of the abdominal and pelvic cavity) above the bladder and behind the pubic bone is opened through the laparoscope. The retropubic space (a space in the pelvis where the bladder and its supporting ligaments are located) is entered and dissected.
The laparoscope is connected to a small, very sophisticated and sensitive video camera that greatly magnifies the retropubic space onto three high-resolution video monitors positioned in front of the surgeon, the surgical assistant, and the scrub technician. This allows the entire surgical team to have a superb view of the operative field.
The paravaginal defect(s), can be very easily identified by the surgeon. A digital vaginal examination under the direct observation of the laparoscope is performed to reconfirm the presence and extent of the defects. The defects are then repaired with several interrupted sutures and permanent stitches.
There are three different types of paravaginal defects that can be identified through the laparoscope, and each defect should be treated differently according to its own types of defect.
With positive intra-abdominal pressure created by the pneumoperitoneum during laparoscopic surgery, paravaginal defects become much more apparent. Digital vaginal examination, under direct viewing through the laparoscope, affords the surgeon additional tactile assessment of the defects. Therefore, intraoperative findings of the paravaginal defects not only confirm the preoperative findings, they dictate the ultimate procedures to be performed.
At the end of the reconstructive surgery, repeat digital vaginal examination under direct laparosopic view allows the surgeon to be confident that all the defects have been repaired.
Dr. Liu has been performing laparoscopic paravaginal defect repair for ten years with very satisfactory results. He attributes this to the ability to see and identify the defects perfectly and place the sutures very precisely through the laparoscope. According to Dr. Liu, “As it is said, ‘If you cannot see, you don’t know what you are missing.’”