Laparoscopic Anatomy of the Pelvic Floor 9783030354978, 9783030354985

Table of contents :
Preface
Why This Atlas?
The Diagnosis of Pelvic Floor Defects Is Clinical
Always a Place for Vaginal Access to Do Reconstructive Pelvic Surgery
Now, a Great Place for Laparoscopy Using Meshes
Which Laparoscopic Technique?
This Atlas? A Hymn to Laparoscopy and Laparoscopists
Acknowledgements
Contents
Part I: Traditional Anatomy of the Pelvic Floor
1: Introduction
1.1 Muscles, Fascias and Ligaments (Fig. 1.1)
2: The Muscles
2.1 Two Categories of Pelvic Muscles Are Individualized (Fig. 2.1)
2.2 Lateral Muscles
2.3 Pelvic Floor Muscles
2.3.1 Obturator Internus Muscle
2.3.2 Levator Ani (L.A.)
2.3.3 L.A. Iliococcygeus
2.3.4 Coccygeus Muscle
2.3.5 Piriformis
2.4 The Superior View of the Pelvic Floor Muscles (Fig. 2.2a)
2.5 The Lateral View of the Pelvic Floor Muscles (Fig. 2.2b)
3: The Fascias
3.1 Endopelvic Fascia (Figs. 3.1 and 3.2)
3.2 Visceral Fascia (Fig. 3.3)
4: The Ligaments
4.1 The Pelvic Ligaments Seen by Laparoscopy
4.1.1 Round Ligament (Fig. 4.1)
4.1.2 Uterosacral Ligament (Fig. 4.2)
4.1.3 The Anatomical Landmarks of the Two Uterosacral Ligaments (Fig. 4.3)
4.2 Visceral Ligaments
4.2.1 The Visceral Ligaments for Pelvis Support (Fig. 4.4)
4.2.2 Ventro-Dorsal Axis (Also Called ‘Lame sacro-recto-génito-pubienne’ Described by Farabeuf)
4.2.3 Medio-Lateral Axis
5: The Attachment Sites for the Surgeon
5.1 The Landmarks of the Pelvic Floor for the Surgeon (Figs. 5.1 and 5.2)
5.2 The Four Risks of the Attachment Site Risks
5.3 The Risks of the Promontory for the Surgeon (Fig. 5.4)
5.4 The Presacral Anatomy Below the Promontory (Fig. 5.5)
Part II: Laparoscopic Normal Anatomy of the Pelvic Floor Seen By Transperitoneal Vision
6: Ventrolateral Abdominal Wall
6.1 Umbilical Artery (Fig. 6.1)
6.2 Inferior Epigastric Artery
6.3 Paravesical Fossa
7: Lateral Anatomy
7.1 The Ureter (Fig. 7.1)
7.2 Laparoscopic Identification (Fig. 7.2)
8: Landmarks of the Ureter
8.1 Ureter in the Promontory Area (Figs. 8.1 and 8.2)
8.2 Lateral Anatomy Below the Adnexa (Fig. 8.3)
8.3 The Ureter Below the Adnexa (Fig. 8.4)
9: Dorsal and Lateral Anatomy of the Pelvis
9.1 Two Hypogastric Nerves, Right and Left (Figs. 9.1 and 9.2)
9.2 The Inferior Hypogastric Plexus (Fig. 9.3)
10: Promontory Area
10.1 The Cranial Area (Fig. 10.1)
10.2 Middle Sacral Artery (Fig. 10.2)
10.3 Sigmoid Colon (Fig. 10.3)
10.4 Left Common Iliac Vein (Fig. 10.4)
10.5 The Vision in Female Cadaver (Fig. 10.5)
Part III: Laparoscopic Normal Retroperitoneal Anatomy of the Pelvic Floor Seen After Peritoneal Incision
11: Prevesical Space, Cooper’s Ligament, Paravesical Space, Arcus Tendineus Fascia Pelvis
11.1 The Prevesical Space
11.1.1 Access to the Prevesical Space, After Filling the Bladder (Fig. 11.1)
11.1.2 Dissection of the Retzius Space in Avascular Loose Tissue (Fig. 11.2)
11.1.3 The ‘Champagne’ Bubbles (Fig. 11.3)
11.1.4 Progressive Dissection of the Prevesical Space (Fig. 11.4)
11.1.5 Focus on Cooper’s Ligament, Technique of Exposition, Left Side (Fig. 11.5)
11.1.6 Focus on Cooper’s Ligament, Technique of Suture, Left Side (Fig. 11.6)
11.2 The Prevesical Space (Continued)
11.2.1 Bladder (Fig. 11.7)
11.2.2 Complete Dissection of the Prevesical Space (Fig. 11.8)
11.2.3 Panoramic View of Dissection Between the Umbilico-Vesical Fascia and Bladder (Fig. 11.9)
11.3 The Paravesical Space
11.3.1 Focus on ATFP, Between Pubis and Ischial Spine (Right Side) (Fig. 11.10)
11.3.2 Focus on Obturator Pedicle, Between Pubis and Ischial Spine, at the Entry in the Obturator Canal, Left Side (Fig. 11.11)
11.3.3 Focus on Obturator Pedicle (Figs. 11.12, Right Side, and 11.13, Left Side)
11.3.4 Focus on Corona Mortis Artery (Fig. 11.14)
11.3.5 Relationship Between the Obturator Nerve and the Corona Mortis Artery (Fig. 11.15)
11.4 The Panoramic View of the Pre- and Paravesical Space
11.4.1 Prevesical Space (Fig. 11.16)
12: The Vesicovaginal Space
12.1 Limits (Fig. 12.1)
12.2 Access to the Vesicovaginal Space (Fig. 12.2)
12.3 The Loose Connective Tissue (Fig. 12.3)
12.4 Section of the Bladder Pillars (Fig. 12.4)
12.5 The Cleavage Line (Fig. 12.5)
12.6 The Panoramic Vision (Fig. 12.6)
12.7 Vesicovaginal Space (Continued)
12.7.1 Bladder Pillars (Fig. 12.7)
12.7.2 Lateral to the Vesicovaginal Space (Figs. 12.8 and 12.9)
12.8 Deep Vesico-Cervico-Vaginal Dissection
12.8.1 Lateral to the Vesicovaginal Space (Fig. 12.10)
12.8.2 Visualization During Hysterectomy (Fig. 12.11)
12.8.3 Visualization with Magnification (Fig. 12.12)
13: The Dorsolateral Dissection of the Uterine Artery
13.1 The Dorsal Approach to Preventive Occlusion (Fig. 13.1)
13.2 The Technique of Dorsal Approach of the Uterine Artery for Preventive Occlusion (Fig. 13.2)
13.3 Visualization of the Uterine Artery and of the Ureter (Fig. 13.3)
13.4 The Titanium Clip (Fig. 13.4)
14: The Rectovaginal Septum
14.1 The Limits (Fig. 14.1)
14.2 Vaginal Venous Plexuses (Fig. 14.2)
15: The Pararectal Space
15.1 Laparoscopic Access (Fig. 15.1)
15.2 The Middle Rectal Artery (Fig. 15.2)
15.3 Deep Dissection (Fig. 15.3)
15.4 Lateral Rectal Dissection in Cadaver (Fig. 15.4)
15.5 Situation of the Medial Pararectal Space of Okabayashi
15.6 Situation of Lateral Pararectal Space of Latzko
15.7 Pelvic Lymphadenectomy: The Main Benchmarks (Fig. 15.5)
15.8 The Pudendal Nerve, Laparoscopic Approach
15.8.1 Definition
15.9 Laparoscopic Dissection of the Right Pudendal Nerve
15.9.1 The View of the Pudendal Nerve by Laparoscopy
15.9.2 View of the Ischial Spine Area (Fig. 15.6)
15.9.3 Visualization of the Sacrospinous Ligament (Fig. 15.7)
15.9.4 Pudendal Nerve Release (Fig. 15.8)
15.9.5 The Pudendal Nerve Dissected Appears White (Fig. 15.9)
15.10 Laparoscopic Dissection of the Left Pudendal Nerve (Continued)
15.10.1 Dissection of the Pudendal Nerve (Fig. 15.10)
15.10.2 Progressive Vision of the Pudendal Nerve (Figs. 15.11 and 15.12)
Part IV: Laparoscopic Anatomy of the Pelvic Floor in Case of Genital Prolapse Seen By Clinical Examination and Transperitoneal Vision
16: Cystocele
16.1 Definition (Fig. 16.1)
16.2 External Aspect of Exteriorized Lateral Cystocele, Associated with Procidentia (Uterine Descent) (Fig. 16.2)
16.3 External Aspect of Large Cystocele (Fig. 16.3)
16.4 Complete Prolapse (Fig. 16.4)
16.5 Correlation in Laparoscopy of Pelvic Floor Defects
16.5.1 Laparoscopic Aspect of Lateral Cystocele (Fig. 16.5)
16.5.2 Laparoscopic Aspect of Central and Lateral Cystocele (Fig. 16.6)
16.5.3 Laparoscopic Aspect of Cystocele and Procidentia (Fig. 16.7)
16.5.4 Laparoscopic Aspect of Exteriorized Cystocele After Total Hysterectomy (Fig. 16.8)
17: External Aspects of Exteriorized Apical Prolapse and Rectocele
17.1 Trachelocele (Figs. 17.1 and 17.2)
17.2 Rectocele
17.3 Clinical Evaluation of the Posterior Pelvic Floor Defects (Fig. 17.3)
17.4 Usual Clinical Aspect of the Rectocele Associated with a Cystocele (Fig. 17.4)
17.5 Laparoscopic Aspect of Large Rectocele (Fig. 17.5)
17.6 Usual Laparoscopic Aspect of Rectocele (Fig. 17.6)
18: External Aspects of Vaginal Vault Prolapse
18.1 Vaginal Vault Prolapse After Hysterectomy (Patient 1) (Fig. 18.1)
18.2 Evident Association with  Cystocele (Patient 2) (Fig. 18.2)
18.3 Same Patient (Patient 2) (Fig. 18.3)
18.4 Laparoscopic View, the Same Patient (Patient 2) (Fig. 18.4)
18.5 Exteriorized Vaginal Vault Prolapse (Patient 3) (Fig. 18.5)
18.6 Laparoscopic Aspect of Vaginal Vault Prolapse (Patient 3) (Fig. 18.6)
19: External Aspects of Enterocele
19.1 Definition
19.2 Clinical Diagnosis Often Evident (Fig. 19.1)
19.3 Laparoscopic Aspect of Enterocele (Fig. 19.2)
19.4 Laparoscopic Exposition for Dissection (Same Patient) (Fig. 19.3)
Part V: Laparoscopic Anatomy of the Pelvic Floor in Women with a Genital Prolapse Seen After Peritoneal Incision
20: Laparoscopic Aspects of Urethro-Cystocele
20.1 Stress Urinary Incontinence: Colposuspension or Burch Procedure (Fig. 20.1)
20.2 Laparoscopic Aspect of Lateral Cystocele Secondary to Paravaginal Defects (Fig. 20.2)
20.3 Paravaginal Repair: Passing Sutures Through the Vagina (Fig. 20.3)
20.4 Post-hysterectomy Paravaginal Repair (Fig. 20.4)
20.5 Paravaginal Repair (Right Side) (Fig. 20.5)
21: Laparoscopic Aspects of Prolapses of Anterior, Median and Posterior Compartments
21.1 Lateral Detachment (Fig. 21.1)
21.2 Hernia (Fig. 21.2)
21.3 Another Aspect of Injuries of Levator Ani Muscle (Fig. 21.3)
21.4 Laparoscopic Aspect of Severe Paravaginal Defects (Fig. 21.4)
21.5 Rectocele and Corresponding Treatment (Fig. 21.5)
Part VI: Laparoscopic Lateral Suspension with Meshes to Treat Genital Prolapse (LLS)
22: Techniques of Laparoscopic Lateral Suspension with Uterus Preservation
22.1 Dissection of the Vesicovaginal Space
22.1.1 Vesicovaginal Cleavage (Figs. 22.1, 22.2 and 22.3)
22.1.2 Final Dissection of the Vesicovaginal Space (Figs. 22.4 and 22.5)
22.1.3 Lateral Cleavage (Fig. 22.6)
22.2 The Choice of the Mesh
22.2.1 How to Choose a Mesh with Ideal Qualities?
22.2.2 The Shape of the Mesh (Fig. 22.7)
22.2.3 Mesh Preparation (Fig. 22.8)
22.3 Pelvic Positioning of the Mesh
22.3.1 Placement of the Median Strip of the Mesh (Fig. 22.9)
22.4 Pelvic Positioning of the Mesh (Continued)
22.4.1 Fixation of the Mesh to the Endopelvic Fascia and the Uterine Isthmus (Figs. 22.10, 22.11, 22.12, 22.13, 22.14 and 22.15)
22.5 Suspension by the Two Arms of the Mesh: Stretched Laterally
22.5.1 The Lateral Suspension (Figs. 22.16 and 22.17)
22.5.2 The Way of the Forceps (Figs. 22.18 and 22.19)
22.5.3 The Change of Direction (Fig. 22.20)
22.5.4 The Grasping of the Mesh on Both Sides (Figs. 22.21, 22.22, 22.23 and 22.24)
23: Final Evaluation of the Correct Technique of Laparoscopic Lateral Suspension
23.1 The Final Evaluation
23.1.1 A Precise and Symmetrical Application (Fig. 23.1)
23.1.2 Positioning
23.1.3 End of Procedure (Fig. 23.2)
23.2 The Correct Technique of LLS
23.2.1 This Figure Precisely Shows the Direction of the Mesh (Fig. 23.3)
23.2.2 This Figure Shows the Final Good Technique (Fig. 23.4)
24: Optional Treatment of the Posterior Compartment and Techniques of Laparoscopic Lateral Suspension for Vaginal Vault Prolapse
24.1 Treatment of the Posterior Compartment
24.1.1 Evaluation of the Posterior Compartment
24.1.2 Treatments of the Posterior Compartment
24.2 The Technique of LLS for Vaginal Vault Prolapse
24.2.1 Cross-Shaped Mesh (Fig. 24.3) and Vaginal Vault Prolapse Suspension (Figs. 24.4 and 24.5)
25: Lateral Suspension: Focus on
25.1 LLS with Mesh, a Recent Technique
25.2 Literature Review and Discussion
References
Part VII: Laparoscopic Sacrocolpopexy to Treat Genital Prolapse (SCP)
26: Techniques of Laparoscopic Sacrocolpopexy (SCP) to Treat Genital Prolapse, With or Without Preservation of the Uterus
26.1 Exposition of the Promontory, Anterior Cul-de-sac and Cul-de-sac of Douglas (Fig. 26.2)
26.2 Dissection of the Presacral Space (Fig. 26.3)
26.3 Dissection of the Vesicovaginal Space
26.4 SCP: Posterior Compartment Correction (Figs. 26.4, 26.5 and 26.6)
26.5 SCP: Fixations of the Mesh (Figs. 26.7, 26.8 and 26.9)
26.6 Peritonization of the Mesh (Fig. 26.10)
27: Sacrocolpopexy: Focus on
References
Anatomical References

Citation preview

Jean-Bernard Dubuisson Jean Dubuisson Juan Puigventos

Laparoscopic Anatomy of the Pelvic Floor

123

Laparoscopic Anatomy of the Pelvic Floor

Jean-­ Bernard Dubuisson • Jean Dubuisson Juan Puigventos

Laparoscopic Anatomy of the Pelvic Floor

Jean-Bernard Dubuisson Department of Obstetrics and Gynecology University Hospitals of Geneva Institut Médico-Chirurgical de Champel Geneva Switzerland

Jean Dubuisson Gynecological Surgery Unit University Hospitals of Geneva Geneva Switzerland

Juan Puigventos Bern Switzerland

ISBN 978-3-030-35497-8    ISBN 978-3-030-35498-5 (eBook) https://doi.org/10.1007/978-3-030-35498-5 © Springer Nature Switzerland AG 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Preface

Why This Atlas? The Atlas is the outcome of 25 years of laparoscopic photos and reflexions on the anatomy and the reconstructive surgery of the pelvic floor in women. During these years, thanks to the clear vision obtained by laparoscopy, we were interested in the diversity of pelvic floor defects and, as a consequence, in the new possibilities of treating genital prolapses.

The Diagnosis of Pelvic Floor Defects Is Clinical It is obvious that the diagnosis of the pathologies of the pelvic floor is essentially clinical and stays the same that the one that would have realized the famous Samuel Pozzi more than one century ago. However, the urodynamics, the ultrasonography and the MRI, prescribed in certain cases, allow to precise at best the tissue damages and to make the most adapted treatment.

Always a Place for Vaginal Access to Do Reconstructive Pelvic Surgery The pathologies of the pelvic floor and in particular the genital prolapses benefited for a long time from the vaginal reconstructive surgery. This one remains effective, well tolerated and of rather easy teaching, thanks to the companionship. During these last years, in vaginal surgery, we saw technical improvements probably related to a better knowledge of the anatomy and also to the progress of the anaesthesia.

Now, a Great Place for Laparoscopy Using Meshes For many decades, surgeons took more care of the patients affected by these pathologies and tried to improve the longevity of the pelvic reconstruction and their quality of life. Since the 1990s, the greatest progress to treat pelvic organ prolapse has been the possibility of treating with the laparoscopic access. The main technical improvement was the association with laparoscopy and implementation of meshes. Today the laparoscopic surgery with meshes offers excellent results and remarkable coverage of the patients, for their quality of life.

Which Laparoscopic Technique? The sacrocolpopexy by laparoscopy is now considered the gold standard to treat pelvic organ prolapse. In this technique, the difficulty may be the access of the promontory. This is evident for the young surgeons with a limited experience in pelvic floor reconstructive surgery. Among

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Preface

the resident gynaecologists and the collaborators who worked with us, some were shy and anxious to have to do the dissection of the promontory during the realization of a laparoscopic sacrocolpopexy. The main reason was the risk of injury of vessels, bowel and ureter. In our team, we have a preference for our technique of laparoscopic lateral suspension using meshes. Almost all preferred to do a lateral suspension because of less operative time and risks. We are convinced that it is a good technique for treating mainly the cystocele and the procidentia of the uterus (colposuspension or isthmo-colposuspension). It has many advantages: safety, simplicity, efficiency and profits for the quality of life of the patients. All these points are developed in the sixth part.

This Atlas? A Hymn to Laparoscopy and Laparoscopists These few lines of introduction explain why we had the idea of publishing this Atlas focused on laparoscopy of the pelvic floor. This book explains the main anatomical structures of the pelvic floor to be known, and shows the different pathologies, with the vision of a laparoscopist. The Atlas also gives the precise and exhaustive description of the technique of sacrocolpopexy and of lateral suspension. For this last technique, the main studies were realized with the great collaboration of Nikolaus Veit-Rubin. Geneva, Switzerland Geneva, Switzerland  Bern, Switzerland 

Jean-Bernard Dubuisson Jean Dubuisson Juan Puigventos

Acknowledgements

With my true affection to my family, my wife Catherine, Pierre, Paul, Jean, our sons, who have supported and encouraged me in my endeavours for many years. And a special thought to Jean who followed me in the long difficult course of gynaecologic surgery. J.B. Dubuisson A special word of friendship and deep gratitude to Dr. Nicklaus Veit-Rubin who helped us so much for 10 years for many studies concerning the laparoscopic lateral suspension to treat genital prolapse. With the most faithful feelings for those who supported us and believed in the technique of laparoscopic lateral suspension of Dubuisson: Pr. Aubert Agostini, Dr. Silvia Berning, Pr. Sassi Boughizane, Dr. Jean Bouquet de Jolinière, Dr. Tina Cadenbach-Blome, Dr. Ladina Christoffel, Dr. Christian Deetjen, Dr. Francesca Delprà, Pr. Anis Feki, Dr. Verena Geissbühler, Dr. Massimo Gianoni, Dr. Martine Henri, Dr. Jörg Humburg, Dr. Stevan Jovanovic, Dr. Sandrine Jacob, Dr. Isabelle Kaelin-Gambirasio, Dr. Armando Librino, Dr. Liliana Mereu, Dr. Giacomo Serboli, Dr. Stefan Mohr, Dr. Nabil Moulay, Dr. Mohamed Osman, Dr. Friedrich Pauli, Pr. Tomaso Simoncini, Pr. Saverio Tateo, Dr. Claire Tourette, Pr. Arnaud Wattiez and Pr. Maciej Wilczak. J.B. Dubuisson, J. Dubuisson, J. Puigventos

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Contents

Part I Traditional Anatomy of the Pelvic Floor 1 Introduction�����������������������������������������������������������������������������������������������������������������   3 1.1 Muscles, Fascias and Ligaments�������������������������������������������������������������������������   4 2 The Muscles�����������������������������������������������������������������������������������������������������������������   7 2.1 Two Categories of Pelvic Muscles Are Individualized ���������������������������������������   8 2.2 Lateral Muscles���������������������������������������������������������������������������������������������������   8 2.3 Pelvic Floor Muscles�������������������������������������������������������������������������������������������   8 2.3.1 Obturator Internus Muscle�����������������������������������������������������������������������   8 2.3.2 Levator Ani (L.A.)�����������������������������������������������������������������������������������   8 2.3.3 L.A. Iliococcygeus�����������������������������������������������������������������������������������  10 2.3.4 Coccygeus Muscle�����������������������������������������������������������������������������������  10 2.3.5 Piriformis�������������������������������������������������������������������������������������������������  10 2.4 The Superior View of the Pelvic Floor Muscles �������������������������������������������������  10 2.5 The Lateral View of the Pelvic Floor Muscles ���������������������������������������������������  10 3 The Fascias������������������������������������������������������������������������������������������������������������������  13 3.1 Endopelvic Fascia �����������������������������������������������������������������������������������������������  14 3.2 Visceral Fascia�����������������������������������������������������������������������������������������������������  16 4 The Ligaments�������������������������������������������������������������������������������������������������������������  19 4.1 The Pelvic Ligaments Seen by Laparoscopy�������������������������������������������������������  20 4.1.1 Round Ligament �������������������������������������������������������������������������������������  20 4.1.2 Uterosacral Ligament�������������������������������������������������������������������������������  20 4.1.3 The Anatomical Landmarks of the Two Uterosacral Ligaments�������������  22 4.2 Visceral Ligaments�����������������������������������������������������������������������������������������������  22 4.2.1 The Visceral Ligaments for Pelvis Support �������������������������������������������  22 4.2.2 Ventro-Dorsal Axis (Also Called ‘Lame sacro-recto-génitopubienne’ Described by Farabeuf)�����������������������������������������������������������  22 4.2.3 Medio-Lateral Axis ���������������������������������������������������������������������������������  22 5 The Attachment Sites for the Surgeon ���������������������������������������������������������������������  25 5.1 The Landmarks of the Pelvic Floor for the Surgeon�������������������������������������������  26 5.2 The Four Risks of the Attachment Site Risks �����������������������������������������������������  28 5.3 The Risks of the Promontory for the Surgeon�����������������������������������������������������  30 5.4 The Presacral Anatomy Below the Promontory���������������������������������������������������  30

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Part II Laparoscopic Normal Anatomy of the Pelvic Floor Seen By Transperitoneal Vision 6 Ventrolateral Abdominal Wall�����������������������������������������������������������������������������������  35 6.1 Umbilical Artery �������������������������������������������������������������������������������������������������  36 6.2 Inferior Epigastric Artery�������������������������������������������������������������������������������������  36 6.3 Paravesical Fossa�������������������������������������������������������������������������������������������������  36 7 Lateral Anatomy���������������������������������������������������������������������������������������������������������  39 7.1 The Ureter �����������������������������������������������������������������������������������������������������������  40 7.2 Laparoscopic Identification���������������������������������������������������������������������������������  40 8 Landmarks of the Ureter�������������������������������������������������������������������������������������������  43 8.1 Ureter in the Promontory Area�����������������������������������������������������������������������������  44 8.2 Lateral Anatomy Below the Adnexa �������������������������������������������������������������������  46 8.3 The Ureter Below the Adnexa�����������������������������������������������������������������������������  46 9 Dorsal and Lateral Anatomy of the Pelvis ���������������������������������������������������������������  49 9.1 Two Hypogastric Nerves, Right and Left �����������������������������������������������������������  50 9.2 The Inferior Hypogastric Plexus �������������������������������������������������������������������������  52 10 Promontory Area���������������������������������������������������������������������������������������������������������  55 10.1 The Cranial Area �����������������������������������������������������������������������������������������������  56 10.2 Middle Sacral Artery�����������������������������������������������������������������������������������������  56 10.3 Sigmoid Colon���������������������������������������������������������������������������������������������������  58 10.4 Left Common Iliac Vein �����������������������������������������������������������������������������������  58 10.5 The Vision in Female Cadaver���������������������������������������������������������������������������  60 Part III Laparoscopic Normal Retroperitoneal Anatomy of the Pelvic Floor Seen After Peritoneal Incision 11 Prevesical Space, Cooper’s Ligament, Paravesical Space, Arcus Tendineus Fascia Pelvis ���������������������������������������������������������������������������������������������  65 11.1 The Prevesical Space�����������������������������������������������������������������������������������������  66 11.1.1 Access to the Prevesical Space, After Filling the Bladder���������������������  66 11.1.2 Dissection of the Retzius Space in Avascular Loose Tissue �����������������  66 11.1.3 The ‘Champagne’ Bubbles �������������������������������������������������������������������  68 11.1.4 Progressive Dissection of the Prevesical Space �����������������������������������  68 11.1.5 Focus on Cooper’s Ligament, Technique of Exposition, Left Side�������������������������������������������������������������������������������������������������  70 11.1.6 Focus on Cooper’s Ligament, Technique of Suture, Left Side �������������  70 11.2 The Prevesical Space (Continued)���������������������������������������������������������������������  72 11.2.1 Bladder �������������������������������������������������������������������������������������������������  72 11.2.2 Complete Dissection of the Prevesical Space ���������������������������������������  72 11.2.3 Panoramic View of Dissection Between the Umbilico-Vesical Fascia and Bladder���������������������������������������������������������������������������������  74 11.3 The Paravesical Space���������������������������������������������������������������������������������������  74 11.3.1 Focus on ATFP, Between Pubis and Ischial Spine (Right Side) �������������  74 11.3.2 Focus on Obturator Pedicle, Between Pubis and Ischial Spine, at the Entry in the Obturator Canal, Left Side ���������������������������  76 11.3.3 Focus on Obturator Pedicle (Right Side, and Left Side)�����������������������  78 11.3.4 Focus on Corona Mortis Artery�������������������������������������������������������������  80 11.3.5 Relationship Between the Obturator Nerve and the Corona Mortis Artery�����������������������������������������������������������������������������������������  80 11.4 The Panoramic View of the Pre- and Paravesical Space�����������������������������������  82 11.4.1 Prevesical Space�������������������������������������������������������������������������������������  82

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12 The Vesicovaginal Space���������������������������������������������������������������������������������������������  85 12.1 Limits�����������������������������������������������������������������������������������������������������������������  86 12.2 Access to the Vesicovaginal Space���������������������������������������������������������������������  86 12.3 The Loose Connective Tissue ���������������������������������������������������������������������������  88 12.4 Section of the Bladder Pillars ���������������������������������������������������������������������������  88 12.5 The Cleavage Line���������������������������������������������������������������������������������������������  90 12.6 The Panoramic Vision ���������������������������������������������������������������������������������������  90 12.7 Vesicovaginal Space (Continued) ���������������������������������������������������������������������  92 12.7.1 Bladder Pillars���������������������������������������������������������������������������������������  92 12.7.2 Lateral to the Vesicovaginal Space���������������������������������������������������������  94 12.8 Deep Vesico-Cervico-Vaginal Dissection ���������������������������������������������������������  96 12.8.1 Lateral to the Vesicovaginal Space���������������������������������������������������������  96 12.8.2 Visualization During Hysterectomy�������������������������������������������������������  96 12.8.3 Visualization with Magnification�����������������������������������������������������������  98 13 The Dorsolateral Dissection of the Uterine Artery ������������������������������������������������� 101 13.1 The Dorsal Approach to Preventive Occlusion ������������������������������������������������� 102 13.2 The Technique of Dorsal Approach of the Uterine Artery for Preventive Occlusion����������������������������������������������������������������������������������������� 102 13.3 Visualization of the Uterine Artery and of the Ureter��������������������������������������� 104 13.4 The Titanium Clip ��������������������������������������������������������������������������������������������� 104 14 The Rectovaginal Septum������������������������������������������������������������������������������������������� 107 14.1 The Limits��������������������������������������������������������������������������������������������������������� 108 14.2 Vaginal Venous Plexuses����������������������������������������������������������������������������������� 108 15 The Pararectal Space ������������������������������������������������������������������������������������������������� 111 15.1 Laparoscopic Access����������������������������������������������������������������������������������������� 112 15.2 The Middle Rectal Artery ��������������������������������������������������������������������������������� 112 15.3 Deep Dissection������������������������������������������������������������������������������������������������� 114 15.4 Lateral Rectal Dissection in Cadaver����������������������������������������������������������������� 114 15.5 Situation of the Medial Pararectal Space of Okabayashi����������������������������������� 114 15.6 Situation of Lateral Pararectal Space of Latzko������������������������������������������������� 114 15.7 Pelvic Lymphadenectomy: The Main Benchmarks������������������������������������������� 116 15.8 The Pudendal Nerve, Laparoscopic Approach��������������������������������������������������� 116 15.8.1 Definition����������������������������������������������������������������������������������������������� 116 15.9 Laparoscopic Dissection of the Right Pudendal Nerve������������������������������������� 116 15.9.1 The View of the Pudendal Nerve by Laparoscopy��������������������������������� 116 15.9.2 View of the Ischial Spine Area��������������������������������������������������������������� 116 15.9.3 Visualization of the Sacrospinous Ligament����������������������������������������� 118 15.9.4 Pudendal Nerve Release ����������������������������������������������������������������������� 118 15.9.5 The Pudendal Nerve Dissected Appears White������������������������������������� 120 15.10 Laparoscopic Dissection of the Left Pudendal Nerve (Continued)������������������� 120 15.10.1 Dissection of the Pudendal Nerve��������������������������������������������������������� 120 15.10.2 Progressive Vision of the Pudendal Nerve��������������������������������������������� 122 Part IV Laparoscopic Anatomy of the Pelvic Floor in Case of Genital Prolapse Seen By Clinical Examination and Transperitoneal Vision 16 Cystocele ��������������������������������������������������������������������������������������������������������������������� 127 16.1 Definition����������������������������������������������������������������������������������������������������������� 128 16.2 External Aspect of Exteriorized Lateral Cystocele, Associated with Procidentia (Uterine Descent)����������������������������������������������������������������������������������������������� 128 16.3 External Aspect of Large Cystocele������������������������������������������������������������������� 130 16.4 Complete Prolapse��������������������������������������������������������������������������������������������� 130

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16.5 Correlation in Laparoscopy of Pelvic Floor Defects����������������������������������������� 132 16.5.1 Laparoscopic Aspect of Lateral Cystocele��������������������������������������������� 132 16.5.2 Laparoscopic Aspect of Central and Lateral Cystocele������������������������� 132 16.5.3 Laparoscopic Aspect of Cystocele and Procidentia������������������������������� 134 16.5.4 Laparoscopic Aspect of Exteriorized Cystocele After Total Hysterectomy����������������������������������������������������������������������������������������� 134 17 External Aspects of Exteriorized Apical Prolapse and Rectocele��������������������������� 137 17.1 Trachelocele������������������������������������������������������������������������������������������������������� 138 17.2 Rectocele����������������������������������������������������������������������������������������������������������� 138 17.3 Clinical Evaluation of the Posterior Pelvic Floor Defects��������������������������������� 140 17.4 Usual Clinical Aspect of the Rectocele Associated with a Cystocele��������������� 140 17.5 Laparoscopic Aspect of Large Rectocele����������������������������������������������������������� 142 17.6 Usual Laparoscopic Aspect of Rectocele����������������������������������������������������������� 142 18 External Aspects of Vaginal Vault Prolapse������������������������������������������������������������� 145 18.1 Vaginal Vault Prolapse After Hysterectomy (Patient 1)������������������������������������� 146 18.2 Evident Association with Cystocele (Patient 2)����������������������������������������������� 146 18.3 Same Patient (Patient 2)������������������������������������������������������������������������������������� 148 18.4 Laparoscopic View, the Same Patient (Patient 2) ��������������������������������������������� 148 18.5 Exteriorized Vaginal Vault Prolapse (Patient 3) ����������������������������������������������� 150 18.6 Laparoscopic Aspect of Vaginal Vault Prolapse (Patient 3)������������������������������� 150 19 External Aspects of Enterocele ��������������������������������������������������������������������������������� 153 19.1 Definition����������������������������������������������������������������������������������������������������������� 154 19.2 Clinical Diagnosis Often Evident ��������������������������������������������������������������������� 154 19.3 Laparoscopic Aspect of Enterocele������������������������������������������������������������������� 154 19.4 Laparoscopic Exposition for Dissection (Same Patient)����������������������������������� 156 Part V Laparoscopic Anatomy of the Pelvic Floor in Women with a Genital Prolapse Seen After Peritoneal Incision 20 Laparoscopic Aspects of Urethro-Cystocele������������������������������������������������������������� 161 20.1 Stress Urinary Incontinence: Colposuspension or Burch Procedure����������������� 162 20.2 Laparoscopic Aspect of Lateral Cystocele Secondary to Paravaginal Defects��������������������������������������������������������������������������������������������������������������� 162 20.3 Paravaginal Repair: Passing Sutures Through the Vagina��������������������������������� 164 20.4 Post-hysterectomy Paravaginal Repair ������������������������������������������������������������� 164 20.5 Paravaginal Repair (Right Side) ����������������������������������������������������������������������� 166 21 Laparoscopic Aspects of Prolapses of Anterior, Median and Posterior Compartments������������������������������������������������������������������������������������������������������������� 169 21.1 Lateral Detachment������������������������������������������������������������������������������������������� 170 21.2 Hernia����������������������������������������������������������������������������������������������������������������� 170 21.3 Another Aspect of Injuries of Levator Ani Muscle������������������������������������������� 172 21.4 Laparoscopic Aspect of Severe Paravaginal Defects����������������������������������������� 172 21.5 Rectocele and Corresponding Treatment����������������������������������������������������������� 174 Part VI Laparoscopic Lateral Suspension with Meshes to Treat Genital Prolapse (LLS) 22 Techniques of Laparoscopic Lateral Suspension with Uterus Preservation����������������������������������������������������������������������������������������������������������������� 179 22.1 Dissection of the Vesicovaginal Space��������������������������������������������������������������� 180 22.1.1 Vesicovaginal Cleavage������������������������������������������������������������������������� 180 22.1.2 Final Dissection of the Vesicovaginal Space����������������������������������������� 182 22.1.3 Lateral Cleavage ����������������������������������������������������������������������������������� 184

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22.2 The Choice of the Mesh������������������������������������������������������������������������������������� 184 22.2.1 How to Choose a Mesh with Ideal Qualities?��������������������������������������� 184 22.2.2 The Shape of the Mesh ������������������������������������������������������������������������� 184 22.2.3 Mesh Preparation����������������������������������������������������������������������������������� 186 22.3 Pelvic Positioning of the Mesh ������������������������������������������������������������������������� 186 22.3.1 Placement of the Median Strip of the Mesh������������������������������������������ 186 22.4 Pelvic Positioning of the Mesh (Continued)����������������������������������������������������� 188 22.4.1 Fixation of the Mesh to the Endopelvic Fascia and the Uterine Isthmus������������������������������������������������������������������������������������� 188 22.5 Suspension by the Two Arms of the Mesh: Stretched Laterally ����������������������� 190 22.5.1 The Lateral Suspension������������������������������������������������������������������������� 190 22.5.2 The Way of the Forceps������������������������������������������������������������������������� 192 22.5.3 The Change of Direction����������������������������������������������������������������������� 194 22.5.4 The Grasping of the Mesh on Both Sides ��������������������������������������������� 194 23 Final Evaluation of the Correct Technique of Laparoscopic Lateral Suspension������������������������������������������������������������������������������������������������������������������� 197 23.1 The Final Evaluation����������������������������������������������������������������������������������������� 198 23.1.1 A Precise and Symmetrical Application ����������������������������������������������� 198 23.1.2 Positioning��������������������������������������������������������������������������������������������� 198 23.1.3 End of Procedure����������������������������������������������������������������������������������� 198 23.2 The Correct Technique of LLS ������������������������������������������������������������������������� 200 23.2.1 This Figure Precisely Shows the Direction of the Mesh����������������������� 200 23.2.2 This Figure Shows the Final Good Technique��������������������������������������� 200 24 Optional Treatment of the Posterior Compartment and Techniques of Laparoscopic Lateral Suspension for Vaginal Vault Prolapse��������������������������� 203 24.1 Treatment of the Posterior Compartment����������������������������������������������������������� 204 24.1.1 Evaluation of the Posterior Compartment��������������������������������������������� 204 24.1.2 Treatments of the Posterior Compartment��������������������������������������������� 204 24.2 The Technique of LLS for Vaginal Vault Prolapse��������������������������������������������� 206 24.2.1 Cross-Shaped Mesh and Vaginal Vault Prolapse Suspension ��������������� 206 25 Lateral Suspension: Focus on ����������������������������������������������������������������������������������� 209 25.1 LLS with Mesh, a Recent Technique����������������������������������������������������������������� 210 25.2 Literature Review and Discussion��������������������������������������������������������������������� 210 References��������������������������������������������������������������������������������������������������������������������� 211 Part VII Laparoscopic Sacrocolpopexy to Treat Genital Prolapse (SCP) 26 Techniques of Laparoscopic Sacrocolpopexy (SCP) to Treat Genital Prolapse, With or Without Preservation of the Uterus������������������������������������������� 215 26.1 Exposition of the Promontory, Anterior Cul-de-sac and Cul-de-sac of Douglas ������������������������������������������������������������������������������������������������������������� 216 26.2 Dissection of the Presacral Space ��������������������������������������������������������������������� 218 26.3 Dissection of the Vesicovaginal Space��������������������������������������������������������������� 218 26.4 SCP: Posterior Compartment Correction����������������������������������������������������������� 220 26.5 SCP: Fixations of the Mesh������������������������������������������������������������������������������� 222 26.6 Peritonization of the Mesh��������������������������������������������������������������������������������� 224 27 Sacrocolpopexy: Focus on ����������������������������������������������������������������������������������������� 227 References��������������������������������������������������������������������������������������������������������������������� 228 Anatomical References������������������������������������������������������������������������������������������������������� 229

Part I Traditional Anatomy of the Pelvic Floor

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Introduction

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1 Introduction

 uscles, Fascias and Ligaments M (Fig. 1.1)

It is classic to distinguish the muscles, the fascias and the ligaments and nowadays to describe the attachment sites for the surgeon. The different levels of the pelvic floor are well defined. Three levels are described as follows: –– The lower level is described with the pelvic and perineal muscles. It includes the urogenital diaphragm or triangular ligament, and muscular membrane, external and inferior to the pelvic diaphragm. The pelvic diaphragm is a large layer of tissue containing muscles and fascias. The pelvic diaphragm limits the inferior border of the abdominopelvic cavity, extending from

the pubis to the coccyx. The muscles are levator ani, coccygeus, piriformis and obturator internus, and the fascias are arcus tendineus fascia pelvis and arcus tendineus levator ani. –– The higher level concerns the ligaments, especially the uterosacral ligaments, the cardinal ligaments and the round ligaments. –– Between them, the middle level includes the numerous fascias covering the pelvic organs. The endopelvic fascia is between the parietal and visceral fascia. It contains smooth muscles, connective tissue, ligaments and vessels. The fascias are vesicovaginal septum and rectovaginal septum. All the three levels are important for the pelvic support. The defects of one level may have deleterious consequences for the two other levels of pelvic support.

1.1  Muscles, Fascias and Ligaments Fig. 1.1  Muscles, fascias and ligaments. (1) Perineal body muscles. (2) Round ligament. (3) Uterosacral ligament. (4) Fascias (modified from H. Rouvière, anatomie humaine, ninth edition, Masson, 1962, p. 1034, Fig. 628, with permission of Elsevier Masson)

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The Muscles

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2  The Muscles

 wo Categories of Pelvic Muscles T Are Individualized (Fig. 2.1)

They do not have the same functions. The two categories are lateral and pelvic floor muscles.

2.2

Lateral Muscles

Some knowledge about these pelvic floor muscles should be known for evaluation of the pathologies, and also for managing the medical or surgical treatments.

2.3.1 Obturator Internus Muscle

The obturator internus is well defined.

It starts from the medial surface of the obturator membrane, the ischium and pubis. So, it exits the pelvic cavity through the lesser sciatic foramen.

2.3

2.3.2 Levator Ani (L.A.)

Pelvic Floor Muscles

The pelvic floor or pelvic diaphragm has an upper muscular layer forming the inferior border of the abdominopelvic cavity. It includes: –– Levator ani; Pubococcygeus or pubovisceral (puboperinealis, pubovaginalis,puboanalis), puborectalis –– Levator ani: Iliococcygeus –– Arcus tendineus fascia pelvis (ATFP) –– Arcus tendineus levator ani (ATLA) –– Coccygeus muscle –– Piriformis

–– Pubococcygeus: Its origin is the pubis (pubovesical ligament) and the fascia of obturator internus muscle. It inserts to anococcygeal body between coccyx and anal canal. –– Puborectalis muscle: Its origin is pubis to the laterorectal, retrorectal, coccygean beams. The union with the contralateral one makes a U-shaped sling around the rectum. –– Pubovaginalis muscle: Its origin is pubis, and goes to the central point of perineum.

2.3  Pelvic Floor Muscles Fig. 2.1  The pelvic muscles. (1) Obturator internus. (2) Cooper’s ligament. (3) ATFP. (4) Iliococcygean. (5) Puborectalis. (6) Pubococcygeus. (7) Piriformis. (8) Coccygean. (9) Obturator canal (modified from P. Kamina, anatomie opératoire, 2000, Maloine, p. 26, Fig. 2.9, permission of Vigot-Maloine)

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2.3.3 L.A. Iliococcygeus Its origin is from the pubis, arcus tendineus fascia pelvis (ATFP) and ischial spine. It reaches the coccyx and the anococcygean ligament.

2.3.4 Coccygeus Muscle From ischial spine to the lateral part of the coccyx and S3–S5.

2.3.5 Piriformis From the anterolateral face of the sacrum between anterior foramen 2 and 3 and great sacrosciatic ligament, the pirifor-

2  The Muscles

mis runs to the gluteal region until greater trochanter. The sciatic nerve is just below it.

2.4

 he Superior View of the Pelvic Floor T Muscles (Fig. 2.2a)

The same vision is obtained by laparoscopy, and the different muscles that we have described are precisely individualized.

2.5

 he Lateral View of the Pelvic Floor T Muscles (Fig. 2.2b)

2.5  The Lateral View of the Pelvic Floor Muscles Fig. 2.2  The classical description of the pelvic floor muscles. (a) Superior view. (b) Lateral view. (1) Obturator internus. (2) Cooper’s ligament. (3) ATFP. (4) Iliococcygeus. (5) Puborectalis. (6) Pubucoccygeus. (7) Piriformis. (8) Coccygeus. (9) Obturator canal (modified from P. Kamina, anatomie clinique, 2008, p. 93, Fig. 8.1)

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The Fascias

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It is classical to individualize lateral fascias and visceral fascias. The pelvic connective tissue has a huge importance for the pelvic support. Two types of functional structures are described as follows:

2. Arcus tendineus fascia pelvis (ATFP or white line) is a condensation of the parietal pelvic fascia covering the inner surface of the obturator internus muscle, 3 cm below the obturator canal. It extends from the dorsal surface of the pubis to the ischial spine.

–– Endopelvic fascia: Lateral/parietal fascias cover the internal surfaces of the muscles of the pelvic floor and the lateral walls of the pelvis. Median/visceral fascias cover each pelvic organ. Parietal and visceral fascias are continuous where the organs penetrate the pelvic floor. –– Surfaces of apposition between the pelvic organs: They are more or less thick and sometimes difficult to visualize.

The cardinal ligaments (transverse cervical) are formed of condensed fibrous tissue and extended from the isthmus towards the pelvic wall (obturator fascia) and uterosacral ligaments. It includes cranial vessels (uterine vessels) and below inferior hypogastric plexus.

3.1

Endopelvic Fascia (Figs. 3.1 and 3.2)

Parietal lateral fascia—Two main enlargements/thickenings are observed: 1. Tendinous arch is settled in before the obturator canal and along the obturator muscle (ATLA).

3.1  Endopelvic Fascia

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Fig. 3.1  Parietal lateral fascia: The two thickenings. (1) ATLA. (2) ATFP

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Fig. 3.2  Parietal lateral fascia: The two thickenings. (1) ATLA. (2) ATFP

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3  The Fascias

Visceral Fascia (Fig. 3.3)

It covers the non-peritonealized surfaces. The vesical, uterine and rectal layers of endopelvic fascia are continuous with the superior fascia of the pelvic diaphragm and the obturator

fascia. Sometimes, it is well seen during the dissection. But in some cases, it is impossible to observe the fascia, because it is too thin. Urethra, bladder, vagina and rectum are covered by endopelvic fascia.

3.2  Visceral Fascia Fig. 3.3  Visceral fascia. (1) ATLA. (2) ATFP. (3) Urethra. (4) Bladder. (5) Rectum. (6) Sacral plexus. (7) Iliac vessels. (8) Vagina (modified from P. Kamina, anatomie opératoire, 2000, Maloine, p. 26, Fig. 2.9, permission of Vigot-Maloine)

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The Ligaments

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4  The Ligaments

The relief of two ligaments is seen in laparoscopy: the round ligament and the uterosacral ligament. The visceral ligaments are only identifiable after incision of the peritoneum and dissection.

4.1

 he Pelvic Ligaments T Seen by Laparoscopy

4.1.1 Round Ligament (Fig. 4.1) The ligament starts at the uterine horns. It is covered by folded peritoneum and represents the cranial margin of the broad ligament. It exits the pelvis via the deep inguinal ring. The role of the round ligament as solid pelvic support is very controversial: often, the ligament is very thin, and its importance in the pelvic support is low or moderate. Its role in pelvic surgery is well known. When the uterus is normal, the two ligaments are symmetrical. The absence of symmetry of the two ligaments is seen in pathologic

cases. It may be observed in case of uterine leiomyoma, adenomyoma or congenital anomaly. Concerning the technique of hysterectomy, its section at 2–3 cm from the uterine horn, at the beginning of hysterectomy, offers the possibility of entering the paravesical space or of starting the bladder dissection.

4.1.2 Uterosacral Ligament (Fig. 4.2) The two uterosacral ligaments are a fascial band passing from the upper portion of the vagina and the cervix of the uterus to the sacrum (S3), containing pelvic splanchnic nerves. Usually, the ligament seems to be more involved in pelvic organ support than the round ligaments. They are usually symmetrical. Their asymmetry is a frequent anomaly that may be congenital or observed after traumatic delivery. Their thickness associated or not with nodule may be seen in endometriosis pathology.

4.1  The Pelvic Ligaments Seen by Laparoscopy

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Fig. 4.1  Round ligament. (1) Round ligament. (2) Umbilical artery. (3) Inferior epigastric artery (the epigastric artery crosses the round ligament, from below)

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Fig. 4.2 Uterosacral ligaments. (1) Uterosacral ligament (right). (2) Ureter. (3) Umbilical artery

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4.1.3 T  he Anatomical Landmarks of the Two Uterosacral Ligaments (Fig. 4.3) This figure shows the landmarks that should be individualized in cases of uterosacral ligament surgery, resection or reconstruction. The resections include the ablation of the recto-vaginal deep nodes of endometriosis. The reapproximation or the plication of the uterosacral ligaments may be used to straighten the uterus or as a complement for reconstruction of the pelvic support in cases of genital prolapse (high uterosacral ligament suspension). The ureter is always spotted because of its closeness of the uterosacral ligaments. It is essential to see the ureter during surgery involving these ligaments.

4.2

Visceral Ligaments

4.2.1 The Visceral Ligaments for Pelvis Support (Fig. 4.4) The anatomists individualize two axes, ventro-dorsal and medio-lateral (transverse), that realize a ‘cross’. These two different axes have an essential function for pelvic support. This is well demonstrated in this drawing.

4.2.2 V  entro-Dorsal Axis (Also Called ‘Lame sacro-recto-génito-pubienne’ Described by Farabeuf) It includes: –– The pubovesical ligaments: these ligaments attach the bladder to the symphysis.

–– The vesico-uterine ligaments: these ligaments are also called bladder pillars. –– The uterosacral ligaments that have already been described.

4.2.3 Medio-Lateral Axis The medio-lateral axis includes several ligaments that are more difficult to individualize. But their importance in the pelvic support is fundamental. –– Lateral ligaments of the bladder: They are also called paracystium or ‘ailerons vésicaux’. –– Vesico-uterine ligaments are well known. They are called bladder pillars for the majority of surgeons. –– Paracervix, also called cardinal ligament or transverse ligament of Mackenrodt: It represents the dorsolateral attachment of the cervix. The paracervix forms a condensed fibrous tissue and extends from the upper vagina and the isthmus towards the pelvic wall (obturator fascia) and the uterosacral ligaments. The paracervix contains cranial vessels (uterine vessels). The inferior hypogastric plexus is located below the vessels. The injury of the plexus at that level may have detrimental effects on the urinary function. –– Parametrium: A recent terminology divided the parametrium into three parts on both sides of the cervix: the ventral parametrium (including vesico-uterine ligament), the lateral parametrium (paracervix) and the dorsal parametrium (including sacro-uterine ligament). –– Lateral ligaments of the rectum: They are also called rectal pillars or ‘ailerons’.

4.2  Visceral Ligaments

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Fig. 4.3  The anatomical landmarks of the uterosacral ligaments. (1) Douglas cul-de-sac. (2) Uterosacral ligament (right). (3) Ureter

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Fig. 4.4  The visceral ligaments for pelvis support. (1) Pubovesical ligaments. (2) Ureter and uterine artery and veins. (3) Rectum. (4) Vesico-uterine ligament. (5) Cardinal ligament. (6) Uterosacral ligament (modified from P. Kamina, anatomie clinique, second edition, Tome 4, Maloine, 2008, p. 154, Fig. 11.6)

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The Attachment Sites for the Surgeon

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5  The Attachment Sites for the Surgeon

In pelvic floor reconstruction for genital prolapse and stress urinary incontinence, the surgeon needs to know precisely the anatomy of the stronger structures that are fixed. These fixed and solid structures can be used as a possible docking point for the descended organs. We describe three areas of attachment that are classic and that have made it possible to develop evaluated surgical techniques. The fourth zone of attachment is the tendinous arch (ATFP) that is more or less individualizable and whose solidity is inconstant and with frequent alteration with age.

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 he Landmarks of the Pelvic Floor T for the Surgeon (Figs. 5.1 and 5.2)

The four attachment sites that may be used for fascia and pelvic organ attachment in prolapse surgery and stress urinary incontinence are: 1. Cooper’s ligament or pectineal ligament: It is an extension of the lacunar ligament, situated on the pectineal line of the pubis. This ligament is the dorsal border of the femoral ring. 2. Ischial spine and sacrospinous ligament attachment: The ischial spine is a thin and pointed triangular eminence

extended from the dorsal border of ischium. The spine gives attachment to several muscles, coccygeus, levator ani and pelvic fascia. The sacrospinous ligament is fixed at its extremity. This ligament is triangular. The base is fixed to the outer edge of the sacrum and coccyx. The tip of the triangle is attached to the spine. It is the strongest ligament of this area, well palpable in vaginal surgery, and well visible by laparoscopy, after a short lateral dissection, in the pararectal space. 3. Sacral promontory: It is the base of the sacrum (S1) that articulates with lumbar vertebra L5. The bone is covered by the anterior longitudinal ligament that can ensure a strong attachment of the pelvic organs, especially for sacrocolpopexy using meshes. 4. Arcus tendineus fascia pelvis (ATFP): This fascial band extends from the pubic symphysis to the ischial spine, with attachment of the endopelvic fascia. It joins with the pubocervical fascia covering the anterior wall of the vagina. In case of loosening of the pubocervical fascia or in case of tears of the arcus (after traumatic childbirth), the bladder and the urethra can fall with the occurrence of lateral cystocele (ipsilateral) or urinary incontinence.

5.1  The Landmarks of the Pelvic Floor for the Surgeon

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Fig. 5.1  The landmarks of the pelvic floor for the surgeon. (1) Cooper’s ligament. (2) Ischial spine and sacrospinous ligament. (3) Sacral promontory and anterior longitudinal ligament. (4) Arcus tendineus fascia pelvis

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5.2

5  The Attachment Sites for the Surgeon

 he Four Risks of the Attachment T Site Risks

There are some vascular and nervous risks in the areas close to the attachment sites (Fig. 5.3). 1. Corona mortis artery and obturator pedicle: The corona mortis artery and the obturator pedicle (especially the obturator nerve) are two risks that can be observed during laparoscopic Burch colposuspension and paravaginal repair. During the Burch procedure, the risk is limited, because the colposuspension is done with

passages of the sutures in the ventral part of the Cooper’s ligament, white coloured and bloodless, far from the vessels and the obturator nerve. 2. Vessels posterior to the ischial spine, and also pudendal and sciatic nerves: These structures may be damaged during vaginal procedure and especially during vaginal sacrospinofixation, according to the Richter procedure. 3. Vessels (left iliac common vein and middle sacral artery), left colon and hypogastric plexus close to the promontory.

5.2  The Four Risks of the Attachment Site Risks

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Fig. 5.3  The risks of the attachment sites. (1) Corona mortis artery. (2) Obturator pedicle. (3) Vessels, bowel, superior hypogastric plexus. (4) Nerves and vessels posterior to the ischial spine

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5.3

5  The Attachment Sites for the Surgeon

 he Risks of the Promontory T for the Surgeon (Fig. 5.4)

Among these four areas, the promontory is the most dangerous. The risks are vascular and nervous. 1. Middle sacral artery: It is situated behind the hypogastric plexus; the middle sacral artery arises from the posterior aspect of the aorta, superior to its bifurcation. It descends, medially, in front of the fourth and fifth lumbar vertebrae, the sacrum and coccyx, ending in the coccygeal gland. The injury of the middle sacral artery during the dissection of the promontory for sacrocolpopexy may cause a bleeding difficult to stop, because it is placed in contact to the promontory bone. 2. Hypogastric plexus or presacral nerve: Hypogastric plexus contains sympathetic fibres. It includes lumbar sympathetic ganglion, superior hypogastric plexus (presacral nerve) and inferior hypogastric nerve. The presacral nerve is situated anterior to the bifurcation of the abdominal aorta. This plexus that is under the peritoneum is hidden by the mesosigmoid.

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 he Presacral Anatomy Below T the Promontory (Fig. 5.5)

Retroperitoneally, in the presacral area, important structures are present. During prolapse surgery, there is no need to dissect this area during the treatment of genital prolapse.

The common iliac artery is divided into the external iliac artery and the internal iliac or hypogastric artery (anterior trunk). The external iliac artery is the largest. Distally, midway between the symphysis of the pubis and the anterior superior iliac spine, it enters the thigh as the femoral artery. The internal iliac artery or hypogastric artery arises in front of the lumbosacral articulation and then heads towards the greater sciatic notch. It crosses in particular the piriformis muscle and divides. The anterior division of the internal iliac artery gives rise to visceral branches: the superior vesical, the middle haemorrhoidal, the uterine and the vaginal arteries. And it also divides into parietal branches: the obturator, the inferior gluteal and the internal pudendal arteries. The posterior division of the internal iliac artery gives rise to the iliolumbar, the lateral sacral and the superior gluteal arteries. The obturator artery, with the obturator nerve, travels below the brim of the pelvis to reach the obturator canal. The uterine artery arises from the anterior division of the internal iliac artery, close to the vaginal artery and the middle haemorrhoidal artery. In its path, the most important area concerns the broad ligament and the cross over the ureter about 2 cm from the uterus. Pelvic plexuses receive branches from the sacral ganglia of the sympathetic trunk and parasympathetic fibres from S2, S3 and S4 spinal nerves.

5.4  The Presacral Anatomy Below the Promontory

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Fig. 5.4  The risks of the promontory for the surgeon. (1) Middle sacral artery. (2) Superior hypogastric plexus. (3) Presacral nerve. (4) Lumbar sympathetic ganglion (modified from P. Kamina, Anatomie clinique, second edition, Tome 4, Maloine, 2008, p. 141, Fig. 10.6 with permission of Vigot Maloine)

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Fig. 5.5  The presacral anatomy below the promontory. (1) Internal iliac artery. (2) Iliolumbar artery. (3) External iliac artery. (4) Umbilical artery. (5) Obturator artery. (6) Obturator nerve. (7) Inferior vesical artery. (8) Sacral plexus. (9) Inferior anal nerve. (10) Sacral nerve (S3). (11) Inferior gluteal artery. (12) Sacral nerve (S2). (13) Sympathetic trunk. (14) Superior gluteal artery. (15) Sacral nerve (S1). (16) Lateral sacral artery. (17) Lumbar sacral trunk (sacral plexus). (18) Middle sacral artery (modified from P. Kamina, Anatomie operatoire, Maloine, 2000, p. 66, Fig. 5.1, permission of Vigot Maloine and author)

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Part II Laparoscopic Normal Anatomy of the Pelvic Floor Seen By Transperitoneal Vision

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Ventrolateral Abdominal Wall

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6.1

6  Ventrolateral Abdominal Wall

Umbilical Artery (Fig. 6.1)

It is a branch of the anterior division of the internal iliac artery (hypogastric). It gives branches as superior vesical arteries.

Within the rectus sheath, the inferior epigastric artery passes superiorly and ramifies to anastomose with the superior epigastric artery.

6.3 6.2

Inferior Epigastric Artery

It is a long and large artery, 7 cm (range 6–8 cm) long and 3.5 mm (range 3–5 mm) large. It arises from the external iliac artery and anastomoses with the superior epigastric artery. It forms with its vein the lateral border of Hesselbach’s triangle. The inferior epigastric artery arises superior to the inguinal ligament and passes in the layer superior to the peritoneum but deep to the transversalis fascia. At the level of the arcuate line (4–6 cm above the pubic bone), it passes superiorly and superficially to perforate the dorsal leaflet of the rectus sheath. The artery enters the rectus muscle in its lateral third and divides into a medial and lateral branch. These branches provide perforators to the skin at various levels.

Paravesical Fossa

The paravesical fossa is situated between the umbilical artery and the inferior epigastric artery: Round ligament (still described) Bladder between umbilical arteries External iliac vessels (Fig. 6.2) The artery arises from the bifurcation of the common iliac artery. It travels caudally, ventrally and laterally, running to the lower limb. Its name changes to femoral artery when it passes dorsal to the inguinal ligament. It provides the main blood supply of the legs. It gives two main branches, the inferior epigastric artery and the deep circumflex iliac artery, that pass along the iliac crest of the pelvic bone.

6.3  Paravesical Fossa

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Fig. 6.1  Umbilical artery. (1) Umbilical artery. (2) Inferior epigastric artery. (3) Paravesical fossa. (4) Round ligament. (5) Bladder. (6) Uterus. (7) External iliac artery

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Fig. 6.2  External iliac vessels. (1) Umbilical artery. (2) Round ligament. (3) Bladder. (4) External iliac artery. (5) Pubic bone. (6) Psoas muscle. (7) Uterus

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Lateral Anatomy

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7.1

7  Lateral Anatomy

The Ureter (Fig. 7.1)

The pelvic segment of the ureter is divided into three parts: behind the broad ligament, under the broad ligament and anterior to the broad ligament at the juxtavesical junction. Concerning histology, the ureter is lined by the urothelium. The lamina propria with loose connective tissue contains elastic fibres interspersed with blood vessels, veins and lymphatics. External to lamina propria, the detrusor includes two muscular layers, an inner longitudinal layer of muscle and an outer circular or spiral layer of muscle. The ureter crosses the pelvic rim at the bifurcation of the common iliac artery. At this level, the ureter has a light constriction. It has a diameter of 3  mm. It is adherent to the peritoneum, ventrally. Its external relationship is the lumboovarian pedicle. At the crossing, the distance between them

is around 4  cm. This part of the ureter is supplied by the common iliac arteries, direct branches from the aorta and ovarian arteries. Within the periureteral adventitia these arteries extensively anastomose. For the surgeon these anastomoses offer the possibility of surgical mobilization of the ureter without compromising the vascular supply as long as the adventitia is not stripped. The ureters are well innervated by the ureteric plexus. The nerves travel alongside the blood vessel supply.

7.2

Laparoscopic Identification (Fig. 7.2)

With the magnification obtained by the 10 mm laparoscope, we can see the characteristic aspect of the ureter when it crosses the big vessels. At this level, we always see the ureter crawling. Few minutes are enough to observe its mobility.

7.2  Laparoscopic Identification

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Fig. 7.1  The ureter. (1) Lumbo-ovarian ligament (right side). (2) Ureter. (3) External iliac artery. (4) Tube. (5) Uterosacral ligament

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Fig. 7.2 Laparoscopic identification of the ureter. (1) Ureter (right). (2) Uterosacral ligament. (3) Bowel

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Landmarks of the Ureter

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8.1

8  Landmarks of the Ureter

Ureter in the Promontory Area (Figs. 8.1 and 8.2)

The ureter enters the true pelvis after it crosses the external iliac artery (right side) or the common iliac artery (left side). These figures show well the crossing of the ureter on the right side. It appears as a bridge above the external iliac artery.

The lower aspect of the ureter, which measures 14 cm in length, passes dorsally and caudally on the wall of the pelvis under cover of the peritoneum. With the appearance of a curved, convex arrangement, especially in the deepest part of the greater sciatic notch, it is always under the uterine artery.

8.1  Ureter in the Promontory Area

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Fig. 8.1  Ureter in the promontory area. (1) Lumbo-ovarian ligament. (2) Ureter. (3) Ovarian fossa. (4) Common iliac vessels. (5) Promontory

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Fig. 8.2  Ureter in the promontory area, another case (right side). (1) Common iliac artery. (2) Internal iliac artery. (3) External iliac artery. (4) Ureter. (5) Promontory

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8.2

8  Landmarks of the Ureter

 ateral Anatomy Below L the Adnexa (Fig. 8.3)

The teeth forceps tends the left uterosacral ligament. The ovary is raised by another forceps (not seen) which allows to observe well the ureter.

8.3

The Ureter Below the Adnexa (Fig. 8.4)

Behind the broad ligament, the ureter is ventrally close to the ovary. It crosses the caudal part of the fossa of Claudius. The dorsal surface of the ureter is in relationship with the internal iliac artery.

In this figure (right side), it is understandable that in case of significant adhesions between the ovary and its fossa and especially in case of joining realizing a weld, there may be an injury of the ureter during ovarian adhesiolysis. It can occur in case of ovarian endometriosis. In the same way, haemostasis too much supported by the bipolar forceps at the level of the peritoneum of the fossa can cause burning of the ureter.

8.3  The Ureter Below the Adnexa

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Fig. 8.3  Lateral anatomy below the adnexa. (1) Ureter. (2) Ovarian fossa. (3) Uterine vessels. (4) Uterosacral ligament. (5) Ovary

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Fig. 8.4  The ureter below the adnexa. (1) Ureter. (2) Ovarian fossa. (3) Uterosacral ligament. (4) Ovary. (5) Isthmus. (6) Tube

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Dorsal and Lateral Anatomy of the Pelvis

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9  Dorsal and Lateral Anatomy of the Pelvis

When the uterus is placed in anteversion and the ovary raised, we observe the different organs that form folds under the peritoneum.

9.1

 wo Hypogastric Nerves, Right T and Left (Figs. 9.1 and 9.2)

Each nerve is the chain between the superior hypogastric plexus and the inferior hypogastric plexus. It includes mostly pre- and postganglionic sympathetic fibres from vertebral

levels of T10–L2. It receives branches from lumbar splanchnic nerves L3–L4. It also contains parasympathetic fibres which arise from splanchnic nerves S3–S4. By laparoscopy, we can see the hypogastric nerve just under the peritoneum, inside of the ureter. After peritoneal incision and dissection deeply, behind the broad ligament, it is seen between the ureter and the uterosacral ligament.

9.1  Two Hypogastric Nerves, Right and Left Fig. 9.1  The hypogastric nerve. (1) Uterosacral ligament. (2) Folds corresponding to the vessels of anterior terminal trunk of internal iliac artery. (3) Hypogastric nerve. (4) Ureter. (5) Right external iliac artery. (6) Rectum

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Fig. 9.2  The hypogastric nerve, another case. (1) Right hypogastric nerve. (2) Adnexa. (3) Small intestine

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9.2

9  Dorsal and Lateral Anatomy of the Pelvis

 he Inferior Hypogastric T Plexus (Fig. 9.3)

It is formed by the union of nerves from superior hypogastric plexus and splanchnic nerves.

It is situated under the paracervix (deep uterine vein) and around the lateral walls of the rectum and also around the lateral surfaces of the bladder and the vagina. It contains sympathetic and parasympathetic preganglionic fibre synapse.

9.2  The Inferior Hypogastric Plexus Fig. 9.3  The inferior hypogastric plexus. (1) Left external iliac artery. (2) Obturator artery. (3) Obturator nerve. (4) Hypogastric artery which continues through uterine artery. (5) Twigs of the inferior hypogastric plexus. (6) Ureter. (7) Uterosacral ligament. (8) Douglas cul-de-sac. (9) Rectum

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Promontory Area

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10  Promontory Area

10.1 The Cranial Area (Fig. 10.1)

10.2 Middle Sacral Artery (Fig. 10.2)

It is important to study this cranial area which is the limit of the pelvic cavity itself. Indeed, it is interested in the technique of sacrocolpopexy.

We see the middle sacral artery crossing the promontory. It is shown by the laparoscopic forceps. During the technique of sacrocolpopexy, the fixation of the mesh is done on the right of the artery, by one or two sutures and so avoiding any risk of haemorrhage.

10.2  Middle Sacral Artery Fig. 10.1  The cranial area. (1) Promontory. (2) Left common iliac vein. (3) Ureter. (4) Bowel covering the superior hypogastric plexus. (5) Tube. (6) External iliac vessels

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Fig. 10.2  Middle sacral artery. (1) Middle sacral artery. (2) Promontory

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10  Promontory Area

10.3 Sigmoid Colon (Fig. 10.3)

10.4 Left Common Iliac Vein (Fig. 10.4)

The left part of the promontory is more or less covered by the sigmoid colon and its accessibility may be compromised, especially in case of obese patients. In case of sacrocolpopexy to treat genital prolapse, the dissection of this area must be limited to what is necessary to avoid injuries of vessels, sigmoid colon, hypogastric plexus and right ureter.

This figure shows the left common iliac vein. This vein is, in most of cases, far and above the promontory. But it is necessary to be all eyes, because the bifurcation of vena cava may be lower and just at the level of the promontory. The pressure of the pneumoperitoneum can bother the vision of the vein. It can chase away the venous blood. And the vein is not visible anymore. Then, the risk is its injury during the passage of the needle through the ligament.

10.4  Left Common Iliac Vein

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Fig. 10.3  Sigmoid colon. (1) Middle sacral artery crossing the promontory. (2) Ureter. (3) Bowel covering the superior hypogastric. (4) External iliac vessels. (5) Uterosacral ligament

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Fig. 10.4  Left common iliac vein. (1) Promontory. (2) Middle sacral artery crossing the promontory. (3) Left common iliac vein. (4) Small intestine

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10.5 The Vision in Female Cadaver (Fig. 10.5) The last figure shows the same view in female cadaver.

10  Promontory Area

10.5  The Vision in Female Cadaver

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Fig. 10.5  The vision in female cadaver. (1) Promontory. (2) Middle sacral artery crossing the promontory. (3) Left common iliac vein. (4) Common iliac arteries

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Part III Laparoscopic Normal Retroperitoneal Anatomy of the Pelvic Floor Seen After Peritoneal Incision

Prevesical Space, Cooper’s Ligament, Paravesical Space, Arcus Tendineus Fascia Pelvis

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11.1 The Prevesical Space 11.1.1 Access to the Prevesical Space, After Filling the Bladder (Fig. 11.1) We perform the peritoneal incision with scissors and a cleavage in the loose tissue. When we are in the correct plane, the dissection is easy and bloodless. The prevesical space or Retzius space is an avascular extraperitoneal space between the pubic symphysis ventrally and the pubic ramus laterally, and the sidewalls are composed of pubic bone and obturator internus muscle. The urinary bladder is seen dorsally. The floor of the Retzius space is formed by the anterior vagina and endopelvic fascia and pubocervical fascia, stretching along the symphysis and inserting at the level of the arcus

tendineus fascia pelvis (ATFP). Lateral to the urethra are the pubo-urethral ligaments. At the floor of the prevesical space, the pubocervical fascia inserts into the ATFP. Above it, the arcus tendineus levator ani (ATLA) is the origin of the levator ani muscles.

11.1.2 Dissection of the Retzius Space in Avascular Loose Tissue (Fig. 11.2) The dissection of the Retzius space is usually easy but it is important to not forget to coagulate the small vessels that may be present. The accumulation of blood in the Retzius space and in the alveolar tissue will hamper the vision and prevent from realizing well the wished operative technique.

11.1  The Prevesical Space

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Fig. 11.1  Access to the prevesical space. (1) Cooper’s ligament. (2) Pubovesical ligament. (3) Bladder

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Fig. 11.2  Dissection of the Retzius space in avascular loose tissue. (1) Bladder. (2) Prevesical space

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11.1.3 The ‘Champagne’ Bubbles (Fig. 11.3) These particular aspects of the dissection of the prevesical space are characteristic, with loose tissue, with description as champagne bubbles.

11.1.4 Progressive Dissection of the Prevesical Space (Fig. 11.4) The bladder is clearly visualized. The pubovesical ligament is preserved. Regardless of the operating technique, this ligament should be protected.

11.1  The Prevesical Space

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Fig. 11.3  The ‘champagne’ bubbles. (1) Bladder. (2) Prevesical space

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Fig. 11.4 Progressive dissection of the prevesical space. (1) Pubovesical ligament. (2) Bladder. (3) Prevesical space

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11.1.5 Focus on Cooper’s Ligament, Technique of Exposition, Left Side (Fig. 11.5)

11.1.6 Focus on Cooper’s Ligament, Technique of Suture, Left Side (Fig. 11.6)

The inguinal ligament of Cooper or pectineal ligament is an extension of the lacunar ligament that runs on the pectineal line of the pubic bone. It is the dorsal border of the femoral ring. The structure of the ligament is strong, facilitating the techniques of colposuspension for stress urinary incontinence and also the reconstruction of the floor of the inguinal canal.

The solidity of this ligament is demonstrated with passage of the curved needle of a suture through the ligament during the Burch procedure.

11.1  The Prevesical Space

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Fig. 11.5  Focus on Cooper’s ligament, technique of exposition, left side. (1) Cooper’s ligament. (2) Pubovesical ligament. (3) Bladder. (4) Pubis. (5) Prevesical space

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Fig. 11.6  Focus on Cooper’s ligament, technique of suture, left side. (1) Cooper’s ligament

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11.2 The Prevesical Space (Continued) 11.2.1 Bladder (Fig. 11.7) To complete the deep dissection until the pelvic floor, we need to empty the bladder. The vesical cleavage in the correct dissection plane is bloodless. The perfect view allows for a complete evaluation of the prevesical space, muscles and fascias.

11.2.2 Complete Dissection of the Prevesical Space (Fig. 11.8) It is not necessary to do such a dissection for the Burch procedure. This large dissection may be useful in some cases of genital prolapse.

11.2  The Prevesical Space (Continued)

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Fig. 11.7 Bladder. (1) Bladder. (2) Obturator internus muscle. (3) Cooper’s ligament. (4) Pubis

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Fig. 11.8 Complete dissection of the prevesical space. (1) Bladder. (2) Obturator internus muscle. (3) Cooper’s ligament. (4) Pubis

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11.2.3 Panoramic View of Dissection Between the Umbilico-Vesical Fascia and Bladder (Fig. 11.9) The umbilico-vesical fascia is a cellular and fibrous leaf, triangular with upper summit, extending of the umbilicus in the pelvic fascia. Its dorsal part is concave and is attached to ventral faces of the bladder, the urachus and the umbilical arteries. It forms the dorsal boundary of the retropubic space. To enter the prevesical space, it is necessary to pass in front of the umbilico-vesical fascia.

11.3 The Paravesical Space The paravesical space is bound laterally by the obturator internus muscle. The dorsal border is the endopelvic fascial sheath around the internal iliac artery and vein and its ventral branches, in the direction of the ischial spine.

11.3.1 Focus on ATFP, Between Pubis and Ischial Spine (Right Side) (Fig. 11.10) The arcus tendineus fascia pelvis (white line) is the thickening of the parietal fascia covering the obturator internus muscle. It is defined as a fibrous enhancement of the endopelvic fascia of 10 cm long. The arcus is located between pubovesical ligament and ischiatic spine. The third dorsal part is common with the arcus tendineus levator ani where it is attached to the upper limit of the levator ani muscles. It is stronger at this level.

11.3  The Paravesical Space

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Fig. 11.9  Panoramic view of dissection between the umbilico-vesical fascia and bladder. (1) Bladder. (2) Pubis. (3) Umbilicovesical fascia. (4) Obliterated umbilical artery

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Fig. 11.10  Focus on ATFP, strained between pubis and ischial spine (right side). (1) Obturator internus muscle. (2) Bladder. (3) ATFP

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11.3.2 Focus on Obturator Pedicle, Between Pubis and Ischial Spine, at the Entry in the Obturator Canal, Left Side (Fig. 11.11) The obturator canal is a passageway formed in the obturator foramen by part of the obturator membrane. It connects the pelvis to the thigh. The obturator artery, obturator

vein and obturator nerve travel through the canal. The obturator artery is a branch of the internal iliac artery that passes on the lateral wall of the pelvis, to the upper part of the obturator foramen, and leaves from the pelvic cavity through the obturator canal. It divides into both a ventral and a dorsal branch.

11.3  The Paravesical Space

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Fig. 11.11  Focus on obturator pedicle, between pubis and ischial spine, at the entry in the obturator canal (left side). (1) Obturator internus muscle. (2) Bladder. (3) ATFP. (4) Obturator canal. (5) Obturator nerve and vessels

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11.3.3 Focus on Obturator Pedicle (Figs. 11.12, Right Side, and 11.13, Left Side) The obturator nerve arises from the ventral divisions of lumbar nerves (L2–3–4) in the lumbar plexus. It courses medial to the psoas major muscle, along the sidewall of the pelvis. Concerning the relationship with the arteries, it passes behind the common iliac artery and on the lateral side of the hypogastric artery and of the ureter. At the end of the path into the pelvis, it is usually above the obturator vessels at the upper

part of the obturator foramen. Finally, the obturator nerve enters through the obturator canal, above the vessels. It divides into two branches, until obturator externus and adductor brevis muscles. It gives the sensory innervation of the skin of the medial face of the thigh and also the motor innervation of the adductor muscles of the lower limb (external obturator, adductor longus, brevis, magnus). But it has no responsibility for the innervation of the obturator internus muscle.

11.3  The Paravesical Space

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Fig. 11.12  Focus on obturator pedicle (right side). (1) Obturator internus muscle. (2) Bladder. (3) ATFP. (4) Obturator canal. (5) Obturator nerve and vessels. (6) Pubis. (7) Cooper’s ligament. (8) Corona mortis vessels

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Fig. 11.13  Focus on obturator pedicle (left side). (1) Obturator internus muscle. (2) Bladder. (3) Obturator canal. (4) Obturator nerve and vessels. (5) Cooper’s ligament. (6) Corona mortis vessels. (7) Branch of lateral vesical artery

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11.3.4 Focus on Corona Mortis Artery (Fig. 11.14) It is an anatomic variant, anastomosis between obturator artery and inferior epigastric artery or another branch of external iliac artery. It is located behind the superior pubic ramus at a variable distance from the symphysis pubis (40– 96  mm). The artery may be huge, with risk of dramatic haemorrhage if injured. This figure gives a general view of the right side.

11.3.5 Relationship Between the Obturator Nerve and the Corona Mortis Artery (Fig. 11.15) This figure shows the proximity between the right obturator nerve and the corona mortis artery. This is of great importance during dissection of this area.

11.3  The Paravesical Space

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Fig. 11.14  Focus on corona mortis artery (right side). (1) Obturator internus muscle. (2) Bladder. (3) Obturator canal. (4) Obturator nerve and vessels. (5) Pubis. (6) Cooper’s ligament. (7) Corona mortis vessels

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Fig. 11.15 Relationship between the obturator nerve and the corona mortis artery. (1) Obturator internus muscle. (2) Bladder. (3) ATFP. (4) Obturator canal. (5) Obturator nerve and vessels. (6) Cooper’s ligament. (7) Corona mortis vessels

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11.4 The Panoramic View of the Pre- and Paravesical Space 11.4.1 Prevesical Space (Fig. 11.16) We see well that the prevesical space or Retzius space is a potential avascular space with vascular borders between the back of the pubic bone and the ventral wall of the bladder.

The prevesical space is bounded ventrally by the transversalis fascia, which inserts into the dorsal surface of the pubic symphysis. The urethra, the pubo-urethral ligaments and the bladder neck form the floor of this space. The prevesical space communicates laterally with the paravesical space. The frontier between them is at the level of the medial umbilical ligaments (obliterated umbilical arteries).

11.4  The Panoramic View of the Pre- and Paravesical Space Fig. 11.16  Prevesical space. (1) Pubis. (2) Cooper’s ligament. (3) Corona mortis artery. (4) Obturator nerve. (5) Obturator internus muscle. (6) Bladder. (7) ATFP

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The Vesicovaginal Space

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12.1 Limits (Fig. 12.1) The space is bounded ventrally by the bladder, laterally by the bladder pillars and dorsally by the vagina. Superiorly, it ends at the point of fusion between the adventitia of the bladder and vagina (loose connective tissue), which is called vesicocervical ligament or supravaginal septum. We see the access to the vesicovaginal space, with incision of the peritoneum. It is easy to do the cleavage close to the round ligament, laterally.

12  The Vesicovaginal Space

12.2 Access to the Vesicovaginal Space (Fig. 12.2) After incision of the peritoneum, the cleavage between bladder and pubocervical fascia is done with scissors, and the bladder pillars are visualized.

12.2  Access to the Vesicovaginal Space

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Fig. 12.1  Limits of the vesicovaginal space. (1) Bladder. (2) Uterus

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Fig. 12.2  Access to the vesicovaginal space. (1) Bladder. (2) Uterus. (3) Bladder pillar

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12  The Vesicovaginal Space

12.3 T  he Loose Connective Tissue (Fig. 12.3)

12.4 Section of the Bladder Pillars (Fig. 12.4)

The cleavage is often easy in the loose connective tissue between the bladder and the pubocervical fascia, covering the anterior wall of the vagina.

The section of the bladder pillar needs often haemostasis of small vessels using bipolar coagulation.

12.4  Section of the Bladder Pillars

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Fig. 12.3  The loose connective tissue. (1) Bladder. (2) Uterus. (3) Loose tissue

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Fig. 12.4  Section of the bladder pillars. (1) Bladder. (2) Uterus. (3) Bladder pillar. (4) Loose tissue. (5) Pubocervical fascia

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12  The Vesicovaginal Space

12.5 The Cleavage Line (Fig. 12.5)

12.6 The Panoramic Vision (Fig. 12.6)

The vesicovaginal cleavage is not yet completed. We see the cleavage line. We follow it to perform the end of the dissection. A flat and atraumatic retractor introduced in the anterior cul-de-sac of the vagina facilitates the dissection.

The good exposition of the vesicovaginal space is necessary for placement of the mesh on the anterior wall of the vagina, during reconstructive surgery for the treatment of pelvic organ prolapse. Usually, the ventral leaf of the vesicouterine peritoneal incision is fixed ventrally to the anterior abdominal wall, above the pubis, with a suture that will be cut at the end of the operation.

12.6  The Panoramic Vision Fig. 12.5  The cleavage line. (1) Bladder. (2) Uterus. (3) Bladder pillar. (4) Loose tissue. (5) Pubocervical fascia. (6) Cleavage line. (7) Round ligament

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Fig. 12.6  The panoramic vision. (1) Bladder. (2) Uterus. (3) Bladder pillar. (4) Pubocervical fascia. (5) Round ligament. (6) Vesicovaginal space

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12.7 Vesicovaginal Space (Continued) 12.7.1 Bladder Pillars (Fig. 12.7) Access to the vesicovaginal space: section of the bladder pillars laterally. The deep layer of the bladder pillars contains

12  The Vesicovaginal Space

autonomic innervation of the bladder and should be avoided to prevent postoperative urinary disorders.

12.7  Vesicovaginal Space (Continued)

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Fig. 12.7  Bladder pillars. (1) Bladder. (2) Loose tissue. (3) Endopelvic fascia. (4) Pillars

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12.7.2 Lateral to the Vesicovaginal Space (Figs. 12.8 and 12.9) The figures show the crossing of the uterine artery over the ureter (left side). The Latzko space is observed between ureter and uterine vessels.

12  The Vesicovaginal Space

12.7  Vesicovaginal Space (Continued)

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Fig. 12.8  Lateral to the vesicovaginal space. (1) Ureter. (2) Uterine artery. (3) Uterosacral ligament

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Fig. 12.9  Lateral to the vesicovaginal space. (1) Bladder. (2) Loose tissue. (3) Ureter. (4) Latzko space. (5) Uterine artery. (6) Cervix

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12  The Vesicovaginal Space

12.8 Deep Vesico-Cervico-Vaginal Dissection

12.8.2 Visualization During Hysterectomy (Fig. 12.11)

12.8.1 Lateral to the Vesicovaginal Space (Fig. 12.10)

Lateral to the vesicovaginal space, we see the relationship of the left uterine artery with the ureter:

We see the crossing of the right uterine artery over the ureter.

–– Uterine artery (a clip has been applicated initially for preventive haemostasis) crossing above the ureter. –– Section of uterine artery during hysterectomy, in its ascending portion: The uterine vessels have been coagulated during hysterectomy.

12.8  Deep Vesico-Cervico-Vaginal Dissection

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Fig. 12.10  Lateral to the vesicovaginal space. (1) Cervix. (2) Ureter. (3) Uterine artery (right side)

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Fig. 12.11 Visualization during hysterectomy (left side). (1) Uterine artery. (2) Ureter. (3) Level of section of uterine artery during hysterectomy. (4) Round ligament. (5) Bladder

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12.8.3 Visualization with Magnification (Fig. 12.12) In the final figure, the left round ligament hides a part of the same field.

12  The Vesicovaginal Space

12.8  Deep Vesico-Cervico-Vaginal Dissection Fig. 12.12 Visualization with magnification (left side). (1) Uterine artery. (2) Level of section of uterine artery during hysterectomy. (3) Round ligament

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The Dorsolateral Dissection of the Uterine Artery

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13.1 T  he Dorsal Approach to Preventive Occlusion (Fig. 13.1) The uterine artery is a branch of the anterior division of the internal iliac artery, often terminal with the umbilical artery. It courses retroperitoneally from lateral to the medial direction until reaching the broad ligament. We know that the upper portion of the cardinal ligament is penetrated by the uterine artery as it travels into the tunnel of Wertheim just above the ureter, 1–2 cm lateral to the isthmus of the uterus, immediately lateral to the uterosacral ligament. To identify and spot the uterine artery, it is enough to do a traction on the umbilical artery at the level of the anterior abdominal wall; it allows its mobilization. It is the main artery which vascularize the uterus. When we occlude both uterine arteries, we devascularize only partially the uterus. It is because many other arteries irrigate the uterus: ovarian, vaginal, uterosacral and round ligament arteries. During difficult myomectomy or hysterectomy, it is important to reduce the blood irrigation of the uterus and so the haemorrhage during dissection, myometrium incision or

13  The Dorsolateral Dissection of the Uterine Artery

section. The best way is occluding the uterine artery before starting the myomectomy or the hysterectomy. Twenty years ago, we described the preventive occlusion or coagulation of the uterine artery before uterine incisions. The uterine artery is easily occluded (usually with one clip) at a specific place: 3–4  cm behind and below the ovary, lateral to the ureter. After short incision of the peritoneum and a soft dissection, we see in all cases the uterine artery, lateral to the ureter. It may be occluded at this place. We must confirm that the artery dissected is the uterine artery, and not umbilical, vesical or vaginal arteries.

13.2 T  he Technique of Dorsal Approach of the Uterine Artery for Preventive Occlusion (Fig. 13.2) Dissection with magnification: A short incision of 2 cm of the peritoneum gives access to the artery and the ureter. The uterine artery is external and above. A small vessel is below the artery.

13.2  The Technique of Dorsal Approach of the Uterine Artery for Preventive Occlusion Fig. 13.1  Uterine artery: The dorsal approach to preventive occlusion (right side). (1) Uterine artery. (2) Ureter. (3) Uterosacral ligament. (4) Douglas cul-de-sac. (5) Uterus. (6) External iliac artery

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Fig. 13.2  The technique of dorsal approach of the uterine artery for preventive occlusion. (1) Uterine artery. (2) Ureter

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13.3 V  isualization of the Uterine Artery and of the Ureter (Fig. 13.3) Another case with magnification.

13.4 The Titanium Clip (Fig. 13.4) Uterine artery occlusion with a 10  mm clip, under direct vision of the ureter: In this figure, in this case, there is no risk for the ureter which is far. There is a good exposition to fix

13  The Dorsolateral Dissection of the Uterine Artery

the clip. It is known that the occlusion of the uterine artery devascularizes more the leiomyomas than the normal myometrium. And the revascularization of the myometrium takes few hours, without removing the clip.

13.4  The Titanium Clip

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Fig. 13.3 Visualization of the uterine artery and of the ureter. (1) Uterine artery. (2) Ureter. (3) Uterosacral ligament. (4) Fimbria

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Fig. 13.4  The titanium clip. (1) Uterine artery

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The Rectovaginal Septum

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14.1 The Limits (Fig. 14.1) The ventral part of the rectovaginal septum is formed by a connective tissue layer fixed to the vagina. The dorsal part is the connective tissue of the rectum. The roof is the peritoneum and the rectouterine peritoneal pouch (cul-de-sac of Douglas). The caudal margin is the perineal body. The perineal body (or central tendon of perineum), pyramidal fibromuscular mass, is in the middle line of the perineum at the junction between the urogenital triangle and the anal triangle. At the level of the perineal body, rectovaginal fascia, puborectalis muscles, transverse perineal muscles and external anal sphincter are joined. It is a very strong structure. The perineal body is fundamental to the integrity of the pelvic floor. Its rupture during vaginal birth leads to widening of the gap between the anterior free borders of levator ani muscle of both sides, thus predisposing the woman to prolapse of the uterus, rectum or even urinary bladder. We start with incision of the peritoneum easily mobilized between the uterosacral ligaments laterally, the rectum is far from this incision. Dissection of the rectovaginal septum: During this cleavage, we must open the correct plane, ‘not too close’ to the

14  The Rectovaginal Septum

vagina with the risk of dissecting the fascia with some bleeding. The cleavage plane is little more dorsal, close to the rectum. Then, the cleavage is easy to do and can go as far as the central tendon of perineum.

14.2 Vaginal Venous Plexuses (Fig. 14.2) Performing the dissection, vaginal venous plexuses are often present in the vaginal wall. The venous plexuses are placed specially at the sides of the vagina; they communicate with the uterine venous plexuses, vesical venous plexuses and rectal venous plexuses, and are drained by the vaginal veins, one on either side, into the hypogastric veins. This point explains some tips during vaginal hysterectomy: the knurling of the dorsal edge of the vagina with absorbable sutures. It is performed when we do classic section of the vagina with scissors or scalpel without electrosurgery or thermofusion, to avoid bleeding. Just below the dissection, the central tendon of perineum is guessed. Laterally, the puborectalis muscles are seen.

14.2  Vaginal Venous Plexuses

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Fig. 14.1  The limits of the rectovaginal septum. (1) Rectum. (2) Peritoneum. (3) Uterosacral ligament. (4) Isthmus

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Fig. 14.2  Vaginal venous plexuses. (1) Rectum. (2) Vaginal venous plexuses. (3) puborectalis muscles

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The Pararectal Space

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We know that the base of the broad ligaments delineates two important spaces: ventrally is the paravesical space and dorsally, towards the sacrum, is the pararectal space. During radical hysterectomy, the extent of lateral dissection towards the pelvic sidewall and therefore excision of the parametrium determines the class of radical hysterectomy.

15.1 Laparoscopic Access (Fig. 15.1) The access is direct after peritoneal incision between the left ureter and the uterosacral ligament.

15  The Pararectal Space

15.2 The Middle Rectal Artery (Fig. 15.2) The pararectal space communicates with the paravesical space, after lateral dissection to the rectum. The middle rectal artery arises with the inferior vesical artery, a branch of hypogastric artery. It may originate from the internal pudendal artery, inferior gluteal artery. It is distributed to the rectum. There are anastomoses with superior rectal artery and inferior rectal artery. It gives branches to the vagina. It penetrates into the rectal wall about 6 cm superior to the anus. Its visualization during dissection of the pararectal space is important for preservation, according to these anatomical considerations (left side).

15.2  The Middle Rectal Artery Fig. 15.1 Laparoscopic access of the pararectal space. (1) Ureter. (2) Rectum. (3) Uterosacral ligament. (4) Douglas cul-de-sac. (5) Uterus. (6) Ovary. (7) Tube

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Fig. 15.2  The middle rectal artery (left side). (1) Ureter. (2) Rectum. (3) Uterosacral ligament. (4) Middle rectal artery

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15.3 Deep Dissection (Fig. 15.3) Rectovaginal septum and deep part of the pararectal space communicate with the paravesical space, after deep lateral dissection to the rectum (right side).

15.4 L  ateral Rectal Dissection in Cadaver (Fig. 15.4) Deep part of the pararectal space, communicating with the paravesical space.

15  The Pararectal Space

15.5 S  ituation of the Medial Pararectal Space of Okabayashi It is the opening space between meso-ureter laterally, uterosacral ligament medially and dorsal leaf of broad ligament ventrally.

15.6 S  ituation of Lateral Pararectal Space of Latzko It is the opening space between pelvic wall, hypogastric artery, uterine artery laterally and ureter medially (left side).

15.6  Situation of Lateral Pararectal Space of Latzko

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Fig. 15.3  Deep dissection of the pararectal space (right side). (1) Ureter. (2) Rectum. (3) ATFP. (4) Ischial spine. (5) Sacrospinous ligament, backward coccygeus. (6) Obturator internus muscle

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Fig. 15.4  Lateral rectal dissection in cadaver (left side). (1) Ureter. (2) Rectum. (3) Uterosacral ligament. (4) Douglas cul-de-sac. (5) External iliac artery. (6) Obturator nerve. (7) Obturator artery. (8) Hypogastric artery which continues through the uterine artery. (9) Twigs of the inferior hypogastric plexus. (10) Median pararectal space of Okabayashi. (11) Lateral pararectal space of Latzko

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15.7 Pelvic Lymphadenectomy: The Main Benchmarks (Fig. 15.5) This figure clearly shows the three benchmarks: external iliac vessels, obturator nerve and umbilical artery.

15.8 T  he Pudendal Nerve, Laparoscopic Approach 15.8.1 Definition The pudendal nerve is a major nerve of the pelvic floor. Its precise anatomy must be known to the pelvic surgeon. The nerve is a major branch of the sacral plexus. It emerges from S2, S3 and S4. It carries sympathetic fibres. These three roots immediately converge above the upper border of the sacrotuberous ligament and the coccygeus muscle. The pudendal nerve passes between the piriformis muscle and the coccygeus muscle and leaves the pelvis through the lower part of the greater sciatic foramen. It crosses over the lateral part of the sacrospinous ligament and re-enters the pelvis through the

15  The Pararectal Space

lesser sciatic foramen along the lateral wall of the ischiorectal fossa, protected in a sheath of the obturator fascia, the pudendal canal (Alcock canal), accompanied by the internal pudendal vessels.

15.9 Laparoscopic Dissection of the Right Pudendal Nerve 15.9.1 The View of the Pudendal Nerve by Laparoscopy The medial part of the right sacrospinous ligament has to be exposed in order to see the pudendal nerve in the fat-filled groove formed by the sacrospinous ligament ventromedially and the sacrotuberous ligament dorso-medially (the ‘biligamentary tunnel’).

15.9.2 View of the Ischial Spine Area (Fig. 15.6) Before section of the sacrospinous ligament and entering the ischiorectal fossa and the pudendal canal.

15.9  Laparoscopic Dissection of the Right Pudendal Nerve

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Fig. 15.5 Pelvic lymphadenectomy area (left side). (1) External iliac vessels. (2) Obturator nerve. (3) Umbilical artery

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15.9.3 Visualization of the Sacrospinous Ligament (Fig. 15.7) It is a triangular ligament. The base is attached to the outer edges of the sacrum and coccyx. The tip of the ligament attaches to the spine of the ischium. It is closely in contact with coccygean muscle.

15  The Pararectal Space

15.9.4 Pudendal Nerve Release (Fig. 15.8) Section of sacrospinous ligament, step by step. The ligament appears cartilaginous at section.

15.9  Laparoscopic Dissection of the Right Pudendal Nerve

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Fig. 15.7  Visualization of the sacrospinous ligament. (1) Sacrospinous ligament

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Fig. 15.8  Pudendal nerve release. (1) Sacrospinous ligament

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15.9.5 The Pudendal Nerve Dissected Appears White (Fig. 15.9)

15.10 L  aparoscopic Dissection of the Left Pudendal Nerve (Continued)

15  The Pararectal Space

15.10.1 Dissection of the Pudendal Nerve (Fig. 15.10) Access by peritoneal longitudinal incision between ureter and uterosacral ligament.

15.10  Laparoscopic Dissection of the Left Pudendal Nerve (Continued)

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Fig. 15.9  The pudendal nerve dissected appears white. (1) Pudendal nerve

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Fig. 15.10  Dissection of the pudendal nerve (left side). (1) Ureter. (2) Uterosacral ligament. (3) Douglas cul-de-sac

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15.10.2 Progressive Vision of the Pudendal Nerve (Figs. 15.11 and 15.12) Access after partial section of the sacrospinous ligament, progressive visualization of the nerve. The pudendal nerve carries sensation to the external genitalia area, especially the clitoris and the anus. It is also a motor nerve with supply to external urethral sphincter and the external anal sphincter, bulbospongiosus and ischiocav-

15  The Pararectal Space

ernosus muscles, and also levator ani muscles (puborectalis included). Pudendal nerve entrapment is a quite rare source of chronic pain and local hypo- or hyperesthesia, in which the nerve is entrapped as it leaves or enters the pelvis in various tunnels built by adjacent muscles, ligaments and bones. Under specific conditions, the release of the nerve can be made by laparoscopy.

15.10  Laparoscopic Dissection of the Left Pudendal Nerve (Continued)

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Fig. 15.11 Progressive dissection of the pudendal nerve. (1) Sacrospinous ligament. (2) Pudendal nerve

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Fig. 15.12 Progressive vision of the pudendal nerve. (5) Pudendal nerve

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Part IV Laparoscopic Anatomy of the Pelvic Floor in Case of Genital Prolapse Seen By Clinical Examination and Transperitoneal Vision

Cystocele

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16.1 Definition (Fig. 16.1) A cystocele is observed when the bladder bulges into the vagina. The underlying mechanism involves weakening of connective tissue and muscles between the bladder and the vagina, after childbirth, connective tissue disorders, menopause and ageing. Several types of cystocele are described. One, two or three vaginal wall attachment failures can occur: the midline defect, the paravaginal defect and the transverse defect. The midline defect or central cystocele is caused by the overstretching of the vaginal wall. The lateral cystocele is secondary to the paravaginal defect, separation of the vaginal connective tissue at the level of the arcus tendineus fascia

16 Cystocele

pelvis (ATFP). The cystocele also occurs with transverse defect due to pubocervical detachment from the apex of the vagina. These three types are often associated.

16.2 E  xternal Aspect of Exteriorized Lateral Cystocele, Associated with Procidentia (Uterine Descent) (Fig. 16.2) The transverse rugae of the vagina are clearly visible. Frequently, this association is observed. This explains the need of treating all pelvic compartments concerned. The soft traction with the Pozzi forceps facilitates the anatomical evaluation.

16.2  External Aspect of Exteriorized Lateral Cystocele, Associated with Procidentia (Uterine Descent) Fig. 16.1 Cystocele. (1) Bladder descent (Pozzi forceps fixed to the cervix)

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Fig. 16.2  Large lateral cystocele with procidentia. (1) Large lateral cystocele. (2) Cervix. (3) Urethral descent

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16.3 E  xternal Aspect of Large Cystocele (Fig. 16.3) The large cystocoele is visualized with externalization. It is a urethro-cystocele when urethral descent is visible. Vaginal rugae are seen, corresponding to a lateral cystocele. The identification of the cervix with the Pozzi forceps shows that the participation of the uterus is present, with evident procidentia. We also see the rectocele.

16 Cystocele

16.4 Complete Prolapse (Fig. 16.4) Three compartments descend (Pozzi forceps attached to the cervix) with exteriorized cystocele, procidentia and rectocele. The associated descent of the cervix is visualized by gentle traction of the Pozzi forceps. This one is hidden by the cystocele. There is an important sagging of the perineum. The thinness of the wall of the cystocele explains why many surgeons prefer to use meshes to strengthen the vesicovaginal fascia during pelvic reconstruction.

16.4  Complete Prolapse Fig. 16.3 Cystocele, procidentia and rectocele. (1) Cystocele. (2) Procidentia (uterus and cervix). (3) Rectocele

Fig. 16.4  Complete prolapse with predominant cystocele (Pozzi tenaculum forceps fixed to the cervix)

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16.5 C  orrelation in Laparoscopy of Pelvic Floor Defects

16.5.2 Laparoscopic Aspect of Central and Lateral Cystocele (Fig. 16.6)

16.5.1 Laparoscopic Aspect of Lateral Cystocele (Fig. 16.5)

By laparoscopy, the descent is evaluated with the level of the pubic bone. We see well that the bladder went down, and also the two round ligaments are very thin. They cannot be used to participate in the reconstruction of the pelvic floor by laparoscopy.

Having a thin curette introduced into the uterus, the uterus is softly pushed. Both side fossa appears, corresponding to the lateral cystocele. It clearly shows the lateral defect.

16.5  Correlation in Laparoscopy of Pelvic Floor Defects Fig. 16.5 Laparoscopic aspect of lateral cystocele. (1) Uterus. (2) Round ligament. (3) Bladder. (4) Evident lateral cystocele. (5) Relief of the uterine manipulator, well seen on the anterior wall of the isthmus. (6) Pectineal line of the pubic bone

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Fig. 16.6 Laparoscopic aspect of central and lateral cystocele. (1) Uterus. (2) Round ligament. (3) Bladder. (4) Pubis. (5) Tube. (6) Umbilical artery

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16.5.3 Laparoscopic Aspect of Cystocele and Procidentia (Fig. 16.7) This is another case of cystocele and procidentia. The bladder is still partially filled. This allows us to see the importance of the degradation of the anterior and central compartments.

16 Cystocele

16.5.4 Laparoscopic Aspect of Exteriorized Cystocele After Total Hysterectomy (Fig. 16.8) By laparoscopy, the descent of the bladder is evident, well below the pubis. Cooper’s ligaments are just below the peritoneum, at the level of the pubic bone. The laparoscopic access to the Retzius space is easy in this case.

16.5  Correlation in Laparoscopy of Pelvic Floor Defects

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Fig. 16.7 Laparoscopic aspect of cystocele and procidentia. (1) Uterus. (2) Round ligament. (3) Bladder. (4) Pectineal line of the pubic bone. (5) Pubis

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External Aspects of Exteriorized Apical Prolapse and Rectocele

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17  External Aspects of Exteriorized Apical Prolapse and Rectocele

17.1 Trachelocele (Figs. 17.1 and 17.2)

17.2 Rectocele

These two figures show the exteriorization of the uterine cervix. In these cases, the degradation of the quality of life of the patient is evident. It is always associated with disinsertion of the cervix from the pericervical ring including the pubocervical fascia and uterosacral-cardinal ligament complex. It explains why the procidentia (uterus) is usually associated with cystocele. In rare cases, it may be isolated due to partial tears of the fascia or congenital anomalies.

It is a posterior vaginal wall prolapse and results when a part of the rectum bulges into the vagina. It is a hernia of the rectum in the vagina. The tears of the rectovaginal fascia are the main cause, usually after vaginal delivery. It is often associated with serious traumatic tissue injuries of the perineum, with partial or complete rupture of the anal sphincter. It often participates in a prolapse that also includes the bladder (cystocele) and the vaginal vault. The common cause of the rectocele is traumatic delivery. It may also occur after hysterectomy.

17.2 Rectocele Fig. 17.1 Trachelocele

Fig. 17.2 Trachelocele

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17  External Aspects of Exteriorized Apical Prolapse and Rectocele

17.3 C  linical Evaluation of the Posterior Pelvic Floor Defects (Fig. 17.3)

17.4 U  sual Clinical Aspect of the Rectocele Associated with a Cystocele (Fig. 17.4)

The exposition of the rectocele after introduction of a vaginal speculum or valve.

The figure shows the exteriorization of the posterior vaginal wall, with enlarged introitus. It is important to differentiate rectocele, prolapse of the bulge through the introitus of the vagina, from rectal prolapse through the anus. These considerations are important for the surgical management.

17.4  Usual Clinical Aspect of the Rectocele Associated with a Cystocele

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Fig. 17.3  Clinical evaluation of the posterior pelvic floor defects

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Fig. 17.4  Usual clinical aspect of the rectocele associated with a cystocele

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17  External Aspects of Exteriorized Apical Prolapse and Rectocele

17.5 L  aparoscopic Aspect of Large Rectocele (Fig. 17.5)

The reconstruction of the posterior compartment using plications and reapproximation of the uterosacral ligaments may be an excellent technique. But it depends on the quality of the ligaments. They should be present and quite strong.

The rectum descent is associated with severe deterioration of the two uterosacral ligaments. The cul-de-sac of Douglas is deep and large.

17.6 U  sual Laparoscopic Aspect of Rectocele (Fig. 17.6) The complete destruction of the two uterosacral ligaments is also well seen in this figure.

17.6  Usual Laparoscopic Aspect of Rectocele

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Fig. 17.5 Laparoscopic aspect of large rectocele. (1) Rectum. (2) Descent of the rectum

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Fig. 17.6  Usual laparoscopic aspect of rectocele. (1) Descent of the rectum. (2) Rectum. (3) Ovary. (4) Tube

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External Aspects of Vaginal Vault Prolapse

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18.1 V  aginal Vault Prolapse After Hysterectomy (Patient 1) (Fig. 18.1) The vaginal vault prolapse after hysterectomy is exteriorized with predominant cystocele. The secondary risk of descent of the vaginal vault, in the months or years after hysterectomy, is usually explained by associated pelvic floor defects due to pelvic floor injuries during past deliveries. It is the reason why some surgeons do a preventive treatment of the descent of the vaginal vault by pelvic reconstruction at the end of total hysterectomy. Typically, by laparoscopy or vagi-

18  External Aspects of Vaginal Vault Prolapse

nal route, the surgeon makes the reapproximation and the crossing of the uterosacral with round ligaments and Douglas cul-de-sac repair using precise sutures.

18.2 E  vident Association with  Cystocele (Patient 2) (Fig. 18.2) The vault prolapse is often associated with predominant externalized cystocele (visualization of the vaginal folds secondary to lateral fascia detachment).

18.2  Evident Association with Cystocele (Patient 2)

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Fig. 18.1  Vaginal vault prolapse after hysterectomy (patient 1). (1) Cystocele and vaginal vault prolapse

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Fig. 18.2  Vaginal vault prolapse: Evident association with cystocele (patient 2)

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18.3 Same Patient (Patient 2) (Fig. 18.3) Same patient when coughing. The cystocele more fell down with disappearance of the vaginal folds.

18  External Aspects of Vaginal Vault Prolapse

18.4 L  aparoscopic View, the Same Patient (Patient 2) (Fig. 18.4) The vault prolapse is associated with cystocele and rectocele. The pelvis is like a shaft, without the uterus, after pushing the bowel above. We see the bladder and the rectum. The vaginal vault is not visible, having descended far into the vagina.

18.4  Laparoscopic View, the Same Patient (Patient 2)

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Fig. 18.3  Same patient when coughing

Fig. 18.4  Vaginal vault prolapse: Laparoscopic view, the same patient (patient 2). (1) Bladder. (2) Rectum

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18  External Aspects of Vaginal Vault Prolapse

18.5 E  xteriorized Vaginal Vault Prolapse (Patient 3) (Fig. 18.5)

18.6 L  aparoscopic Aspect of Vaginal Vault Prolapse (Patient 3) (Fig. 18.6)

The bladder is emptied. The vaginal vault is externalized with minimal rectocele.

The bladder is emptied. The vaginal vault is pushed. A tampon (or a vaginal valve or a malleable atraumatic abdominal retractor) is introduced into the vagina, deeply. It offers facilities to see the different pelvic organs (ureters, bladder and rectum) and to perform elective surgeries.

18.6  Laparoscopic Aspect of Vaginal Vault Prolapse (Patient 3)

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Fig. 18.5 Externalized vaginal vault prolapse (patient 3)

Fig. 18.6 Laparoscopic aspect of vaginal vault prolapse (patient 3). (1) Bladder. (2) Vaginal vault ascended by the valve. (3) Rectum. (4) Sigmoid colon. (5) Uterosacral ligament

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External Aspects of Enterocele

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19.1 Definition An enterocele is essentially a vaginal hernia in which the peritoneal sac containing a portion of the small bowel extends into the rectovaginal space between the posterior surface of the vagina and the anterior surface of the rectum. Congenital enterocele is extremely rare. The enterocele occurs among patients with pelvic floor defects or after hysterectomy. We also see enterocele after elective reconstructive surgery of the anterior compartment, the Burch procedure, ‘ventrofixation’ for instance. These procedures may open too much the posterior compartment usually deficient and weak.

19  External Aspects of Enterocele

19.2 Clinical Diagnosis Often Evident (Fig. 19.1) The hernia of the cul-de-sac of Douglas after hysterectomy is confirmed by the bimanual examination (vaginal, rectal).

19.3 Laparoscopic Aspect of Enterocele (Fig. 19.2) The hernia of the cul-de-sac of Douglas is well seen, with the fixed transverse line corresponding to the scar of a past total hysterectomy. The descent concerns mostly the cul-de-sac of Douglas and the rectum: enterocele and rectocele.

19.3  Laparoscopic Aspect of Enterocele

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Fig. 19.1  External aspect of enterocele. (1) Enterocele. (2) Rectum and posterior wall of the vagina

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19.4 L  aparoscopic Exposition for Dissection (Same Patient) (Fig. 19.3) We see the aspect of the enterocele after vaginal introduction of a tampon. In case of laparoscopic treatment, the exposition of the hernia with a transvaginal gaze or a retractor

19  External Aspects of Enterocele

makes the dissection of the sac fast and easy. The closing of the hole is facilitated by the use of the uterosacral ligaments and by culdoplasty. The limits of dissection are well seen, with control of ureters and rectum that are quite far.

19.4  Laparoscopic Exposition for Dissection (Same Patient) Fig. 19.3 Laparoscopic exposition for dissection of enterocele (same patient). (1) Fixed transverse line post-hysterectomy. (2) Enterocele. (3) Rectum. (4) Ovary. (5) Tube. (6) Bladder. (7) Uterosacral ligament. (8) External iliac artery

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Part V Laparoscopic Anatomy of the Pelvic Floor in Women with a Genital Prolapse Seen After Peritoneal Incision

Laparoscopic Aspects of Urethro-Cystocele

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20.1 S  tress Urinary Incontinence: Colposuspension or Burch Procedure (Fig. 20.1)

20.2 L  aparoscopic Aspect of Lateral Cystocele Secondary to Paravaginal Defects (Fig. 20.2)

The colposuspension is performed on the right side. In the right extremity of the figure, we see the fixation with nonabsorbable sutures between the pubocervical fascia and the Cooper’s ligament. The colposuspension remains not done on the left side. We see well the left urethro-cystocele before the left colposuspension. The asymmetry between the two sides is evident. The anatomical effectiveness of the technique on the right side is clear.

Detachment at the level of the endopelvic fascia and levator ani from the ATFP is at the origin of paravaginal defects. These injuries may be treated specifically by paravaginal repair. The endopelvic fascia is then attached to the ATFP (or Cooper’s ligament) in order to ensure the ventrolateral support of the vagina. On the right side, the protected finger introduced in the lateral cul-de-sac of the vagina gives a good exposition of the fascia that needs to be fixed.

20.2  Laparoscopic Aspect of Lateral Cystocele Secondary to Paravaginal Defects Fig. 20.1  Stress urinary incontinence. Colposuspension or Burch procedure. (1) Vagina not yet suspended. (2) Right colposuspension done. (3) Bladder. (4) Cooper’s ligament. (5) Pubis

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Fig. 20.2 Laparoscopic aspect of paravaginal defect (right side). (1) Bladder. (2) Vagina (paravaginal defect). (3) Cooper’s ligament. (4) Obturator muscle. (5) Corona mortis vessels. (6) Burch procedure still done

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20.3 P  aravaginal Repair: Passing Sutures Through the Vagina (Fig. 20.3) The exposition with the vaginal finger facilitates the fixation. The sutures in the vagina should not be transfixed. In this case, when transfixing the Cooper’s ligament, we have to take care of the right corona mortis vessels, visible on the right part of the figure.

20.4 Post-hysterectomy Paravaginal Repair (Fig. 20.4) The lateral colposuspension is started after limited cleavage of the bladder. The vagina and its endopelvic fascia are well individualized. The passage of a nonabsorbable suture should

20  Laparoscopic Aspects of Urethro-Cystocele

be performed quite deeply, in the fascia or the Cooper’s ligament. Often, the fascia and the vagina of the lateral cystocele are moored to a strong structure, the Cooper’s ligament. The degree of suspension elevation is precisely evaluated by the vaginal finger to avoid overcorrection. And then the knot is made. Several sutures are performed to treat the whole of the cystocele area.

20.4  Post-hysterectomy Paravaginal Repair

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Fig. 20.3  Paravaginal repair: passing sutures through the vagina (right side). (1) Bladder. (2) Vagina, paravaginal defect exposed by the finger. (3) Cooper’s ligament. (4) Obturator muscle. (5) Corona mortis vessels

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Fig. 20.4 Post-hysterectomy paravaginal repair (right side). (1) Vagina. (2) Cooper’s ligament. (3) Pubic bone. (4) Obturator muscle. (5) Corona mortis vessels

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20.5 P  aravaginal Repair (Right Side) (Fig. 20.5) The ventrolateral part of the vagina and its endopelvic fascia are suspended to the lateral pelvic wall with few nonabsorb-

20  Laparoscopic Aspects of Urethro-Cystocele

able sutures. The ‘mooring’ to the side wall can be done at the level of the ATFP, the obturator internus muscle or the Cooper’s ligament. In this figure, we see the fixation to the right Cooper’s ligament.

20.5  Paravaginal Repair (Right Side)

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Fig. 20.5  Paravaginal repair (right side). (1) Bladder. (2) Vagina. (3) Cooper’s ligament. (4) Obturator muscle. (5) Corona mortis vessels

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Laparoscopic Aspects of Prolapses of Anterior, Median and Posterior Compartments

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21.1 Lateral Detachment (Fig. 21.1)

21.2 Hernia (Fig. 21.2)

The lateral cystocele and uterus descent are evaluated by laparoscopy on the right side. ATFP and levator ani muscle are detached from obturator internus muscle fascia. The severity of destruction of the pelvic floor is demonstrated with the deep hole well seen.

In this another case, the destruction of the pelvic floor is evident with such a right deep hole that should be compared to a ‘hernia’. On the right, we observe the obturator nerve and Cooper’s ligament.

21.2 Hernia

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Fig. 21.1  Lateral detachment seen by laparoscopy (right side). (1) Bladder. (2) ATFP. (3) Obturator internus muscle. (4) Holes. (5) Subsidence of levator ani muscle

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Fig. 21.2  The deep hernia (right side). (1) Bladder. (2) ATFP. (3) Obturator internus muscle. (4) Holes: the deep hernia. (5) Subsidence of levator ani muscle. (6) Obturator nerve. (7) Cooper’s ligament. (8) Obturator canal

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21.3 A  nother Aspect of Injuries of Levator Ani Muscle (Fig. 21.3) In this case, we see multiple ‘disinsertions’ of the right levator ani muscle which extend the entire length of the ATFP. In addition, bladder and vagina are detached laterally.

21.4 L  aparoscopic Aspect of Severe Paravaginal Defects (Fig. 21.4) The pelvic floor defects are of great variety. In this figure, we see laparoscopic aspects corresponding with lateral cystocele and vaginal vault descent. We also see multiple disinsertions

of left levator ani muscle from obturator internus muscle and fascias, and also bladder from levator ani muscle. The detachment is observed on both sides of ATFP, below and above it. We observe that the biggest hole above the ATFP is quite posterior, close to the ischial spine, which is not seen in this figure.

21.4  Laparoscopic Aspect of Severe Paravaginal Defects

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Fig. 21.3  Disinsertions of levator ani muscle (right side). (1) Bladder. (2) ATFP. (3) Obturator internus muscle. (4) Holes. (5) Subsidence of levator ani muscle. (6) Obturator nerve. (7) Obturator canal. (8) Ischial spine

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21.5 Rectocele and Corresponding Treatment (Fig. 21.5) A case of laparoscopic treatment of rectocele with the rectovaginal cleavage is performed until the pelvic floor. After horizontal incision of the peritoneum, the rectovaginal dissection is usually bloodless in the correct cleavage plane.

The puborectal muscles are easy to differentiate from the rectum. Then, it is possible to cover with a mesh. The mesh can be cut to the size of the posterior vaginal dehiscence and then fixed to the puborectal muscles and the isthmus with few sutures or tackers. Then, it can be left free. It can also be joined to the promontofixation mesh, which is itself attached to the pubocervical fascia.

21.5  Rectocele and Corresponding Treatment

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Fig. 21.5  Rectocele and corresponding laparoscopic dissection. (1) Puborectal muscle. (2) Vagina. (3) Rectum. (4) Uterus

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Part VI Laparoscopic Lateral Suspension with Meshes to Treat Genital Prolapse (LLS)

Techniques of Laparoscopic Lateral Suspension with Uterus Preservation

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22.1 Dissection of the Vesicovaginal Space 22.1.1 Vesicovaginal Cleavage (Figs. 22.1, 22.2 and 22.3) The dissection is started by a horizontal incision of the peritoneum of the ventral cul-de-sac between bladder and uterus. The cleavage consists of anterior dissection of the vesicovaginal space in the right plane, between endopelvic fascia and detrusor, as in the technique of sacrocolpopexy. The cleavage plane is usually easy to find. It may

be more difficult after the caesarean section. In case of difficulty, it is sufficient to partially fill the bladder with serum coloured with methylene blue. The line of dissection to follow is then found. The dissection is made step by step with curved atraumatic scissors and with bipolar coagulation forceps for haemostasis. The bloodless space opens as and when between forward the vesical wall and behind the ventral part of the vagina. We see the vesicovaginal space after dissection with a precise haemostasis. The cranial part of the bladder pillars is often coagulated and cut.

22.1  Dissection of the Vesicovaginal Space

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Fig. 22.1  LLS: Vesico­ vaginal cleavage and peritoneal incision (the bladder is well seen). (1) Bladder. (2) Uterus

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Fig. 22.2 LLS: Vesicovaginal cleavage. (1) Bladder. (2) Uterus. (3) Vagina and fascia

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22.1.2 Final Dissection of the Vesicovaginal Space (Figs. 22.4 and 22.5) During the dissection, the introduction and the maintenance of a fixed pressure of a malleable flat blade or retractor with soft edges (or a Breisky vaginal retractor) into the anterior cul-de-sac of the vagina facilitate the cleavage. The height of dissection is on average 6 cm. It may be longer, depending on the severity of the anterior vaginal wall descent. It is just necessary to reach the level of the trigone, but no more low, to avoid any risk of post-operative dysuria. However, we believe that it is crucial to reach the lowest point possible close to the pelvic floor muscles in order to treat concomitant

cystocele adequately. This point of technique may limit the risk of secondary low hernia, close to the urethra. After cleavage, the fixation of the anterior flap of the peritoneum to the anterior abdominal wall is performed. We use a single suture with a long and straight needle, transfixing the anterior abdominal wall. It gives a good exposition of the vesicovaginal space. At this moment of the intervention, in case of posterior compartment treatment, we add another step of rectovaginal dissection. After the anterior dissection, we perform the posterior cleavage of the rectovaginal space until the perineal body and the anorectal junction are reached. These two steps allow mobilization of the bladder and the rectum from the apex of the vagina.

22.1  Dissection of the Vesicovaginal Space

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Fig. 22.3  LLS: The end of the vesicovaginal cleavage. (1) Bladder. (2) Bladder pillars. (3) Vagina and fascia

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Fig. 22.4 LLS: Vesicovaginal dissection facilitated by a ‘vaginal retractor’. (1) Vagina and fascia. (2) Bladder

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22.1.3 Lateral Cleavage (Fig. 22.6) It is important to release the side parts of the ventral face of the vagina to handle the lateral cystocele. The dissection is close to the vagina, and the ureter is far. This lateral dissection facilitates the precise placement of an anterior mesh.

22.2 The Choice of the Mesh 22.2.1 How to Choose a Mesh with Ideal Qualities?

of shrinkage of the mesh is imperative. The mesh should not deteriorate with time; a good longevity of the mesh may avoid the recurrence. Lightweight meshes with large pores of polypropylene have advantages: increased flexibility, reduction in discomfort, and reduction of risk of infection and shrinkage. Several studies have shown the qualities of titanium-coated polypropylene mesh (TiLOOP mesh®, pfm medical).

22.2.2 The Shape of the Mesh (Fig. 22.7)

For ‘preserving-uterus lateral suspension’, we use a T-shape mesh with a median strip cut in a piece of polyproIt is essential to choose a mesh that has certain physico-­ pylene mesh or a precut TiLOOP® (titanium-coated polychemical properties. The absence of chronic pain after propylene mesh Dubuisson 65 g/m2). The anterior strip is placement is an indispensable condition. Its structure 60  mm  ×  50  mm. The two lateral long side arms are should limit the risk of infection and erosion. The low risk 2 × 18 cm.

22.2  The Choice of the Mesh

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Fig. 22.5  LLS: Final vision of the end of vesicovaginal dissection, the vaginal retractor is still in place. (1) Bladder. (2) Uterus. (3) Vagina and fascia

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Fig. 22.7  LLS: The shape of the mesh

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22.2.3 Mesh Preparation (Fig. 22.8) The mesh is prepared by rolling and stitching of the two arms to facilitate the introduction through the 10 mm optic trocar. We can get in the mesh just by first introducing an arm, then median strip and finally the second arm.

22.3 Pelvic Positioning of the Mesh 22.3.1 Placement of the Median Strip of the Mesh (Fig. 22.9) The dimensions of the median strip must be adapted to the surface of the dissected and free anterior wall of the vagina,

and of the uterine isthmus or upper part of the vaginal vault. The edges of the strip should not touch the upper edge of the bladder. The ureter should be visible from a distance. The placement of the median strip on the anterior wall of the vagina is facilitated by the transvaginal blade. The median strip of the mesh is flattened over the vesicovaginal dissection plane. It is very important that no space exists between the mesh and the endopelvic fascia. It is to avoid the secondary appearance of ‘encysted pockets’ between these two structures that favour pain, erosions and recurrence. Then, it is fashioned over this area and fixed.

22.3  Pelvic Positioning of the Mesh Fig. 22.8  LLS: Mesh preparation for introduction

Fig. 22.9  LLS: Placement of the median strip of the mesh

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22.4 P  elvic Positioning of the Mesh (Continued) 22.4.1 Fixation of the Mesh to the Endopelvic Fascia and the Uterine Isthmus (Figs. 22.10, 22.11, 22.12, 22.13, 22.14 and 22.15) It is necessary to fix the mesh to the endopelvic fascia of the anterior wall of the vagina and the isthmus. This last fixation to the isthmus will partially enhance the pericervical ring. In general, the mesh is fixed with absorbable tackers (Absorba TackTM®, 4.1 mm × 5.1 mm, vicryl component, Medtronic)

introduced in a 5 mm trocar. The resorption time of the tacker is complete in few weeks, without any problem. In our experience, we did not have any complication with these tackers, even with transfixion of the vagina. Three or four sutures are placed preferentially at the bottom end of the strip and laterally on the top of the strip, and always on the isthmus to prevent uterus sliding. Thus, this last suture on the isthmus is important to avoid a recurrence or descent of the uterus and the cervix. More sutures may be necessary, but avoiding always too much sutures. Absorbable sutures are used by some authors. Intraperitoneal knots are often used.

22.4  Pelvic Positioning of the Mesh (Continued)

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4 Fig. 22.10  LLS: Anterior placement of the strip. (1) Fixation of the peritoneum to the anterior abdominal wall above the pubic bone for exposition. (2) Bladder. (3) Mesh. (4) Isthmus

Fig. 22.11  Fixation of the mesh to the endopelvic fascia of the anterior wall of the vaginal with absorbable tackers

Fig. 22.12  LLS: Fixation of the mesh with sutures (intraperitoneal knots)

Fig. 22.13  LLS: Continuation of fastening using sutures

Fig. 22.14  LLS: Vaginal fixation at the bottom end of the strip

Fig. 22.15  LLS: The end of the fixation

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22.5 S  uspension by the Two Arms of the Mesh: Stretched Laterally 22.5.1 The Lateral Suspension (Figs. 22.16 and 22.17) The suspension must be carried out in a well-adapted transverse axis. The good result is obtained when the uterus is

returned to its original physiological position in the middle of the pelvic cavity. We see the procedure on the left side. The skin lateral incision for suspension is well defined: 3  mm skin incision on both sides. It is located at 4  cm ­posterior to the anterior superior iliac spine, 2 cm above the iliac crest.

22.5  Suspension by the Two Arms of the Mesh: Stretched Laterally

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Fig. 22.16  LLS: The skin lateral incision for suspension (left side). (1) Anterior superior iliac spine. (2) Incision for the left accessory trocar 2

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Fig. 22.17  LLS: The skin lateral incision (left side). (1) Skin incision

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22.5.2 The Way of the Forceps (Figs. 22.18 and 22.19) From ‘outside-in’, a Manhes-type 5  mm forceps takes two different directions: First, a direction perpendicular to the abdominal wall: It perforates the aponeurosis, and not the peritoneum. The forceps should stop just behind the peritoneum without perforating it. Second, the direction of the forceps changes: The forceps takes a way perpendicular to the

previous one. Then the forceps is pushed towards the round ligament at the level of its uterine insertion. During its whole journey, the forceps are in a retroperitoneal tunnel, under transperitoneal visualization. The forceps ‘slides’ under the peritoneum, above the external iliac artery, until the round ligament. The forceps passes below the ligament until the vesicovaginal space, previously prepared with the vesicovaginal cleavage.

22.5  Suspension by the Two Arms of the Mesh: Stretched Laterally Fig. 22.18  LLS: The way of the forceps (right side). (1) The forceps, perpendicular to the skin. (2) External iliac artery. (3) Round ligament

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Fig. 22.19  LLS: The way of the forceps: Change in direction of the laparoscopic forceps (right side). (1) The forceps, changing direction. (2) External iliac artery. (3) Round ligament. (4) Ureter

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22.5.3 The Change of Direction (Fig. 22.20) In this figure, on the other side, we see the change of direction at 90°, towards the round ligament, and then under this one.

22.5.4 The Grasping of the Mesh on Both Sides (Figs. 22.21, 22.22, 22.23 and 22.24) The extremity of the side arm of the mesh, placed in the open vesicovaginal space, is grasped by the same forceps

and pulled backwards through the previously formed tunnel. The arm of the mesh must be well flattened and applicated ­without any torsion. The same procedure is made on the opposite side. This technique of grasping and externalizing the mesh is important for the success of the procedure. The sliding of the mesh in its tunnel must be performed slowly. It is important not to widen the tunnel diameter to avoid any risk of secondary slip.

22.5  Suspension by the Two Arms of the Mesh: Stretched Laterally

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Fig. 22.20  LLS: The change of direction (left side). (1) External iliac artery. (2) Round ligament. (3) The forceps changing direction. (4) Uterus. (5) Vesicovaginal space

Fig. 22.23  LLS: The grasping of the mesh (right side)

1 3 1 2 Fig. 22.21  LLS: The grasping of the mesh (left side). (1) Round ligament. (2) Uterus

Fig. 22.22  The traction of the arm of the mesh (left side)

2 Fig. 22.24  LLS: The grasping of the mesh (left side): We see that the forceps are far from the bladder, ureter and external iliac artery. (1) Bladder. (2) Ureter. (3) External iliac artery

Final Evaluation of the Correct Technique of Laparoscopic Lateral Suspension

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23.1 The Final Evaluation 23.1.1 A Precise and Symmetrical Application (Fig. 23.1) The tension of the mesh is symmetrically adjusted. By this procedure we provide symmetrical lateral tension-free suspension of the central mesh part attached to the vagina and isthmus. Procidentia of the uterus and cystocele are hereby treated.

23.1.2 Positioning The symmetrical lateral tension-free suspension of the mesh which is attached to the vagina and isthmus is again

evaluated. Apex prolapse and cystocele are hereby treated without tension. This figure shows that the uterus is in physiological position, without any tension, well situated in the centre of the pelvic cavity.

23.1.3 End of Procedure (Fig. 23.2) Then the peritoneum is closed over the graft so as to cover it completely with absorbable sutures. At the end, the exteriorized extremity of the side arms is cut at the level of the skin always after exsufflation.

23.1  The Final Evaluation Fig. 23.1  LLS: A precise and symmetrical application

Fig. 23.2  LLS: End of the procedure

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23.2 The Correct Technique of LLS 23.2.1 This Figure Precisely Shows the Direction of the Mesh (Fig. 23.3) The arms of the mesh must be in a transverse position. The angle made by the round ligament and the arm of the mesh must be 45°. There is usually no fixation of the mesh to the abdominal wall. Indeed, the mesh adheres very quickly to the abdominal wall, which is favoured by its trip in bayonet. We fix the mesh to the abdominal wall (aponeurosis) with one absorbable stitch only in very thin patients, when it is

considered that the mesh will not adhere well to the abdominal wall.

23.2.2 This Figure Shows the Final Good Technique (Fig. 23.4) Good application of the anterior strip of the mesh with an adequate fixation, soft lateral suspension, without tension, and fixation, with exteriorization of the mesh at about 4 cm behind the iliac spine, cutting of the mesh at the level of the skin, bilaterally.

23.2  The Correct Technique of LLS

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Fig. 23.3  The different directions of the mesh and the round ligament





Fig. 23.4  The correct technique

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Mesh cut at the level of the skin 



Good tension

Large application of the strip Good technique …

Optional Treatment of the Posterior Compartment and Techniques of Laparoscopic Lateral Suspension for Vaginal Vault Prolapse

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24.1 Treatment of the Posterior Compartment 24.1.1 Evaluation of the Posterior Compartment With the technique of ‘uterus-preserving lateral suspension’, the posterior compartment has to be evaluated and restored if necessary. This step is optional. It is always clinically evaluated and more precisely when there is a preoperative constipation. This step is always carried out when there is an associated rectocele and/or enterocele. In the case of anterior and posterior pelvic floor defects, the anatomical result of the posterior compartment is better when we associate posterior repair with a laparoscopic rectovaginal mesh or with a posterior colporrhaphy performed vaginally.

24.1.2 Treatments of the Posterior Compartment We use two techniques to treat the posterior compartment defects.

The first possibility is a laparoscopic treatment. It starts with the rectovaginal dissection. We place a posterior rectangular mesh (polypropylene) of the size of the rectovaginal dissection corresponding to the defect (usually rectangle of 6–7 cm side). The mesh is always fixed. The aim is to avoid the rectangular mesh from coiling secondarily with the physiological movements of neighbouring organs. We use absorbable tackers or few sutures, just to prevent movement or winding. The placement is always performed before the anterior fixation of the mesh of LLS for practical operational facilities. The fixation of the mesh to the puborectal muscles with suture or tackers is easy to do. The peritoneal closure may be associated with a culdoplasty (Figs. 24.1 and 24.2). The second possibility is to treat the posterior compartment vaginally. A posterior colporrhaphy through the vaginal route is a good association especially in case of perineal insufficiency.

24.1 Treatment of the Posterior Compartment Fig. 24.1  Treatment of the posterior compartment: The laparoscopic option with the placement of a rectovaginal mesh

Fig. 24.2 Rectovaginal mesh: The end of the procedure

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24.2 T  he Technique of LLS for Vaginal Vault Prolapse We can use two techniques of laparoscopic lateral suspension for vaginal vault prolapse (uterus absent) or after supracervical hysterectomy. The first one is the suspension with a T-shape mesh (polypropylene mesh or TiLOOP®), for lifting the anterior vaginal wall, and treating the apical loss of support, with eventually concomitant treatment of the posterior vaginal wall (rectovaginal reinforcement with mesh or vaginal posterior colporrhaphy). The second procedure is the suspension with a cross-­ shaped mesh (polypropylene or titanium-coated polypropyl-

ene mesh, TiLOOP EndoLAS®, pfm medical). The cross-shaped mesh is only indicated in large vaginal vault prolapse.

24.2.1 Cross-Shaped Mesh (Fig. 24.3) and Vaginal Vault Prolapse Suspension (Figs. 24.4 and 24.5) The mesh has two strips and two arms: one strip fixed to the anterior wall, and the other strip fixed to the posterior wall of vagina, 60  ×  50  mm each. Each strip can be cut shorter depending on the extent of vagina to be covered. The ‘wing spread’ is 415 × 30 mm each.

24.2 The Technique of LLS for Vaginal Vault Prolapse Fig. 24.3  The cross-shaped mesh

Fig. 24.4  LLS for vaginal vault prolapse: Aspect after fixation of the mesh to the vaginal vault

Fig. 24.5  LLS for vaginal vault prolapse: the suspension

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Pelvic organ prolapse (POP) may affect the woman’s quality of life. It is currently accepted that POP has a prevalence of 3–6% when defined by symptoms and up to 50% when based on vaginal examination [1–3]. However, only 10–20% of women need precise evaluation of their condition [4]. The main treatment is surgical. There are a significant number of corrective surgical techniques for POP described in the literature, which shows that there is still a lack of consensus on this issue. The traditional vaginal techniques with native tissue are still performed in many centres. Recent advances in laparoscopy and in robot-assisted laparoscopy explain that many centres are orienting themselves and practising these new techniques for prolapse.

25.1 LLS with Mesh, a Recent Technique Laparoscopic sacrocolpopexy has been considered to be the gold standard for the treatment of POP [5] since 20 years. This technique requires dissection at the level of the promontory, which can be challenging, particularly in obese women and when anatomic variation exists. Serious neurological or ureteral morbidity as well as life-threatening vascular injury can be the consequence of potential lesions in the sacral area [6]. Moreover, significant dorsolumbar pain in up to 50% of patients has been described following the use of sutures or nonabsorbable tackers at the sacrum [7]. According to these potential problems, laparoscopic lateral suspension with mesh (LLS) could be an alternative, already first published 15 years ago [8].

25.2 Literature Review and Discussion Several studies [8–11] were published, with results of the technique of LLS with mesh, to treat POP. The more recent study [11] concerns 417 patients treated between 2003 and 2011, in the University Hospitals of Geneva. For the follow­up, at 1 year, 78.4% of patients were asymptomatic, and anatomic success rates were 91.6% for the anterior compartment, 93.6% for the apical compartment and 85.3% for the posterior compartment. The complication rate of Clavien-Dindo grade III or higher was 2.2% [12]. The mesh exposure rate was 4.3%, and the reoperation rate was 7.3%. Of the 417 patients, 214 participated in the telephone interview. Over 85% rated their situation as improved, and satisfaction was associated with the absence of concomitant hysterectomy. This large series of LLS with mesh showed that the technique is feasible and effective in a population of slightly overweight patients with low post-operative complications at 1 year and high long-term satisfaction. With a mean follow-­up of 7.2 years (11–79 months), to our knowledge, this is one of only a few reports of laparoscopic prolapse repair including more than 200 patients followed up for more than 30 months. Comparing this study with large series on sacrocolpopexy and sacral hysteropexy, we observe that the patients not only

25  Lateral Suspension: Focus on

had comparable demographic characteristics and gynaecological and obstetric history, but also had acceptable perioperative outcomes [13–16]. At 1 year, anatomically there was a significant reduction in POP-Q points Aa, C and Ba as compared with the preoperative assessment. The overall objective success rate of more than 90% at 1 year in both the anterior compartment and the apical compartment is comparable to the success rates following sacrocolpopexy and sacral hysteropexy reported in previous studies [6, 17]. The low rate of post-operative symptomatic prolapse is a proof of the success of the technique in terms of subjective cure rate. Overall, the results indicate excellent outcomes according to the composite criteria described by Barber et al. [18]. With the technique of uterus-preserving lateral suspension, the posterior compartment has to be evaluated and restored if necessary. Indeed, the anatomic result of the posterior compartment was better when there was associated posterior repair with a rectovaginal mesh or by posterior colporrhaphy. The suspension axis of a lateral mesh may lead to enterocele or pouch of Douglas hernia if the perineal muscles are insufficient or a rectocele is present. Moreover, Burch colposuspension may be a risk factor for the posterior compartment and was frequently performed in the series [11]. This could explain that the most common site of de novo prolapse in the absence of posterior treatment is the posterior compartment. These findings suggest the need for such concomitant treatment. Only 4% of patients developed de novo constipation, which is a lower rate than previously reported for sacropexy, probably because of the absence of potential lesions of the hypogastric plexus with the lateral technique. Perioperative complications of Clavien-Dindo grade III or more occurred rarely [11], and conversion to laparotomy was not necessary, which is in accordance with previously reported results with other techniques. However, lesions of the superior hypogastric plexus, right hypogastric nerve and spondylodiscitis are known complications of sacral fixation, and several cases have been described in the literature [19]. The advantage of the lateral technique is that it avoids dissection at the level of the promontory and the associated risks of neurological, vascular, ureteral or other tissue lesions, which are commonly reported in obese women. Mesh-related complications including exposure or extrusion occurred in 4.3% of patients [11] which is consistent with findings reported for other laparoscopic prosthetic POP repairs [20]. During the period of their study [11], the authors switched from polyethylene meshes to polypropylene meshes and later to titanium-coated polypropylene meshes. The majority of their mesh complications occurred with polyethylene. It is well known that knitted meshes with larger pores greater than 1 mm allow macrophage and leucocyte migration and thus improve flexibility, promote tissue ingrowth and reduce infection and probably erosion. Polypropylene is the mesh material with the lowest stiffness and allows the development of well-organized, fibrous, mature connective tissue [21]. A titanium layer over

References

polypropylene may improve the benefits of polypropylene, as demonstrated in hernia repair. However, in POP surgery, there is no evaluation demonstrating any superiority in terms of patient outcome or satisfaction. After LLS [11], only 7.3% of patients had reoperation for POP, which is consistent with the systematic review of Nygaard et al. [22] which found a median reoperation rate for prolapse recurrence of 4.4% after abdominal sacrocolpopexy (0–18.2%) with follow-up intervals ranging from 6 months to 3 years, and is lower than the 23% recurrence rate for laparoscopic sacrocolpopexy found by Maher et al. [23]. LLS seems to preserve normal sexual function, but the absence of dyspareunia after this surgical procedure has to be confirmed. We can only speculate about the fact that more women were sexually active after surgery than before. The independent factors predicting higher satisfaction rate after POP surgery with LLS were the absence of concomitant hysterectomy with POP surgery and the absence of constipation at 1 year. It is known that in recent years, changes in attitudes towards sexuality, the psychological value of the reproductive organs and the desire to preserve fertility have led to a growing interest in uterus-preserving surgery for POP. LLS is an efficient uterus-preserving option [24]. LLS with mesh to treat genital prolapse is a feasible alternative to sacrocolpopexy, especially in obese patients. LLS can be performed with or without uterus preservation with low complication rates and high long-term patient satisfaction.

References 1. Barber MD, Maher C.  Epidemiology and outcome assessment of pelvic organ prolapse. Int Urogynecol J. 2013;24(11):1783–90. 2. Nygaard I, Barber MD, Burgio KL, Kenton K, Meikle S, Schaffer J, et  al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA. 2008;300(11):1311–6. 3. Handa VL, Garrett E, Hendrix S, Gold E, Robbins J. Progression and remission of pelvic organ prolapse: a longitudinal study of menopausal women. Am J Obstet Gynecol. 2004;190(1):27–32. 4. Morrill M, Lukacz ES, Lawrence JM, Nager CW, Contreras R, Luber KM.  Seeking healthcare for pelvic floor disorders: a population-­based study. Am J Obstet Gynecol. 2007;197(1):86. e1–6. 5. Akladios CY, Dautun D, Saussine C, Baldauf JJ, Mathelin C, Wattiez A. Laparoscopic sacrocolpopexy for female genital organ prolapse: establishment of a learning curve. Eur J Obstet Gynecol Reprod Biol. 2010;149(2):218–21. 6. Matthews CA.  Minimally invasive sacrocolpopexy: how to avoid short- and long-term complications. Curr Urol Rep. 2016;17(11):81. 7. Vieillefosse S, Thubert T, Dache A, Hermieu JF, Deffieux X.  Satisfaction, quality of life and lumbar pain following laparoscopic sacrocolpopexy: suture vs. tackers. Eur J Obstet Gynecol Reprod Biol. 2015;187:51–6.

211 8. Dubuisson JB, Jacob S, Chapron C, Fauconnier A, Decuypere F, Dubernard G.  Laparoscopic treatment of genital prolapse: lateral utero-vaginal suspension with 2 meshes. Results of a series of 47 patients. Gynecol Obstet Fertil. 2002;30(2):114–2009. 9. Dubuisson JB, Yaron M, Wenger JM, Jacob S. Treatment of genital prolapse by laparoscopic lateral suspension using mesh: a series of 73 patients. J Minim Invasive Gynecol. 2008;15(1):49–55. 10. Dubuisson J, Veit-Rubin N, Bouquet de Jolinière J, Dubuisson JB.  Laparoscopic lateral suspension: benefits of a cross-shaped mesh to treat difficult vaginal vault prolapse. J Minim Invasive Gynecol. 2016;23(5):672. 11. Veit-Rubin N, Dubuisson JB, Gayet-Ageron A, Lange S, Eperon I, Dubuisson J.  Patient satisfaction after laparoscopic lateral suspension with mesh for pelvic organ prolapse: outcome report of a continuous series of 417 patients. Int Urogynecol J. 2017;28(11):1685–93. 12. Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250(2):187–96. 13. Rozet F, Mandron E, Arroyo C, Andrews H, Cathelineau X, Mombet A, et al. Laparoscopic sacral colpopexy approach for genito-urinary prolapse: experience with 363 cases. Eur Urol. 2005;47(2):230–6. 14. Rivoire C, Botchorishvili R, Canis M, Jardon K, Rabischong B, Wattiez A, et  al. Complete laparoscopic treatment of genital prolapse with meshes including vaginal promontofixation and anterior repair: a series of 138 patients. J Minim Invasive Gynecol. 2007;14(6):712–8. 15. Claerhout F, De Ridder D, Roovers JP, Rommens H, Spelzini F, Vandenbroucke V, Coremans G, Deprest J. Medium-term anatomic and functional results of laparoscopic sacrocolpopexy beyond the learning curve. Eur Urol. 2009;55(6):1459–67. 16. Krause HG, Goh JT, Sloane K, Higgs P, Carey MP. Laparoscopic sacral suture hysteropexy for uterine prolapse. Int Urogynecol J Pelvic Floor Dysfunct. 2006;17(4):378–81. 17. Gutman R, Maher C.  Uterine-preserving POP surgery. Int Urogynecol J. 2013;24(11):1803–13. 18. Barber MD, Brubaker L, Nygaard I, Wheeler TL 2nd, Schaffer J, Chen Z, et al. Defining success after surgery for pelvic organ prolapse. Obstet Gynecol. 2009;114(3):600–9. 19. Propst K, Tunitsky-Bitton E, Schimpf MO, Ridgeway B. Pyogenic spondylodiscitis associated with sacral colpopexy and rectopexy: report of two cases and evaluation of the literature. Int Urogynecol J. 2014;25(1):21–31. 20. Maher C, Feiner B, Baessler K, Schmid C. Surgical management of pelvic organ prolapse in women. Cochrane Database Syst Rev. 2013;(4):CD004014. 21. Le TH, Kon L, Bhatia NN, Ostergard DR. Update on the utilization of grafts in pelvic reconstruction surgeries. Curr Opin Obstet Gynecol. 2007;19(5):480–9. 22. Nygaard IE, McCreery R, Brubaker L, Connolly A, Cundiff G, Weber AM, et  al. Abdominal sacrocolpopexy: a comprehensive review. Obstet Gynecol. 2004;104(4):805–23. 23. Maher CF, Feiner B, DeCuyper EM, Nichlos CJ, Hickey KV, O’Rourke P.  Laparoscopic sacral colpopexy versus total vaginal mesh for vaginal vault prolapse: a randomized trial. Am J Obstet Gynecol. 2011;204(4):360.e1–7. 24. Veit-Rubin N, Dubuisson J, Constantin F, Lange S, Eperon I, Gomel V, Dubuisson JB. Uterus preservation is superior to hysterectomy when performing laparoscopic lateral suspension with mesh. Int Urogynecol J. 2019;30:557–64.

Part VII Laparoscopic Sacrocolpopexy to Treat Genital Prolapse (SCP)

Techniques of Laparoscopic Sacrocolpopexy (SCP) to Treat Genital Prolapse, With or Without Preservation of the Uterus

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We will describe the techniques usually performed, with or without preservation of the uterus. Laparoscopic sacrocolpopexy is proposed to treat symptomatic post-hysterectomy vaginal vault or multicompartment genital organ prolapse with high success rates. In this figure, we see the different trajectories of the main organs of the promontory area: iliac vessels, ureter and middle sacral artery (Fig. 26.1). The main surgical steps of the procedure are described below.

26.1 Exposition of the Promontory, Anterior Cul-de-sac and Cul-de-sac of Douglas (Fig. 26.2) A perfect exposition of the promontory area is essential to prevent complications. The Trendelenburg position is recommended. The promontory dissection is improved by the

mobilization of the left colon which can be transitorily fixed to the left anterior and lateral abdominal wall. The loops of small intestine are pushed back. Posterior dissection needs an anterior retraction of the uterus by using a uterine manipulator. For the anterior dissection, the uterus is pushed dorsally. In case of a post-hysterectomy vaginal vault prolapse, a malleable retractor or a Breisky retractor introduced into the vagina helps to show the correct dissection planes.

26.1 Exposition of the Promontory, Anterior Cul-de-sac and Cul-de-sac of Douglas Fig. 26.1  Exposure of sacral promontory: anatomical landmarks. Ureter (yellow line), right common iliac artery and middle sacral artery (thick and thin red lines, respectively). (1) Middle rectal artery, (2) Ureter, (3) Right common iliac artery, (4) Hypogastric nerve, (5) Uterosacral ligament

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Fig. 26.2  SCP: Exposition of the promontory. (1) Middle sacral artery. (2) Promontory

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26.2 D  issection of the Presacral Space (Fig. 26.3) The presacral space is dissected until the exposure of the anterior longitudinal vertebral ligament. The middle sacral artery is held to the left of the dissection. There is no reason to coagulate it. The left common iliac vein needs to be visualized. It is usually above our area of dissection. But it may be very difficult to see in obese patients. A right lateral superficial peritoneal incision is then extended medial to the ureter and lateral to the rectum from the promontory area to the recto-­ uterine pouch. The incision will enable the mesh to be peritonealized at the end of the procedure. Right hypogastric nerve must be seen and needs to be carefully avoided at the level of the promontory and also below. The hypogastric nerve is seen by transparency under the peritoneum.

Uterus is generally preserved in order to decrease operative time and also the risk of mesh exposure. In case of a uterine pathology, supracervical hysterectomy is preferred and has two advantages: It may prevent subsequent mesh erosion of the vaginal vault, and the isthmus ensures a secure attachment of the mesh.

26.3 Dissection of the Vesicovaginal Space The dissection of the vesicovaginal space is made in the right plane. The cleavage is performed between fascia and detrusor. The dissection is done as for the LLS technique. The cranial part of the bladder pillars is often coagulated and cut. The procedure is performed with curved atraumatic scissors and with bipolar coagulation forceps for haemostasis.

26.3 Dissection of the Vesicovaginal Space

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Fig. 26.3  SCP: Dissection of the sacral promontory, reaching the anterior longitudinal ligament (presacral space). (1) Incision of the peritoneum. (2) Bowel

2 1

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26.4 S  CP: Posterior Compartment Correction (Figs. 26.4, 26.5 and 26.6) A posterior compartment correction is associated in case of a significant high rectocele. To start the dissection, the peritoneum opposite the torus uterinus is grasped and incised. After

large opening between the uterosacral ligaments, it is easy to find the good cleavage plan that is bloodless. Dissection of the rectovaginal space is performed easily until reaching the levator ani muscles bilaterally (puborectal muscle) and the perineal body. But we know that low rectocele and perineal body insufficiency are better corrected through vaginal way.

26.4  SCP: Posterior Compartment Correction

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Fig. 26.4  SCP: Landmarks of the rectovaginal space. (1) Left levator ani muscle (puborectal). (2) Vagina. (3) Perineal body. (4) Rectum. (5) Right puborectal muscle

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Fig. 26.5  SCP: Recto-­ vaginal space: General view during dissection. (1) Puborectal muscle. (2) Rectum. (3) Uterine isthmus. (4) Vagina

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26.5 S  CP: Fixations of the Mesh (Figs. 26.7, 26.8 and 26.9) A polypropylene monofilament macroporous nonabsorbable mesh or a titanium-coated polypropylene mesh is placed along the anterior vaginal wall and passed through the right broad ligament via a peritoneal window. The cranial part of the mesh is attached to the previously dissected promontory with a single interrupted nonabsorbable stitch

put on the anterior longitudinal ligament. We do not recommend the use of tackers because of the potential risk of lumbosacral discitis. The caudal part of the mesh is attached to anterior vaginal wall with absorbable tackers and/or absorbable sutures. A patch of the mesh is placed along the posterior vaginal wall if necessary, attached to the levator ani (puborectal) but not fixed at the promontory level in order to prevent excessive tension (tension-free principle).

26.5  SCP: Fixations of the Mesh

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Fig. 26.6  SCP: Left levator ani muscle (puborectal) exposure after complete dissection of the rectovaginal space. (1) Puborectal muscle. (2) Perineal body. (3) Rectum. (4) Vagina

4

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Fig. 26.7  SCP: Technique of placement of the nonabsorbable suture in the anterior longitudinal ligament

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26.6 Peritonization of the Mesh (Fig. 26.10) Finally, complete peritonization of the mesh is achieved with a running absorbable suture to minimize complications related to bowel adhesions.

26.6  Peritonization of the Mesh

225

Fig. 26.8  SCP: Placement of the mesh fixed to the promontory with sutures. (1) Promontory. (2) Suture placed in the ligament. (3) Right ureter. (4) Right adnexa. (5) Bowel

4 5 2 3 1

Fig. 26.9  SCP: Mesh fixed to the cervix and the promontory. Tension adapted to the severity of the cervix descent. The patient had a supracervical hysterectomy in the same time. (1) Cervix. (2) Mesh well applicated on the pubocervical fascia. (3) Adnexa. (4) Right ureter

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Fig. 26.10 SCP: Peritonealization with a continuous absorbable running suture to cover completely the mesh

Sacrocolpopexy: Focus on

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Laparoscopic sacrocolpopexy (SCP) is an effective procedure with a high success rate. There are few publications in the literature concerning long-term results of SCP. The subjective cure rate varies between 79% and 98% with a follow-­ up between 30.7 and 66  months. These excellent results are specially associated with the strong anchorage of the mesh to the promontory. The reoperation rate for pelvic organ prolapse recurrence is between 5% and 20.2%. It concerns mainly the anterior compartment. In those series, the surgical techniques described are very heterogeneous [1–6]. In some cases, recurrence of cystocele may be related to the posterior axis of the mesh fixed to the promontory, with insufficient flexibility, which opens too much the anterior compartment. As laparoscopic lateral suspension, a main advantage is that SCP does not shorten the vagina that is important in women with sexual activity. Specific complications related to SCP are not frequent; they include bowel symptoms like constipation or obstructed defecation, and nerve and vascular injury. Post-operative chronic pain may be avoided by a moderate tension of the mesh. Chronic lumbar pain de novo is not rare. More rarely, spondylodiscitis may occur. Because of the seriousness of this complication, the diagnosis must be made, as early as possible, and treated with ablation of the mesh, surgical washing, drainage and antibiotics [7]. It should be remembered that SCP is a high-morbidity

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procedure because of dissection and opening of the presacral space. For experienced surgeons, SCP remains the gold standard for the treatment of the pelvic floor defects.

References 1. Higgs PJ, Chua HL, Smith AR. Long-term review of laparoscopic sacrocolpopexy. BJOG. 2005;112(8):1134–8. 2. Rivoire C, Botchorishvili R, Canis M, et  al. Complete laparoscopic treatment of genital prolapse with meshes including vaginal promontofixation and anterior repair: a series of 138 patients. J Minim Invasive Gynecol. 2007;14(6):712–8. 3. Bui C, Ballester M, Chereau E, Guillo E, Darai E. Functional results and quality of life of laparoscopic promontofixation in the cure of genital prolapse. Gynecol Obstet Fertil. 2010;38(10):563–8. 4. Sarlos D, Kots L, Ryu G, Schaer G. Long-term follow-up of laparoscopic sacrocolpopexy. Int Urogynecol J. 2014;25(9):1207–12. 5. Sergent F, Resch B, Loisel C, Bisson V, Schaal JP, Marpeau L. Mid-­ term outcome of laparoscopic sacrocolpopexy with anterior and posterior polyester mesh for the treatment of genitourinary prolapse. Eur J Obstet Gynecol Reprod Biol. 2011;156(2):217–22. 6. Granese R, Candiani M, Perino A, Romano F, Cucinella G.  Laparoscopic sacrocolpopexy in the treatment of vaginal vault prolapse: 8 years’ experience. Eur J Obstet Gynecol Reprod Biol. 2009;146(2):227–31. 7. Vieillefosse S, Thubert T, Dache A, Hermieu JF, Deffieux X.  Satisfaction, quality of life and lumbar pain following laparoscopic sacrocolpopexy: suture vs. tackers. Eur J Obstet Gynecol Reprod Biol. 2015;187:51–6.

Anatomical References

1. Baggish MS, Karram MM. Anatomy and gynecologic surgery. 2nd ed. Philadelphia, PA: Saunders Elsevier; 2015. 2. Dubuisson JB.  Laparoscopic anatomy of the female genital tract, normal and pathologic aspects. Tuttlingen, GE: Endo: Press; 2014. (Karl Storz Endoscopy internet). 3. Kamina P. Anatomie clinique, vol. 4. 2nd ed. Paris: Maloine; 2008. 4. Netter FH. Reproductive system, vol. 2. New York: CIBA; 1965.

5. Poirier P, Charpy A.  Traité d’anatomie humaine, vol. 5. Paris: Masson; 1907. 6. Rouvière H. Anatomie humaire descriptive et topographique, vol. II. 9th ed., revisée par Cordier G et Delmas A. Paris: Maloine; 1962. 7. Sobotta coordonné par Putz R, Pabst R. Atlas d’anatomie humaine, vol. 2. Cachan: Editions Médicales Internationales; 2010.

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