Introduction

Hysterectomy is one of the most frequently performed disciplines in the discipline of gynaecology. The operative laparoscopic hysterectomy has gained popularity over the years and plays a significant more important role than the traditional abdominal and vaginal hysterectomy. Today hysterectomy can be performed to a patient if she happens to have symptomatic multifibroid uterus, infertility and bleeding abnormalities that are resistant to therapy.

Uterine prolapse cases are usually surgically treated in various facilities that have the relevant instruments that are required to carry out the procedures. Prolapse of any pelvic organ happens when the connective muscles within the body cavity become weak and therefore are unable to hold the pelvis in its natural orientation. Connective tissues often weaken with age, after childbirth, strenuous physical labour and when one gains weight. Those women who experience the uterine or any other pelvic organ prolapse, they usually have problems with the urinary incontinence, vaginal ulceration as well as sexual dysfunction.

Sacrocolpopexy

Sacrocolpopexy is a recommended procedure that can be used to treat and manage uterine prolapse in elderly women. In some facilities, doctors can use da Vinci Sacrocolpopexy which is a state-of-the-art surgical system that is designed to help the surgeon to perform a minimally invasive surgery small incisions.

Sacrocolpopexy is a term that can be divided into various parts that will give a better understanding of the term. Firstly, we need to understand that Sacrocolpopexy is a procedure used to surgically treat vaginal vault prolapse which involves the use of mesh to hold the vagina in the correct anatomical position. Basically, the term literally means lifting the vagina to the pelvic bone and here is how the term Sacrocolpopexy can be divided into, Sacro which is the portion of the back bone of the pelvis, colpos- the vagina, and pex is to suspend or lift up.

Sacrocolpopexy can be performed along with total hysterectomy to treat uterine prolapse and provide a long term support of the vagina. Total laparoscopic hysterectomy is a minimally invasive procedure used to remove the uterus completely. When total laparoscopic hysterectomy is performed along with Sacrocolpopexy, the long term cure rates are often very high, and are rated at about 90%. The procedure will provide complete support to the vagina to the top and front of the vagina which is an area that is most likely to prolapse.

The laparoscopic hysterectomy is often preferred by women as well as the surgeons because it offers various benefits over the traditional open abdominal approach. The benefits may include:

• ·        Significantly less pain since it involves only making small incisions unlike with the open approach
• ·        Less loss of blood, and hence no need for blood transfusion
• ·        less scarring due to the small incisions that are made
• ·        less risk of infection
• ·        hospital stay are often very short
• ·        shorter recovery time
• ·        The patients can return to their normal activities within a very short time.

Sacrocolpopexy has always been performed as an open surgery where a 6-12 inch horizontal incision is made in the lower abdomen. The large incision allows the surgeon to access the inter-abdominal organs manually as well as the uterus. The laparoscopic hysterectomy is minimally invasive and involves making five small incisions. The surgeon can view the internal organs on a monitor in which images are sent by a camera that is inserted in one of the incisions. In fact, when laparoscopic hysterectomy is done, most women go home the next day.

Contraindications of Sacrocolpopexy

Sacrocolpopexy has several contraindications or complications where some can be the many for any surgical procedure. They may include:

• ·        Anaemia
• ·        Need for coagulation
• ·        Infections such as cystitis, bacterial or fungal vaginal infection
• ·        Active venous thromboembolism
• ·        Hyperglycaemia which can tend to be uncontrolled
• ·        Fistula such as the urethral fistulas, vesico-utero
• ·        Vaginal cancer, cervical cancer

Prevention of the complications

The postsurgical complications of Sacrocolpopexy can be reduced by understanding the risks of the surgical procedure. A complication such as neurapraxia can be avoided by adopting proper positioning and padding of pressure points. The length of time of the surgical procedure can be reduced in order to reduce the length of time the patient is in a position that increases risk for injury.

Venous thromboembolism can be reduced by using the prophylactic measures including placement of sequential compression devices early postoperative ambulation, and prophylactic doses of heparin in patient with increased risk factors.

Steps that lead to a successful Total Laparoscopic Hysterectomy

1.       Preparation and Positioning

Patients should be placed in a dorsal lithotomy position with the pnenumoboots. The arms should be tucked at the sides and a foam mattress should be placed directly under the patient in order to prevent sliding during the steep Trendelenburg. The table should be placed in a low position while the monitor is positioned in a way that is directly facing the surgeon. For the positioning to be very effective, the surgeon should have adequate knowledge about the equipment in the operating room. The operating room should not be crowded in order to allow free movement and easier access of the equipment that will be required at some point.

2.       Insertion of a uterine manipulator

Placing the uterine manipulator properly is very important for procedure to be successful. First, you can place a Sims Speculum into the vagina, grab the cervix with a tenaculum, and sound the uterus. Selecting the uterine manipulator of the appropriate tip size is also very important. You can insert the tip of the uterine manipulator as far into the cervix it will go, the release the tenaculum while keeping tension of the cervical stitch.

3.       Entry into the abdomen placement of the trocar

The internal organs can be accessed by first making small incisions in the abdomen. Through the incisions you can place the trocars. Trocars should be placed lateral to the rectus abdominus muscles.

4.       Handle the ovaries

The surgeon should stay close to the ovaries in order to avoid the pelvic sidewall during ovarian removal and the ascending uterine vessel during ovarian conservation. Special care should be upheld when desiccating parametrial veins that run between the ovary and the round ligament. This helps to prevent bleeding.

5.       Mobilize the bladder

It is wise to mobilize the bladder from the lower uterine segment by identifying the vesicouterine peritoneal fold and dissecting anteriorly.  Patients who have had a prior caesarean delivery ma have a scarred area, hence the surgeon should stay relatively high on the uterus during the dissection. If fat is encountered during the dissection, a re-evaluation of the route of dissection should be done because fat belongs to the bladder, thus when it is encountered it shows that the dissection is moving too close to the bladder.

6.       Keep the uterine vessels safe

 It is important to use the harmonic scalpel to skeletonize uterine vessels and then desiccating the ascending uterine vessels with the bipolar grasper. It is very important to observe the bubbles coming and going during the process. When the bubbles stop, it shows that the vessels has been desiccated and is safe to transect with the harmonic scalpel, where to cuts can be made in an inverted V-shaped anterior and medial and posterior and medial to the vascular pedicle. The vascular pedicle therefore falls out laterally which gives an easy access to the cervical cup.

7.       Remove the uterus

First the surgeon should separate the uterus and cervix from the vaginal apex. After the separation, you can pull the uterus into the vagina if it fits. The uterus can be removed where a glove with a pair of sponges is placed into the vagina in order to maintain pneumoperitoneum. However, if the uterus is too large to be removed through the vagina, it can be morcellated transvaginally.

8.       Cuff closure of the vagina

Closure should always start at the distal angle of the vaginal cuff and proceed in such a way that you’re including the vaginal mucosa and the pubocervical and rectrovaginal fascia. It is important to make sure that each bite is approximately 1 cm in thickness, however you should make sure you do not underestimate the thickness by viewing under the magnification of the laparoscope.

9.       Closure of the port size

Incision in the lower quadrant should be closed using the appropriate sutures such as the vicryl sutures with a fascia closure device. The skin should therefore be closed with a monocryl suture with regards to the subcutaneous fashion. 

Conclusion

Older women are often at a high risk for having prolapse conditions of the pelvic floor that would require intervention. Better interventions would be in form of total laparoscopic hysterectomy which can be performed along with the Sacrocolpopexy. These procedures have higher rates of success and when performed along each other they offer long term support to the vagina. Total laparoscopic hysterectomy is safe and effective for older women. However, before undergoing the surgery, the patients require a thorough history and physical examination as well as appropriate pre-operative testing.