This video demonstrates Sacrocolpopexy in patients with severe adhesion performed by Dr R K Mishra at World Laparoscopy Hospital. Pelvic organ prolapse (POP) regards an increasing number of women. The gold standard procedure for the POP is laparoscopic sacrocolpopexy. Adhesions often occur after pelvic surgery, with a lower incidence after laparoscopy. We present a laparoscopic sacrocolpopexy in a patient with severe pelvic adhesions. Laparoscopic surgical procedures for the treatment of POP are effective and safe techniques and prevent the formation of adhesions, but complex adhesions cases can increase the difficult of surgical procedures.

Sacrocolpopexy is a gold-standard surgical procedure for the correction of pelvic organ prolapse, particularly apical prolapse of the vagina. It involves suspending the vaginal apex to the sacral promontory using a synthetic mesh. While the procedure is highly effective, performing sacrocolpopexy in patients with severe intra-abdominal adhesions presents unique challenges for surgeons, requiring advanced laparoscopic skills and careful preoperative planning.

Etiology of Adhesions
Adhesions in the pelvic cavity commonly result from:

Previous abdominal or pelvic surgeries (e.g., hysterectomy, cesarean section)

Chronic pelvic inflammatory disease

Endometriosis

Radiation therapy

These adhesions can obscure normal anatomy, increase the risk of organ injury, and complicate dissection during sacrocolpopexy.

Preoperative Assessment

Imaging: MRI or CT scans can help evaluate the extent of adhesions and plan the surgical approach.

History: Detailed surgical history and previous complications should be reviewed.

Consent: Patients should be counseled regarding the increased risk of bowel, bladder, or vascular injury and potential conversion to open surgery.

Surgical Challenges

Limited visibility: Dense adhesions can obscure the sacral promontory and surrounding structures.

Increased operative time: Careful adhesiolysis is required to safely create a pathway for mesh placement.

Risk of injury: Adhesions increase the risk of inadvertent bowel, bladder, or ureteral injury.

Mesh placement: Proper tension-free fixation of the mesh can be difficult in a scarred environment.

Surgical Techniques for Adhesion Management

Laparoscopic adhesiolysis: Sharp and blunt dissection is performed under direct vision to free the vagina, rectum, and sacral promontory.

Hydrodissection: Saline injection can help separate planes and reduce tissue trauma.

Energy devices: Ultrasonic or bipolar devices may be used cautiously to minimize collateral thermal damage.

Sequential approach: Begin with adhesiolysis in areas distant from vital structures to create safe working space.

Mesh Fixation
Once adequate exposure is achieved, a polypropylene or composite mesh is positioned and fixed to the vaginal apex and sacral promontory. Attention must be given to avoid tension and ensure the mesh lies flat without folding or twisting, which is particularly challenging in patients with distorted anatomy due to adhesions.

Postoperative Considerations

Bowel function: Monitor closely due to risk of inadvertent bowel injury or delayed obstruction.

Infection prevention: Prophylactic antibiotics are crucial due to prolonged operative time.

Follow-up: Assess for mesh-related complications, recurrence of prolapse, or de novo urinary/bowel symptoms.

Conclusion
Sacrocolpopexy in patients with severe adhesions is technically demanding but feasible with careful preoperative planning, meticulous adhesiolysis, and advanced laparoscopic skills. Surgeons must be prepared for longer operative times, increased risk of complications, and possible conversion to open surgery. When performed successfully, it provides durable prolapse correction and significantly improves the patient’s quality of life.

For more information: https://www.laparoscopyhospital.com/