腹腔镜治疗泌尿生殖道脱垂（图文演示）

10. Dissection
• Objective
The inter-recto-vaginal dissection is the first step of the operative procedure. It is performed to dissect free the following structures:
- the rectum on its anterior and lateral surfaces down to the anal canal;
- the posterior vaginal wall;
- the levator ani muscles.

• Median dissection

1. Uterosacral ligaments
2. Posterior vaginal wall deformed by the valve
3. Rectum
The ribbon retractor introduced into the posterior vaginal cul-de-sac should be anteverted as far as possible to stretch the uterosacral ligaments. The exposed peritoneum is opened from one uterosacral ligament to the other in a V-shaped incision. A grasper retracts the inferior margin of the incised peritoneum, allowing access to an avascular plane that corresponds to the rectovaginal fascia. The dissection should be begun in a median plane, in contact with the posterior vaginal wall.

• Lateral dissection

1. Rectum
2. Laterorectal space
The lateral dissection is begun in contact with the uterosacral ligament to find the posterolateral wall of the vagina.
The space thus created enables the surgeon to perform a lateral dissection at a distance from the rectum and to gain access to the posterior portion of the levator ani muscles covered by their aponeurosis. This operative step requires a progressive dissection of the fatty laterorectal tissue, with care taken not to injure the hemorrhoidal vessels. In case of injury, a bipolar grasper should be used to perform hemostasis.

• Exposure of the levator ani muscles

1. Levator ani muscles
2. Rectum
Access to the levator ani muscles must be wide to anchor the prosthetic strip adequately.
The dissection is begun in contact with the pubococcygeus portion of the levator ani muscle and is pursued to the left of the rectum anteriorly and medially, to expose the pubococcygeus and the puborectalis fibers of the left levator ani muscle. The dissection of the right levator ani muscle is performed in an identical manner.
After exposure of the levator ani muscles, the remaining attachments of the rectum to the vagina are dissected free to allow for optimal positioning of the prosthesis.
A voluminous rectocele can make dissection of the inter-recto-vaginal space difficult, because it causes a considerable portion of the rectum to come into contact with the posterior surface of the vagina. Care must be taken to always perform the dissection against the posterior vaginal wall to avoid rectal injury.

11. Posterior prosthesis
• Inserting the prosthesis

The prosthesis is inserted into the abdominal cavity via the camera trocar.

• Attaching to the levator ani muscles

1. Rectum
2. Levator ani muscles
The prosthetic material is attached with a suture onto the right and left levator ani muscles. On the right, a forehand throw is anchored deep into the right levator ani muscle (pubococcygeus and puborectalis fibers). The muscle is taken cephalad to caudad at a distance from the rectum, while rotating the needle 180°. The suture is then tied, securing the mesh.
The needle is inserted in the same fashion on the left (backhand throw). Throughout this step, the assistant holds the ribbon retractor in an anteverted position in the posterior cul-de-sac.

• Vaginal attachment

1. Posterior wall of the vagina
The prosthesis is attached to the posterior wall of the vagina. When the two ends have been firmly anchored to the levator ani muscles, the midpoint of the curved portion of the mesh is anchored on the vagina deep in the previously dissected space. This is done to prevent the intestinal loops from coming between the curved portion of the mesh and the vagina.

12. Closure
Closure of the rectouterine pouch
1. Uterosacral ligaments
2. Rectum
3. Peritoneum
This is done with a suture to reapproximate the uterosacral ligaments and to re-peritonealize the rectouterine pouch.
A single stitch successively takes hold of the following elements:
- the uterosacral ligaments, laterally to medially;
- the left edge of the prosthesis, cephalad to caudad;
- the peritoneum, posteriorly to anteriorly;
- the peritoneum, anteriorly to posteriorly;
- the right edge of the prosthesis, caudad to cephalad;
- the right uterosacral ligament, medially to laterally.

13. Promontory
• Incision of the peritoneum

1. Posterior peritoneum
Preparation of the promontory requires a 25° to 30° Trendelenburg position.
This step takes advantage of the exposure that was achieved by suspending the uterus from the abdominal wall. The bulge of the promontory is identified tactually with the scissors’ tips. The assistant pushes back the distal ileal loops with a flat grasper. The posterior peritoneum is opened with the tip of monopolar scissors, while a grasper lifts it off from the posterior plane to prevent injury of the median presacral vessels. Once the peritoneum is incised, gas pressure opens the retroperitoneal dissection plane. This incision enables the surgeons to identify the primitive iliac venous axis as well as the ureter, both of which must remain outside and posterior to the dissection plane.

• Exposure of the promontory

1. Anterior longitudinal ligament
The anterior surface of the promontory is carefully dissected free with instrument tips to expose the pearly white surface of the anterior longitudinal ligament and the median sacral vessels. The peritoneal incision is continued down to the anterior rectal region. The exposure is facilitated by manipulating the ribbon retractor. We recommend opening the peritoneum rather than making a tunnel with a dissector, which can injure the vessels that run perpendicular to the axis of dissection.
It is possible to begin this part of the procedure by exposing the promontory and then performing the posterior step.

14. Vesico-vaginal dissection
• Ribbon retractor

1. Bladder
The bladder is identified by the balloon of the catheter. The ribbon retractor is placed in the anterior cul-de-sac or at the fornix of the vagina in the case of a hysterectomy. The ribbon retractor is directed posteriorly after transverse incision of the retrovesical peritoneum. The assistant holds the anterior edge of this peritoneum with an atraumatic grasper.

• Dissection

The dissection begins on the midline. The pearly white anterior surface of the vagina can be used as a landmark. By dividing the adhesional tissue with scissors, the bladder can be separated from the vagina. The dissection is performed over a 25 mm width to the retrotrigonal space.

15. Anterior mesh
• Anterior mesh

1. Uterus
2. Vesico-vaginal space
The tip of the mesh is bevelled and fitted with a preknotted, threaded suture. It is placed underneath the bladder, as far as possible from the vesico-vaginal dissection plane. The prosthesis is then attached laterally along the entire length of the vagina with 2 running sutures. The stitches should not transfix the vagina.

• Anterior prolapse of the uterus

1. Uterus
2. Uterine isthmus
When a decision is made to preserve the uterus, it is essential to remove the ribbon retractor and to retract the uterus posteriorly. This makes it possible to continue the running suture to attach the mesh to the level of the uterine isthmus, thereby preventing the cervix from protruding. The mesh is then slit lengthwise to take on the shape of the letter Y, the limbs passing through the open broad ligament in its avascular portion.
It is possible to pass the mesh on only one side of the uterus, through the right broad ligament.

16. Promontory fixation
• Fixation stitch

1. Mesosigmoid
2. Promontory covered by the anterior longitudinal ligament.
A single fixation stitch with non-absorbable suture is sufficient. A 26 mm long needle is used, directed forehand, grasped in the distal third of the needle holder’s jaws and directed 120° anteriorly. The stitch is performed laterally to medially and very gently, making sure that it does not enter the periosteum.

• Promontory fixation

1. Uterus
2. Anterior prosthesis
3. Posterior prosthesis
4. Promontory
The posterior prosthesis and then the anterior prosthesis are grasped after obtaining an appropriate tension. Although the traction created must not be too strong, it must offset the pressure of the pneumoperitoneum. The fixation is achieved by an extra-corporeal knot that can be used to evaluate the strength of the repair. The extra prosthetic material is cut and removed.

17. Repair of peritoneum

1. Anterior prosthesis
2. Posterior prosthesis
This is done using absorbable braided suture. The running suture first closes the anterior detachment. It passes through the right broad ligament when the uterus is preserved, and closes the peritoneal opening anterior to the prostheses, excluding them completely from the abdominal cavity. The surgeon must watch out for the right ureter, which remains attached to the right part of the posterior parietal peritoneum.

18. Drainage/closure
Because there is no bleeding, drainage is rarely necessary. Nevertheless, a Redon drain may be placed in the subperitoneal detachment. The trocar wounds are closed in the usual manner.

The urinary catheter can be removed when bowel function is restored on POD2, making hospital discharge possible on POD3.

19. Reference
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Scali P, Blondon J, Bethoux A, Gerard M. Les operations de soutenement-suspension par voie haute
dans le traitement des prolapsus vaginaux. J Gynecol Obstet Biol Reprod (Paris) 1974;3:365-78.
Wattiez A, Canis M, Mage G, Pouly JL, Bruhat MA. Promontofixation for the treatment of prolapse.
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