Vaginal vault suspension and enterocele repair by Richardson-Saye laparoscopic technique: description of training technique and results.

OBJECTIVES: To describe the Richardson-Saye technique for laparoscopic vaginal vault suspension and enterocele repair (vaginal apex reconstruction) and the appropriate training needed for performance of this technique.
METHODS: Before using this technique, Drs Carter, Winter, and Mendelsohn first received training by observation of skilled surgeons performing the procedure, attending courses, and finally being tutored and proctored by Dr Saye on the appropriate performance of the technique. They then used this technique to surgically treat eight patients, 42 to 85 years of age, mean age 62 years, between March and September of 1999.
RESULTS: We included eight patients in this study who underwent the Saye-Richardson vaginal vault suspension and enterocele repair (apical vaginal vault reconstruction) by the suture technique. In all patients at six-month follow-up, the vaginal apex remains intact and well supported. We describe here the entire vaginal vault suspension and enterocele repair procedure with all its relevant details.
CONCLUSION: Laparoscopic reconstruction of the disrupted vaginal apex followed by reattachment to the previously broken uterosacral ligament with the use of permanent suture provides a secure and anatomically correct vault suspension. Before performing this technique, physicians should undergo proper training, including observation, courses, tutoring, and proctorship by a surgeon experienced in performing this technique.

INTRODUCTION

The arrival of laparoscopic techniques for pelvic vault reconstruction has resulted in an ability to clearly visualize the fascial defects that are the basis of vault prolapse.

The proper performance of pelvic vault reconstruction, specifically apical enterocele repair and vaginal vault suspension, requires a paradigm shift in the understanding of the anatomy of the pelvis. Rather than viewing the anatomy in relation to the organ that protrudes into the vagina (such as rectocele), it is now necessary to view defects in pelvic support as defects in the actual fascia, or what can be termed in a paradigm shift, a “hernia.” Richardson[1] clearly described the anatomic defects in apical enterocele. Ross[2] elegantly reviewed apical vault repair, which is the cornerstone of pelvic vault reconstruction. Vaginal prolapse is present when the vaginal apex lies below the level of the hymenal ring. This occurs when the upper one third of the vagina that is suspended by the cardinal/uterosacral ligament complex breaks free of its attachments via the uterosacral ligaments to the sacrum. In addition, the middle one third of the vagina, which is maintained by lateral attachments, has frequently broken free. Lateral defects are often found in the anterior quadrant of these patients and can be unilateral or bilateral (paravaginal defects or detachments of the pubocervical fascia from its lateral attachment to the fascia of the obturator interna muscle at the level of the arcus tendineus fascia of the pelvis. The arcus tendineus pelvic fascia is the tendinous aponeurosis of the obturator internus muscle anteriorly and the levator ani complex posteriorly).[3-6] All pelvic support defects must be addressed to ensure integrity of the vagina and functional correction of associated stress incontinence, if it exists. This paper focuses on a technique for laparoscopic reconstruction of the vaginal apex and its secure reattachment to the broken uterosacral ligament complex.

MATERIALS AND METHODS

To learn the appropriate performance of the Richardson-Saye procedure for apical enterocele repair (vaginal apex reconstruction) and vault suspension by the laparoscopic technique, Drs Carter, Winter, and Mendelsohn observed skilled surgeons as they performed these procedures. Then, after careful study of the anatomy and assurance that they had acquired appropriate suture skills, they performed these procedures under the guidance of Dr Saye in both tutorial and proctorship surgical environments.

A step-by-step approach to the performance of this procedure gives the best assurance for its success. First, the anatomy must be understood by careful study of both written materials and videos. Then the procedure is observed in a live course setting and only then, with the assistance of an individual skilled at performing this procedure, is the procedure to be attempted. Following these appropriate training steps will lead to the best results in the hands of those who would like to begin using these procedures.

The apex of the vagina after hysterectomy is formed by the connection of the pubocervical fascia to the rectovaginal (Denonvilliers) septum (rectovaginal fascia). The rectovaginal fascia is a distinct fibrous tissue layer between the vagina and rectum in a diaphragm-like configuration, with its principle attachments located peripherally: cranially to the cul-de-sac peritoneum, the uterosacral ligaments and the base of the cardinal ligaments; caudally to the perineal body; and laterally to the fascia covering of the levator ani muscles. In the cul-desac, the rectovaginal fascia merges with the fibers of the uterosacral ligaments. In the area lateral to the upper vagina, it merges into the more lateral fibers of cardinal/uterosacral complex. An enterocele can occur if the pubocervical fascia separates from the rectovaginal fascia in the midline[1,7] ()

Richardson AC. Apical enteroceles. Image (top left) of a beginning enterocele. Notice the separation of the pubocervical fascia at the anterior wall from the rectovaginal fascia of the posterior vaginal wall. Further separation and further decent (top right, lower left) of the vaginal apex is noted (true vaginal vault prolapse). A diagrammatic representation (lower right) of the enterocele (shown in top right image) when pushed upward back into the abdomen before repair. (Reprinted with permission of A. Cullen Richardson, MD.)

Pelvic support defects are similar to hernias. With the exception of enteroceles, such as described here, pelvic support defects are not associated with protrusions of peritoneal sacs containing intra-abdominal contents. However, they do have disruptions in the continuity of their supporting connective tissues as in midline cystoceles and in rectocele defects. These disruptions in supporting connective tissue are also seen in paravaginal defects. These defects can be made visible in preoperative and intraoperative inspection. They behave just as other hernias: they either remain stable or increase in size. Only very small hernias in children are known to spontaneously resolve with any regularity. Failure to identify accurately and repair properly each of these pelvic floor defects will result in failure of the operation.

The operative repair of pelvic floor support defects must address each anatomic defect posteriorly, laterally and anteriorly as described by Richardson[1, 5–7] and Shull.[8] Clinical evaluation of women with pelvic floor defects is performed using the techniques described by Shull.[9] The effectiveness of addressing fascial defects has been demonstrated for the rectocele by Porter[10] and Kenton[11] following the principles of Richardson.[7] The effectiveness of the defect-specific approach to the paravaginal area by reattaching the pubocervical fascia laterally to the fascia of the obturator interna muscle at the level of the arcus tendineus fascia of the pelvis has been demonstrated by Shull8 and Richardson[5,6] as well as by Liu[12] using a laparoscopic technique. Transverse, midline, and lateral ligament defects in the anterior vaginal wall must also be addressed as described by Richardson[5,6]

Identifying and repairing defects in the lower and middle third of the vaginal fascia must be accomplished, but as described by Ross[2] the cornerstone of pelvic floor reconstruction is the apical vault repair. The technique described herein is to be performed in conjunction with the repair of the individual defects that have been identified so as to provide a secure and long- lasting repair of apical enterocele and vault eversion. This technique is based on the teachings of Saye[13] and his surgical instruction.

Operative Procedure

After general endotracheal anesthesia has been induced, careful pelvic examination using the techniques of Shull[9] is performed. Insufflation with CO2 is performed and placement of laparoscopic trocars is accomplished. A 10-mm trocar for the 10-mm laparoscope is placed at the umbilicus. If the endo-stitch (US Surgical, Norwalk, CT) is used, a 10-mm port is established on the operator's side and a 5-mm port is established on the assistant's side, both lateral to the inferior epigastric vessels with placement dependent on the individual anatomy. If 2-0 Ethibond (Ethicon, Somerville, NJ) is used 5-mm ports are established bilaterally. The patient is then placed in the Trendelenburg position, and the bowel is swept out of the pelvis. Using a rectal sizer placed in the vaginal vault, the vault is inverted so that the peritoneal lining is visible in the pelvic cavity. The peritoneal lining overlies the separated rectovaginal and pubocervical fascia (). The uterosacral ligaments are identified on both sides with care taken to identify as well the course of the ureters anterolateral to the uterosacral ligaments.

The vaginal vault is inverted using a rectal sizer so that it can be visualized within the pelvic cavity. The peritoneal lining overlying the rectovaginal and pubocervical fascia can be clearly seen.

The uterosacral ligaments are identified as they enter into the sacrum that is the unbroken portion of the uterosacral ligaments, and these portions are used for the reattachment to the vaginal apex. The unbroken portion of the uterosacral ligaments are then tagged with suture to initiate the procedure (). The peritoneum overlying the break between the pubocervical and rectovaginal fascia is then opened. The pubocervical fascia is identified ventrally between the vagina and the bladder by sharp dissection. The rectovaginal fascia is identified posteriorly (). Redundant peritoneum and excess vagina are excised. Corner stitches are then placed on each side that approximate the edges of the pubocervical to the rectovaginal fascia overlying the vaginal mucosa.

The left uterosacral ligament is shown here. The uterosacral ligaments are visualized as they enter into the sacrum and are tagged by suture for later identification.

The peritoneum has been divided and with sharp dissection the pubocervical and rectovaginal fascia have been identified. The break between them is clearly visible.

Permanent 2-0 suture (Ethibond, Ethicon Somerville, NJ; Surgidek, US Surgical Norwalk, CT) is used for all aspects of the repair. This corner stitch is then incorporated into the ipsilateral uterosacral ligament, which had been previously tagged (). The corner of the now reapproximated pubocervical and rectovaginal fascia along the edges and corner of the vaginal apex is then incorporated into the ipsilateral uterosacral ligament as it courses to the sacrum. In this way, the rectovaginal pubocervical complex is sutured to the unbroken portion of the uterosacral ligament forming a very secure attachment of the vaginal apical corner (). This procedure is performed on both sides of the apical vault providing very secure support of the lateral and upper corners of the vaginal vault.

A corner stitch is placed through the pubocervical and rectovaginal fascia.

The lateral edges and apical corner of the vaginal vault are secured to the unbroken portion of the uterosacral ligament as it courses to the sacrum. The left apical corner is shown here.

The rectovaginal fascia is then approximated to the pubocervical fascia across the center of the vaginal vault with interrupted sutures (). Reinforcing sutures from the uterosacral ligaments to the posterior rectovaginal fascia are then placed bilaterally. These sutures do not cross the midline but rather reinforce the attachment of the corner of the vaginal apex to the ipsilateral uterosacral complex thus providing for appropriate anatomical connection of the rectovaginal septum and maintaining the maximum transverse dimension of the upper portion of the vagina that would be possible (). Cystoscopy is performed to visualize the ureteral orifices to assure the ureters were not kinked during the suspension of the uterosacral ligaments to the vaginal vault.

Interrupted sutures close the apex of the vaginal vault. Restoring the integrity of the attachment of the pubocervical to the rectovaginal fascia.

Completed vaginal vault apical support is visualized.

After completion of the enterocele repair and vault suspension by suture technique as described herein, additional vault defect repairs are then performed. If a paravaginal defect has been identified, the space of Retzius is entered and this is repaired. If the patient is suffering from stress urinary incontinence, a laparoscopic Burch is also performed. Remaining fascial defects of the rectovaginal septum (rectocele defects) and of the anterior vaginal vault (transverse or midline) are repaired vaginally. In the event that the pubocervical or rectovaginal septum cannot be safely or effectively identified and dissected free by laparoscopic approach, the tags placed on the uterosacral ligaments are left in place and the dissection of the pubocervical and rectovaginal fascia is performed from a vaginal approach. The tags that had then been placed on the upper portions of the uterosacral ligaments are used then to bring the uterosacral ligaments into the repair, which is accomplished vaginally. Reinforcement of this repair can then be performed under laparoscopic visualization if necessary.

RESULTS

Drs Carter, Winter, and Mendehlsohn performed this type of apical vaginal vault repair and suspension in conjunction with multiple other defect repairs in eight patients, between March of 1999 and September 1999. Patient age range was 42 to 85, with a mean of 62 years. The apical vault has remained intact and supported in four patients with six months of follow-up and in four with one year of follow-up. No complaints of dyspareunia or pelvic pain have occurred associated with this repair. The repair has required between one hour and two-and-a-half hours of surgical time, depending on the extent of the dissection to identify the apex and the uterosacral ligaments, with the longer times occurring in patients who have extensive adhesions to the enterocele.

The results presented here represent the first eight cases performed after appropriate training had been received through lectures, courses, tutoring, and proctorship. These cases were performed after training given by Drs Saye and Richardson who have performed over 150 of these procedures over the past six years. These results demonstrate that this technique can be learned and performed successfully if appropriate time and energy is expended in the learning process.

DISCUSSION

The diagnosis and treatment of apical enterocele (apical vaginal vault defect) and vaginal vault prolapse requires an understanding of the anatomy and surgical techniques that represent a paradigm shift from our previous teaching and training, ie, gynecologists were to concentrate on the organ rather than the fascia. These defects are, in fact, fascial defects and can, in fact, be described as hernias. By undergoing proper training through lectures, evaluation of the surgical anatomy, attending specific courses dedicated to this problem, together with observation of good surgical technique as performed by recognized experts such as Drs Richardson and Saye, when combined with onsite tutoring and proctoring, laparoscopic gynecologists can make these surgical procedures part of their armamentarium.

The loss of the upper suspensory fibers of the paracolpium and parametrium will lead to uterine prolapse and vaginal prolapse after hysterectomy. In addition, the separation of the pubocervical from the rectovaginal fascia will result in apical enterocele. Defects in the pubocervical fascia result in a cystocele with the defect occurring either laterally (paravaginal defects), transversely, or midline. Defects in the rectovaginal fascia result in rectocele with protrusions occurring through splits in the rectovaginal fascia, which must be reapproximated to restore integrity. Each of these defects must be approached individually, and all defects must be repaired to ensure restoration of the integrity of the vaginal tube and its support structures. The vaginal apex in particular depends on the cardinal/uterosacral ligaments.[14] An apical enterocele occurs when the pubocervical separates from the rectovaginal fascia and when the peritoneum is in contact with the vaginal mucosa.[1]

Surgical correction for vaginal vault prolapse requires: 1) Reconstruction of the vaginal tube; 2) Re-establishment of the suspension; 3) Lateral attachment of the reconstructed vagina; and 4) Excision of redundant peritoneum and vaginal mucosa if required. The reconstruction of the vaginal tube requires that the upper edges of pubocervical and rectovaginal fascia be closed. Re-establishing suspension requires that the closed tube be suspended to a normal segment of cardinal/uterosacral complex. Lateral attachment requires that the pubocervical fascia be attached to the side wall in a paravaginal repair, if necessary. Posterior attachment requires that the rectovaginal fascia be attached to the fascia over the ileococcygeous fascia, if necessary. The repair described in this paper satisfies the need for appropriate reconstruction and support of the apical portion of the vaginal vault as part of the complete vaginal vault reconstruction procedure. The technique described herein differs from other techniques by maintaining the anatomy of the apex of the vaginal vault in its transverse dimensions by attaching each corner of the apex individually to its ipsilateral uterosacral ligament and maintaining the anatomically appropriate transverse dimension of the apex of the vagina.

Site specific fascial defects performed in the vaginal route have also been described using similar anatomical landmarks and corrections.[15] Using the vaginal technique, Miklos et al[15] successfully completed enterocele repair in 17 patients, and all patients also underwent a uterosacral ligament vaginal vault suspension.

An alternative technique to laparoscopic vaginal apex reconstruction and vault suspension has been described by Nezhat et al.[16] This technique uses Mersilene mesh to secure the apex of the vagina to the anterior surface of the sacrum.[16]

In all of this discussion it is essential to remember that pelvic muscles relieve tension on the endopelvic fascia and that the fascia stabilizes the organs above the pelvic floor.[3] The mechanism of prolapse can then be described in this order: the pelvic floor muscles are damaged; the pelvic floor opens; the vagina now sits between high abdominal pressure and low atmospheric pressure; the ligaments can sustain this load for a short time only and then the ligaments fail and prolapse will occur. Therefore, the treatment of fascial defects is surgical as described in this paper. However, the treatment of muscle injury is reeducation.[3] Therefore, the success of surgical intervention for vaginal vault prolapse and stress urinary incontinence will be improved by the addition of pelvic floor muscle re-education.[17]