Laparoscopic Hysteroperineopexy for Pelvic Dysfunction after Proctocolectomy

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Video Description

Pelvic distortion can be a significant cause of chronic discomfort and pain. We present the case of a 30-year old G2P2 woman with persistent pelvic pressure, pain, and pooling of blood and discharge in the posterior vagina following a complex surgical history, including proctocolectomy for ulcerative colitis. Based on her pre-operative assessment, her symptoms were respectively felt to be caused by adhesions of small bowel within the empty posterior cul-de-sac, pelvic varicosities, and tethering of the posterior vagina towards the sacrum.

In this video, we demonstrate an individualized surgical approach to pelvic dysfunction following proctocolectomy. In step one, her anatomy is restored through adhesiolysis and development of the rectovaginal space.

In step two, the varicosities are addressed by opening of the presacral space and ligation of tributaries to the mid-sacral vein. In step three, a hysteroperineopexy is performed for pelvic organ suspension.

Presented By

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Dr. Meghan McGrattan
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Dr. Darl Edwards
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Dr. Nucelio Lemos


Mount Sinai Hospital, University of Toronto

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What is Pelvic Dysfunction after Proctocolectomy?

Laparoscopic hysteroperineopexy is a minimally invasive surgical technique aimed at correcting pelvic dysfunction that can occur after a proctocolectomy—the removal of the rectum and part or all of the colon. This procedure specifically addresses issues like pelvic organ prolapse, which results from the weakened support of pelvic organs, leading to discomfort and functional problems. During the operation, the uterus and perineal body are repositioned and secured to restore normal pelvic anatomy and support. Performed through small incisions using a laparoscope, this surgery offers benefits such as reduced recovery time, less post-operative pain, and minimal scarring compared to open surgery. It’s designed to improve symptoms of prolapse and enhance the patient’s quality of life by stabilizing the pelvic floor and maintaining the correct positioning of pelvic organs.

What are the Risks of Pelvic Dysfunction after Proctocolectomy?

The risks associated with laparoscopic hysteroperineopexy for pelvic dysfunction after proctocolectomy, though relatively low due to its minimally invasive nature, include:

  • Infection: As with any surgical procedure, there’s a risk of infection at the incision sites or within the pelvic cavity.
  • Bleeding: There is a potential for significant bleeding during the surgery, which may require further intervention.
  • Injury to Nearby Organs: The surgery carries a risk of accidental damage to adjacent organs such as the bladder, ureters, or intestines.
  • Adhesions: Formation of scar tissue post-surgery can lead to pelvic pain and potentially affect organ function.
  • Recurrence of Prolapse: Despite the corrective procedure, there’s a chance that prolapse symptoms could recur, necessitating additional treatment.
  • Anesthesia Risks: Complications related to anesthesia, though rare, can occur and include reactions or respiratory issues.
  • Pelvic Pain: Some patients may experience ongoing or new pelvic pain post-surgery.

Patients should discuss these potential risks with their healthcare provider to make an informed decision about undergoing laparoscopic hysteroperineopexy, considering both the benefits and possible complications.

Video Transcript: Pelvic Dysfunction after Proctocolectomy

Laparoscopic hysteroperineopexy for pelvic dysfunction after proctocolectomy. This video presents a case of complex pelvic pain in a patient with a long-standing history of surgical ulcer diverticulitis, and demonstrates an approach to laparoscopic hysteroperineopexy after proctocolectomy.

Our patient is a 30-year-old woman with a history for recurrent ulcerative colitis, for which she has undergone four abdominal surgeries. This concluded with the proctocolectomy and permanent ileostomy. She has had two caesarean sections, and two exploratory laparoscopies. Her medical history is similarly complex.

 Since her last bowel surgery three years ago, she has experienced constant pelvic pain, pressure, and pooling of discharge and blood in the posterior vagina., which released with position change.

Her initial pelvic assessment in a supine position was relatively unremarkable. However, when in a standing position descent of the cervix and posterior fornix were noted. Difficult to capture in the Pop-Q was the deviation of her vaginal axis, which became distorted and angled towards the sacrum. Elevation of the cervix in this position reduced her discomfort.

A uroflow study was preformed to evaluate for urinary retention, secondary to her pelvic organ malposition, and was normal. Based on her history and clinical findings, a hypothesis was formed to account for her symptoms given the variations from normal pelvic anatomy as seen here.

Number one, small bowel adhesions collecting within the empty posterior cul de sac may be contributing to a sense of pressure within the pelvis. Number two, pelvic varicosities and venous congestion maybe contributing to her pain. Number three, tethering of the posterior vagina towards the sacrum in the absence of a rectum and sigmoid colon may be creating a pocket for secretions to collect.

 The following surgical approach was designed. In step one, we restore her anatomy with adhesiolysis and development of the rectovaginal space. In step two, the varicosities are addressed by opening the presacral space and identifying relevant neuro anatomy, then ligation of the tributaries to the mid-sacral vein. In step three, we will suspend the pelvic organs with a hysteroperineopexy.

 Upon abdominal entry, dense adhesions were appreciated throughout the pelvis, including surrounding the ileostomy site. Using gentle dissection and cold scissors, the small bowel adhesions along the interior abdominal wall were taken down, restoring the ileostomy.

Attention was then turned to the pelvis, using a combination of bipolar cautery, cold scissors, and blood dissection, adhesiolysis was systematically performed. As hypothesised, adhesions of small bowel were present throughout the pelvis, with a significant collection of small bowel loops stuck within the posterior cul de sac.

These were carefully resected, and the small bowel reduced to expose the posterior aspect of the peritoneum. As the sacrum promontory was revealed, venous dilatation became visible along the tributaries of the mid-sacral vein. Having cleared the pelvis and small bowel the varicoceles were again appreciated.

With adhesiolysis complete, the posterior peritoneum was tented and incised over the sacral promontory. Using a combination of sharp and blunt dissection the presacral space was opened, and we began to locate our notable structures. Dissection continued until the hypogastric plexus was identified, as displayed here by the Maryland Grasper.

Now, mindful of our neuro anatomy attention was turned to the pelvic varicosities. Using our bipolar device, the tributaries of the mid-sacral vein were then identified and ligated. Our aim was to dissect and remove the varicosities in order to help treat the congestion noted within the pelvis.

During the process of dissection around the varicosities within the presacral space, brisk bleeding was encountered. The impacted veins were carefully desiccated, again using the bipolar device. This reoccurred numerous times, in spite of repeated use of coagulation.

Once it was established that it would not be possible to dissect around these vessels without encountering further bleeding, the approach was shifted to a transperitoneal coagulation of the varicosities. Having addressed the pelvic varicosities, attention was then turned to the posterior cul de sac. Using scissors the peritoneum was incised at the cervical isthmus.

Using blunt dissection, this space was further expanded along the plane that was previously the rectovaginal space, to better expose the perineal body and rectovaginal fascia for suturing. Bleeding then recurred from the varicosities in the presacral space.

A decision was made to suture ligate these mid-sacral tributaries using a braided absorbable  suture, as we had already made several attempts at desiccation. An intracorporeal knot was tied, and Surgicel cellulose was then secured tightly underneath for further haemostasis.

Now, satisfied with our haemostasis, attention was returned to the hysteroperineopexy. Using a barbed monofilament absorbable suture, a stitch was passed through the apex of the perineal body, and then up through the mid-vagina. The suture was then advanced through the right uterosacral, passed through the central portion of the paracervical ring, then down through the insertion of the opposite uterosacral.

Using the same barbed suture, we continued with the culdoplasty and uterosacral ligament shortening, passing the suture from one uterosacral ligament to the other in five points on each side. The tension on the suture was carefully adjusted along the way so that adequate support was provided to the perineal body.

Finally, the sacral origin was reached, several stitches were taken back along the path of suturing to lock them in place, and the suture was cut flush with the peritoneum and removed from the patient’s abdomen. At the end of the hysteroperineopexy, support was felt to be adequate and the patient’s anatomy had been restored.

At the patients six-week post-operative follow up she had recovered well, and reported resolution of all of her symptoms. However, three months later she returned to the clinic with a recurrence of her pelvic pain. The symptoms of pressure and pooling of vaginal secretions remained resolved.

Given the maintained structural restoration and incomplete ligation of presacral veins at the time of surgery, we hypothesis that her pain is likely due to recurrence of her varicosities. In summary, pelvic distortion can be a cause of chronic discomfort and pain, and each patient requires an individualised approach.

Through restoration of anatomy and suspension, we were able to resolve her structural complaints and symptoms. However, given the incomplete management of her varicosities, her fullness recurred and further management through embolization is pending.