Presented by:
Sara Kasasni
Affiliations:
Queen’s University
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What is Laparoscopic Sacrohysteropexy Using the Modified Oxford Technique?
Laparoscopic sacrohysteropexy is a minimally invasive procedure used to treat apical pelvic organ prolapse while preserving the uterus. The modified Oxford technique uses surgical mesh to suspend the uterus to the sacral promontory, with additional mesh fixation to the cervix and uterus intended to provide secure, durable support. Here’s what it involves:
- Pelvic and Retroperitoneal Assessment: Important structures, including the ureters, pelvic vessels, uterus, and sacral promontory, are identified before dissection.
- Broad Ligament Windows: Openings are carefully created through the broad ligaments on each side of the uterus to provide a pathway for the mesh.
- Mesh Placement: A tailored polypropylene mesh is introduced laparoscopically and passed through the broad ligament windows around the uterine body.
- Cervical and Uterine Fixation: The mesh is secured to the anterior cervix and posterior uterus to provide additional fixation and reduce the possibility of mesh detachment.
- Sacral Fixation: The mesh is appropriately tensioned and attached to the anterior longitudinal ligament over the sacral promontory, elevating and supporting the uterus and vaginal apex.
- Retroperitonealization: The mesh is covered with peritoneum to separate it from the bowel and other abdominal structures.
- Assessment of Support: The position of the uterus and degree of apical support are evaluated before completing the procedure.
- Cystoscopy: The bladder and urinary tract may be inspected at the end of surgery to confirm bladder integrity and assess urinary tract function.
The modified Oxford approach aims to restore apical support while preserving the uterus and providing additional points of mesh fixation to maintain the desired anatomical position.
What are the Risks of Laparoscopic Sacrohysteropexy Using the Modified Oxford Technique?
Although laparoscopic sacrohysteropexy avoids hysterectomy and can provide effective prolapse correction, it involves dissection around important pelvic structures and the permanent implantation of surgical mesh.
- Mesh-Related Complications: Mesh exposure, erosion, infection, contraction, or detachment can occur and may require additional treatment or surgery.
- Vascular Injury and Bleeding: The sacral promontory lies close to major blood vessels, and injury during dissection or mesh fixation can cause significant hemorrhage.
- Ureteral Injury: Creation of the broad ligament windows and pelvic dissection occur near the ureters, creating a risk of ureteral injury.
- Bladder Injury: Dissection and mesh fixation near the cervix and anterior pelvis can potentially injure the bladder.
- Bowel Injury or Adhesions: Bowel can be injured during laparoscopic dissection, and inadequate coverage of the mesh may contribute to adhesions or bowel complications.
- Nerve Injury: Dissection and fixation near the sacral promontory can potentially affect nearby nerves and contribute to pain or neurologic symptoms.
- Recurrent Prolapse: Prolapse may recur despite successful initial repair or develop in another vaginal compartment.
- Pain or Painful Intercourse: Mesh placement, scarring, or altered pelvic support can contribute to chronic pelvic pain or discomfort during intercourse.
- General Surgical Risks: Infection, blood clots, anesthesia-related complications, urinary retention, and rarely conversion to open surgery are possible.
Careful identification of the ureters and major vessels, appropriate mesh tension and fixation, and complete retroperitonealization of the mesh help reduce complications while providing uterine-preserving apical support.