Objective: To describe the laparoscopic dissection of the sacral promontory during a laparoscopic sacrocolpopexy, with a special focus on anatomical landmarks and surgical traps.
Setting: Department of Gynecology, CMCO, Strasbourg University Hospital, France.
Patients: Women with invalidating genital prolapse
Interventions: Laparoscopic sacrocolpopexy is performed using three operative ports (one midline, suprapubic port and two lateral ports) and a 0-degree umbilical Karl Storz optical port. In order to suture a polypropylene mesh to the anterior vertebral ligament, the promontory area must be dissected. To improve sacral promontory exposure, the rectum is usually suspended to the left anterior abdominal wall by means of T’Lift™ tissue retraction systems. By palpating the area under the aortic bifurcation and the confluence of iliac veins, the sacral promontory is identified. The right ureter is also identified. Using two duck jaw fenestrated forceps, the peritoneum is lifted --retroperitoneal vessels are fixed to the vertebral elements, and widely opened. The promontory is carefully dissected until the anterior vertebral ligament becomes visible. As the presacral space is rich in blood vessels and nerve elements, surgeons are advised to preserve it.
However, the surgical approach to the vertebral ligament is sometimes difficult in obese women, when patients present anatomical variations such as a low iliac venous circulation confluence, a duplicity of middle sacral vessels, periosteal perforators, a winding right common iliac artery, or in the presence of lymph nodes.
Discussion: Laparoscopic sacrocolpopexy complications rates such as bleeding originating from the promontory varying from 0 to 4.7%, which sometimes require conversion to open abdominal sacrocolpopexy. Described by radiologists at almost 3cm from the sacral promontory, the right ureter can also be injured during reperitonization.
Conclusion: Laparoscopic dissection of the promontory requires specific and careful attention to be paid to non-infrequent anatomical variations.