Sacrohysteropexy

By Dr. Kiran Pandey,
Dr. Pavika Lal,
Dr. Garima Gupta

1. SACROHYSTEROPEXY
Present Designation
NAME: DR.KIRAN PANDEY
MD,MAMS,FICOG,FIMSA,FICM
CH
DESIGNATION: Head of
Department, Department of
OBG, GSVM medical College
Kanpur
AREA OF INTEREST : GYNAE-
Oncology, Infertility,
Adolescent Health,
urogynaecology, High Risk
Pregnacy

2. MAJORACHIEVEMENTS
President 2016-18, KanpurObsand GynaeSociety
Secretary UPSC-AGOI 2017-2019
Organizing Secretary WWWCON -2018 (International Conference)
Organizing Secretary AGOI surgical video workshop and UPSC Annual CME December
2018
Organizing chairperson –Adolescent Workshop ,Emergency Obstetrics Workshop
October 2018
Organizing Chairperson –National Adolescent Conference YOUTH SUMMIT and CME 2017
Organizing Secretary, National conference of obsand gynae2015
Organizing chairperson, urogynaecology, NDVH, Pelvic floor repair workshop, National
conference
HONOURS,AWARDS AND PUBLICATIONS
AWARDS: 11 National,8 state level and 8 district level awards & >30 awards at IMA
Received “President appreciation award” from adolescent health committee at AICOG
FOGSI facilitated with “Nariswasthyaaward” in AICOG(Orissa)
Awarded certificate of appreciation for excellent contribution in family welfare
Received “MatrashaktiSammanAward” on international women’s day
Honouredby Mr. SatyadevPachauri, Minister of Khadiand Village Industries
Received best women doctor in IMA UP state
Received “Women of Substance Award” on international womens’sday 2009-10
“GYTI Award” from NIF India at RashtrapatiBhawan
FOGSI AWARD for original research work “ Dr. Chitratharaand Dr. Gangadharan
Preventive and Research Oncology Award”
PUBLICATIONS IN VARIOUS BOOKS; published more than 100 research papers in
national and international journals.

3. INTRODUCTION
In India nulliparousprolapse–
1.5-2% of genital prolapse
Lifetime risk of women undergoing
surgery for prolapse-19%
Nulliparousprolapsedoes not
usually follow the typical route of
pathopahysiologyi.e. Cystocoele–
Traction -Retroversion -Prolapse
SmithFJ,HolmanCD,MoorinRE,TsokosN:Lifetimeriskofundergoingsurgeryforpelvicorgan
prolapse.ObstetGynecol2010,116(5):1096–1100

4. PREVALENCE
Higher in Indian women
Anaemic
Malnourished
Maternal
depletion
syndrome

5. Deliveries
conducted by
untrained dais
at home
Pelvic
tears
Further
weakness
of pelvic
floor
Significant
detrimental effects
on sexual and
reproductive
functions
infertility
CONTRIBUTARY FACTORS

6. Chronic
irritation
infection
Formation of
large decubitus
ulcers
EFFECTS
As the cervix remains outside it is susceptible to:

7. ETIOLOGY
Inherent
defects
in pelvic
support
Ehlers
danlos
syndrome
Congenital
shortness of
vagina
Spinabifida
occultaand
split pelvis
Deep utero–
vesical&
utero-rectal
pouches

8. ADDITIONAL RISK FACTORS
Conditions that increase intra-abdominal pressure :
may precipitate the symptoms of genital prolapse.
CurrOpinUrol.2017 Sep;27(5):428-434 Obesity and pelvic organ prolapse.
Lee UJ
1
,KerkhofMH,van LeijsenSA,HeesakkersJP.
Overweight
obese
constipation
Chronic
coughing
Repeated
heavy
lifting

9. MANAGEMENT
Treatment options are based on the following factors:
Age
Desire
for future
children
Sexual
activity
Severity of
symptoms
Degree of
prolapse

10. CONSERVATIVE MANAGEMENT
Provideonlytemporaryrelief
Beneficialonlyinmilddegreesofprolapse.
Theconservativemethodsinclude:
Less beneficial in nulliparousprolapsedue to intrinsic
weakness of the muscles of pelvic floor
Changes in diet and lifestyle
•Increasing fibrein diet
•Weight loss
Pelvic floor exercises (kegel’sexercises)
•Strengthens muscles suroundingopening of
urethra, vagina and rectum

11. Pessary
Types:
A)Ring pessary: For initial stages
B) Shelf pessaryor gellhorn: For higher
degree of prolapse.

12. SURGICAL MANAGEMENT
Aims of prolapsesurgery
Alleviate
symptoms
Restore
normal
anatomy of
visceral
organs and
their
functions
Minimal
surgical
complications

13. TYPES OF
SURGERIES
•Various conservative approaches available for treatment of
nulliparousprolapse.
•Main objective of operation buttress the weakened
supports of the uterus.
•Done either by autologoustissue or providing substitute
like Mersilenetapes
used as slings or mesh to support uterus.

14. EVOLUTIONOF PROLAPSE SURGERY
Vaginal hysterectomy was the standard treatment.
↓
Fothergill’s surgery/ Manchester’s Operation:
conservative approach. To overcome its limitations the
surgery that came was:
↓
Sling surgeries:
•Shirodkar
•Khanna’s
•Purandares
↓
Sacrohysteropexy
↓
Pectopexy(most advanced and new surgery)

15. FOTHERGILL’S OPERATION
First conservative approach
described by Donald and Fothergill(in
1888) also known as Manchester
Operation.
Alternativetovaginalhysterectomyfor
youngnulliparousprolapse.
Essential pre-requisite
elongation of cervix.

16. The STEPS of Fothergill’s surgery:
Preliminary D & C
Amputation of cervix
Plicationof mackenrodt’s
ligament in front of cervix
Anterior colporrhaphy

17. LIMITATIONSOFFOTHERGILL’S
OPERATION:
→Cervical amputation (main steps)
Leads to complications-
Habitual abortion ( 2
nd
trimester)
Preterm deliveries
PROM
Fibrosis stenosis cervical dystocia
Recurrence
→ Cannot correct complete eversionof the vagina.

18. SLING OPERATION
More effective
Feasibile
Initially body tissues like fascia lataand rectus
sheath were used replaced by synthetic slings
minimal tissue reaction and remain unabsorbed
giving lifelong support.

19. ShirodkarVN.Contributions to obstetrics and gynaecology.Edinburg: E & S Livingstone Ltd;
ShirodkarVN.C R Soc Franc Gynec.1952;22:99.[PubMed][Google Scholar]
Shirodkar, VN. Second World Congress of International Federation of Gynaecology and Obstetrics, Montreal. 1958.
PurandareVN. New surgical technique for surgical correction of genital prolapsein young women J ObstetGynaecolIndia.
1965:53–62.
VirkudA.Modern gynecology(Ch 18)II. New Delhi: APC Publishers; 2015. pp. 210–211.
Shirodkarsling: 1958
Purandre
cervicopexy: 1965
Khannasling: 1972 Virkudsling: 1999
CONSERVATIVE SLING OP FOR
GENITAL PROLAPSE IN YOUNG
WOMEN

20. LIMITATIONS OF SLING
OPERATIONS
Main limitation selection criteria:
Uterocervicallength (< five inches)
Absent or minimal cysto/rectocele.
Ligament inherently weak recurrence of prolapse.
Nowusage of native tissue replaced by Merlisene
tapes, so this problem has been reduced to some extent.
In some sling operations uterus becomes retroverted.

21. SACROHYSTEROPEXY
Problems encountered in Sling and Fothergill’s operation
eversionof vagina and retroversion of uterus
overcome by sacrohysteropexy.
The earliest literature on Sacrohysteropexyfound to
be dated in year 2001.
Involves resuspensionof prolapsed uterus using a
strip of synthetic mesh
Restoring normal anatomy
Preserving the normal sexual and reproductive
functions.

22. •Cervix is lifted upwards, towards sacral
promontory using soft synthetic mesh.
•It can be performed via:
•Abdominal
•Laproscopic
•Robotically assisted methods
•We mainly perform abdominal
sacrohysteropexy.

23. PROCEDURE
Prerequisites: Avoid constipation before as well
as after procedure so that bowel doesn’t obscure the
view of the surgeon while performing the procedure.
Type of anaesthesia:
General anaesthesia
Combined(epidural or spinal)
Position of the patient:
Supine position in open procedures.
Trendelenberg’sposition in laproscopicprocedures.
BarrangerE, FritelX, PigneA (2003). "Abdominal sacrohysteropexyin young women with uterovaginalprolapse: long-term follow-
up".Am J ObstetGynecol.189(5): 1245–50

24. PROCEDURE
1.Exposure of the anterior longitudinal ligament over
sacral promontory and utero-sacral ligaments on
the posterior aspect of the uterine cervix:
2.Sacral promontory is exposed.
3.Peritoneum over the sacral promontory is held with
non-toothed forceps and incised longitudinally as much
as uptoutero-sacral ligaments
It is cleared off from loose aerolartissue, vessels etc as
there are maximum chances of injury to median
sacral vessles.
One should be cautious not to injure the Ureter which
lies retroperitoneallyand laterally.
The tense white and shiny anterior longitudinal ligament
is visualised.

25. Sacral Promontory Exposed

26. 2.Meanwhile, a soft polypropylene porous mesh is
taken, and is given the shape of “Y”.
3.2-3 bites of 3-0, prolinesuture are taken on the
anterior longitudinal ligament and they are kept
long enough so that mesh can be sewed in it
through sutures.
4.Now, the longitudinal limb of “Y” mesh is placed
over sacral promontory and is fixed in its position
by tightening the sutures which were taken earlier
during the procedure.

27. Mesh Fixation At Sacral
Promontory

28. 5.2-3bitesarealsotakenonthemeshattheposterior
aspectoftheuterusatthelevelofutero-sacral
ligaments.
6.TheUtero-vesiclefoldisdissectedoutandthe
bladderispusheddownsoastoexposecervico-
isthmicarea,followedbyplacementofboththe
horizontallimbsoverthisarea.
7.Openingsaremadeintheavascularareaofbroad
ligamentonbothsidebelowtheattachmentofround
ligamentandhorizontallimbof“Y-shaped”mesh
arepassedanteriorlythroughtheseopenings.

29. Fixation Of Y-Limb Of Mesh On Anterior
Aspect Of CervicoisthumicArea

30. 8.Thetractiononmeshshouldbeoptimumas
excessivetighteningofthemeshwhilebringingit
fromposterior(sacralpromontory)toanterior
aspect(cervico-ishthmicjunction)ofuterusmay
leadtopost-operativedraggingpain.
9.Toreducetheproblemsofmesherosionand
irritationtotheinternalorgans,theperitoneum
thatwascutisagainperitonised.

31. Reperitonizationof
uterovesicalfold

32. MAIN ADVANTAGES
Surgical sutures are placed on bony point
stronger repair.
Less recurrence of prolapse.
Vaginal length not compromised no
interference with patient’s sexual life (problems
like dyspareuniaetc.)
Uterine axis unalteredremains anteverted.
Inherent weakness of uterine supports, in
case of nulliparousprolapsecovered up byuse
of synthetic mesh.
ShirodkarVN.C R Soc Franc Gynec.1952;22:99.[PubMed][Google Scholar]

33. COMPLICATIONS
Haemorrhagethrough median sacral vessels.
Bowel injury
Pain: General pelvic discomfort and tenderness on
intercourse due to vaginal tethering or mesh erosion.
Mesh exposure/extrusion
Infection of mesh
Change in bladder and bowel function:
Deep Vein Thrombosis (DVT)

34. REVIEWOFSEVERALSTUDIESON
SACROHYSTEROPEXY
In a systematic review of surgery for women with apical
prolapse(183 women)with uterine prolapsecomparing
abdominal sacrohysteropexywith vaginal hysterectomy:
There was no difference in repeat prolapsesurgery
between the groups at 1 to 8-year follow-up (low
quality evidence).
In few case studies, bowel obstructions reported
which needed surgical re-intervention to release
bowel adhesions.
In some case studies, adhesions were noted between
bowel and non-peritonised mesh in less than 1%.

35. •UTI
•Perinealinfections
•Perinealinjuries
•Postoperativedraggingpain
EFFECTONPREGNANCY
•Patientusuallycarrypregnancyuptotermwithout
significantrelapseofsymptomsoranatomical
fallacy
.
PandevaI, MistryM, Fayyad A. Efficacy and Pregnancy Outcomes of Laparoscopic Single Sheet Mesh Sacrohysteropexy. NeurourolUrodyn. 2017;36:787-793.
BalsakD, EserA, ErolO, AltintasDD, AksinS. Pregnancy and Vaginal Delivery after Sacrohysteropexy. Case Rep ObstetGynecol. 2015:3.
AlbowitzM, SchyrbaV, BollaD, SchoningA, HornungR. Pregnancy After a Laparoscopic Sacrohysteropexy: a Case Report. GeburtshilfeFrauenheilkd. 2014 Oct;74:947-949
REVIEWOFOTHERCOMPLICATIONS
REPORTEDAFTERSACROHYSTEROPEXY

36. REVIEW OF OUR
CASES
In a period of three years,we have operated 20
cases and amongst those,in one obese patient
uretericinjury happened which was identified
and repaired at the same time.
During the follow up period of our patients (8 in
no.),among those who were desirous of
pregnancy,3 patients carried pregnancies till
term and they also successfully delivered by
caesarean section.
There wereno complications like mesh
erosion or pain although the follow up period in
our study is less than two years.

37. PECTOPEXY
Newest technique for apical prolapsesurgery.
Lateral part of iliopectinealligament( extension of
lacunarligament that runs on the pectinealline of
pubic bone) used to suspend uterus and its
supporting structures.
This ligament is situated at the level of S2 and forms
anchor point of physiological axis of vagina.
More feasible in obese patients since in
sacrohysteropexy, reaching sacral promontory
becomes very difficult.
No risk of injury to the median sacral vessels leading
to haemorrhage.
Faure JP, HauetT, ScepiM, ChansigaudJP, KaminaP, Richer JP. The pectinealligament: anatomical study and surgical applications.SurgRadiolAnat.2001;23:237–242.[PubMed][Google Scholar]
CossonM, BoukerrouM, LacazeS, LambaudieE, FaselJ, MesdaghH, et al. A study of pelvic ligament strength.EurJ ObstetGynecolReprodBiol.2003;109:80–87.[PubMed][Google Scholar]
NoéKG, SchiermeierS, AlkatoutI, AnapolskiM. Laparoscopic pectopexy: a prospective, randomized, comparative clinical trial of standard laparoscopic sacral colpocervicopexywith the new laparoscopic pectopexy-postoperative results
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38. PECTOPEXY

39. CONCLUSION
Several studies have found it to be a better
alternative than sling or Fothergill’s operation
because:
Attachment is fixed on to a bony point so as to
provide a fixed robust and better support.
Enables the patient to retain her sexual as well
as reproductive functions.