PMC6216082_01
Prolaps POP-Q 4 - preoperative consideration.
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A close inspection of the lower pelvic region showed unremarkable left adnexa and barely visible ones on the right that were located along with the hernial sac inside the vagina (Fig. 1).
Preparation of the sacro-promontory.
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After presentation of the right ureter, the peritoneum was opened over the sacrum on the promontorial level and the anterior longitudinal ligament of the spine was exposed without injuring the inferior hypogastric plexus or the median sacral artery (Fig. 2).
View of the posterior cervical wall after the preparation.
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Next, an incision was made on the parietal peritoneum on the dorsal wall of the cervix uteri and it was partially separated from the cervix (Fig. 3).
Niemeyer Helix.
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Using a Niemeyer Helix (Fig. 4), which was inserted directly through the abdominal wall, a retroperitoneal tunnel was formed between the promontorium and the cervix uteri, following the anatomical location of the right uterosacral ligament (Fig. 5).
Mesh (tape) used by the operation.
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A 20 x 1 cm polypropylene mesh was used for the procedure (Fig. 6).
Fixation of the tape on the cervix.
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Next, the distal end of the mesh was anchored to the cervix with non-absorbable interrupted sutures 2-0 (Fig. 7).
Fixation of the tape on the anterior longitudinal ligament at the sacro-promontory.
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The proximal end of the graft was attached to the right side of the longitudinal anterior ligament of the sacral spine with the same type of sutures (Fig. 8).
Postoperative consideration without prolapse.
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The wound was closed with continuous stitches, narrowing the vestibule of the vagina and maintaining proper anatomy (Fig. 9).