Outside-In: Intraperitoneal Anterior and Posterior Plication During Prolapse Surgery.

Objective: To demonstrate a novel technique of intraperitoneal vaginal wall plication combining the benefits of anterior and posterior colporrhaphy with laparoscopic sacrocolpopexy.

Design: Video demonstration of laparoscopic anterior and posterior colporrhaphy techniques, highlighting the various clinical scenarios in which they would be beneficial.

Setting: Sacrocolpopexy is recommended for the treatment of advanced-stage prolapse [1-3]. Frequently, these patients have significant vaginal elongation and laxity that can make reconstruction challenging. This case series performed at a tertiary care hospital highlights a series of women undergoing laparoscopic sacrocolpopexy whose repairs were optimized with the use of intraperitoneal vaginal wall plication.

Interventions: A series of plication stitches using delayed absorbable suture is placed on redundant anterior or posterior vaginal walls. This technique reduces excess vaginal tissue and reinforces the reconstruction. Stitches can be placed vertically or horizontally to narrow the vagina, depending on the repair needs. Vertical plication shortens the vaginal walls and provides additional traction to allow dissection extension to the trigone anteriorly or the rectovaginal septum posteriorly, thus optimizing mesh placement [4]. This plication also adds bulk to the vaginal tissue where the mesh is attached, potentially decreasing the risk of mesh exposure.

Conclusion: Intraperitoneal vaginal wall plication is the outside-in version of anterior and posterior colporrhaphy. This novel technique can optimize dissection and mesh placement and provide support for attenuated vaginal walls. It also balances the ratio of mesh to vaginal tissue without increasing mesh burden.