Sacrocolpopexy is a recognised and well established procedure for apical vaginal prolapse. Concerns regarding the use of synthetic mesh in the pelvis have resulted in reduction in mesh surgery. Recently, the laparoscopic approach to use autologous rectus fascia for stress incontinence as a mid urethral sling has proven effective in the medium term (1). In this video, we demonstrate the use of autologous rectus fascia laparoscopically to restore apical support in patents with apical prolapse.

Three patients with apical prolapse underwent autologous rectus fascia laparoscopic sacrocolpopexy (ARFLS). Ethical approval was obtained. Patients had apical prolapse to the level of the hymen or beyond (Point C at zero or beyond in the POP-Q system). The procedure involved harvesting a 6x2 cm strip of rectus fascia (RF) through a 4 cm transverse suprapubic incision. One end of the RF strip was anchored with 2/0 Ethibond suture and the needle kept attached to the suture. After routine laparoscopic entry, the rectovaginal space was dissected with endoscopic scissors and the RF strip was sutured to the vaginal vault with 2/0 Prolene (three sutures). Peritoneum over the pre sacral space was opened and the other end of the RF strip was sutured to the sacral promontory with the 2/0 Ethibond suture. The RF strip was kept tension free. Peritoneum was sutured over the graft and the sacral promontory. In case of intact uterus, the rectus fascia graft is sutured to the back of the cervix and uterosacral ligaments with 2/0 proline sutures. The other end of the fascia with 2/0 Ethibond is then fixed to the sacral promontory by passing the needle through the promontory and tying it to the free end of the suture after uterine elevation. The peritoneum over the rectus fascia graft and the sutures is closed burying the graft and the sutures.

The procedure was successfully completed in all cases, with no complications. Apical (vault and uterine) elevation at 6 cm above the hymen was achieved in all cases. Patients were discharged 24 hours after surgery.

Autologous rectus fascia laparoscopic sacrocolpopexy (ARFLS) is feasible and safe. It restores apical vaginal support using autologous native tissue graft with avoidance of mesh use. It combines the benefits of using autologous graft and the advantages of minimal access surgery.

Fayyad AM, Hasan MR. Novel technique of laparoscopic mid-urethral autologous rectus fascial sling for stress urinary incontinence. BJOG. 2024 Nov;131(12):1587-1590.