The most commonly used abdominal approach to vaginal vault prolapse involves a sacro-colpopexy. This procedure utilizes a mesh bridge to attach the vaginal apex to the sacral promontory. The ideal candidate for an abdominal sacro-colpopexy is a reproductive age woman who is sexually active and can safely undergo an abdominal procedure. Although the success rate of a sacro-colpopexy exceeds 90 percent, the actual surgical procedure can be rather challenging and should only be performed by those experienced with the technique and its potential complications. Most remarkably, bleeding from the pre-sacral plexus can result in life threatening hemorrhage. If the suspending mesh is sutured to the sacral promontory, care must be taken in placement of the sutures so as to not to tear small blood vessels. Typically, 2 to 4 bone anchors are required to achieve this purpose. If bleeding does occur, pressure should be applied on the bleeding area and time given to allow for coagulation. Although uni- or bipolar cautery can be utilized, further bleeding can persist. Sterile tacs can also be used. Alternatively, if a blood vessel is visible it can be ligated individually. Other techniques involve cauterizing a piece of rectus muscle over the bleeding site to result in coagulation of the blood vessel. In our series of over 50 sacro-colpopexies utilizing bone anchors, we have not encountered problematic bleeding.  Attachment of the suspension mesh to the vaginal wall requires three to four rows of permanent sutures. It is important to attach the mesh posteriorly as well as anteriorly along the vaginal apex. An enterocele is usually present and should be ligated once a mesh is in place. Typically plicate the uterosacral ligaments in the midline in order to achieve obliteration of the enterocele. The mesh is then attached to the bone anchor sutures and laid in a fairly loose fashion as excessive tension can increase a risk of erosion.   Post-operative care should allow for slow resumption of normal activities. A sacro-colpopexy is can be followed by a a paravaginal repair or retropubic urethropexy such as a Burch colposuspension. Once the vault is suspended, most patients will also require a rectocele repair and/or perineoplasty.                                                            

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