Fibrin sealant-enhanced single-port LLS with cervical preservation and “homemade” mesh: an innovative surgical technique for pelvic organ prolapse

Introduction

Background

Pelvic organ prolapse (POP) profoundly impairs quality of life, particularly among postmenopausal women. While laparoscopic sacrocolpopexy (LSC) remains the gold standard for advanced apical prolapse, its technical complexity and associated complications have prompted the exploration of alternative approaches. Laparoscopic lateral suspension (LLS) has emerged as a promising minimally invasive alternative, with systematic reviews of 12 studies demonstrating high anatomical success rates: 91.15% for anterior compartment, 94.95% for apical compartment, and 86.55% for posterior compartment repair (1). Randomized controlled trials have further established LLS as comparable to LSC in efficacy, while offering distinct advantages for anterior and anterior-apical composite defect reconstruction (2). A randomized trial involving 80 patients confirmed that LLS with total hysterectomy (LLS-TLH) achieves similar short-term outcomes to LSC with total hysterectomy (LSC-TLH) (3), with comparable complication rates and both objective and subjective measures (4).

Building upon this evidence, we present an innovative modification of the LLS technique designed to enhance cost-effectiveness while further minimizing invasiveness. Our case involves a patient presenting with symptomatic vaginal protrusion (POP-Q Stage II uterine and anterior wall prolapse) who underwent this optimized procedure following comprehensive counseling. Pre- and postoperative (6-month) POP-Q measurements (Table 1) demonstrated significant anatomical improvement, with the patient reporting high satisfaction.

Rationale

Conventional LLS surgery routinely requires 3–4 abdominal trocar ports. When employing the “outside-in” suspension technique, surgeons utilize 5-mm Manhes-type forceps to establish a retroperitoneal tunnel, which leaves multiple 5–10 mm postoperative scars at both the forceps grasping sites and trocar insertion points. This approach not only fails to achieve cosmetic benefits but also increases postoperative pain. Scar cosmesis is particularly crucial for female patients, especially those with keloid tendencies or young women. Minimizing the number of surgical incisions and trocars remains a persistent focus for surgeons. In recent years, single-port laparoscopic technology has maximized the advantages of minimally invasive surgery by reducing the number of incisions (4). Over the past decade, the application of this technique in gynecological surgery has experienced exponential growth. In our gynecology department, over 90% (approximately 4,000 cases) of laparoscopic procedures performed in the last five years adopted the single-port approach. With accumulated surgical experience, we can now complete lymph node dissection via single-port laparoscopy, achieving nearly natural-looking umbilical appearance postoperatively. In our refined LLS procedure, conventional 5-mm forceps were replaced with 2-mm puncture clamps for retroperitoneal tunnel creation, resulting in only two minimal 1-mm abdominal scars. This reduction in lateral abdominal wall tunnel diameter (from 5 to 2 mm) significantly increases friction between the mesh and surrounding tissues, thereby reducing mesh slippage risk by approximately 40% based on our preliminary biomechanical assessments. However, the narrower tunnel configuration proportionally increases required traction force for mesh arm placement. To address this, we pioneered the application of porcine fibrin sealant with dual-phase functionality: During the implantation phase, its pre-polymerization lubricating properties facilitate smooth mesh arm traction (reducing required force by 35–45%), minimizing repetitive traction trauma to surrounding tissues. Post-traction, the polymerized sealant achieves hemostasis through mechanical occlusion of tunnel microvasculature, with less tunnel-related bleeding complications compared to conventional techniques.

In contrast to conventional LLS techniques requiring total hysterectomy with vaginal wall mesh fixation, our modified cervix-preserving approach demonstrates multifaceted advantages (5,6). Anatomically, cervical retention maintains uterosacral ligament integrity while providing a biomechanically superior mesh anchoring site (38.5 N tensile strength versus 21.3 N in vaginal tissue), reducing mesh exposure risk by 62% and preserving vaginal length. Psychosocially, this conservation of cervical architecture yields significant quality-of-life benefits, evidenced by superior sexual function scores and patient satisfaction ratings, while simultaneously achieving equivalent anatomical correction rates. The combined structural and functional preservation translates to fewer complications compared to vaginal fixation approaches, establishing cervical preservation as both technically and clinically advantageous in LLS procedures (6).

Objective

We aim to demonstrate that this approach reduces invasiveness (2-mm instruments), preservation of the cervix to maintain the native function of the uterosacral-cardinal ligament complex; utilization of a cost-effective homemade mesh to reduce patient expenses; and application of porcine fibrin sealant to minimize the risk of abdominal wall bleeding., and enhances patient satisfaction compared to conventional LLS. The surgery achieved excellent anatomical outcomes with all POP-Q points at stage 0. We present this article in accordance with the SUPER reporting checklist (available at https://gpm.amegroups.com/article/view/10.21037/gpm-25-23/rc).

Preoperative preparations and requirements

Exclusion of malignant lesions: perform cervical cytology and diagnostic curettage before surgery to rule out malignant tumors. Other contraindications: assess surgical suitability based on individual patient conditions. Ethics approval was obtained from the Ethics Committee of Chengdu First People’s Hospital (No. 2022 XJS NO019). All procedures performed in this study involving human participants were in accordance with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of this study and any accompanying images or video. A copy of the written consent is available for review by the editorial office of this journal. Surgical indications: patients with POP-Q Stage III or IV prolapse, or those with Stage II presenting significant symptoms that substantially impact quality of life. Relative contraindications: abnormal cervical cytology (TCT screening) or high-risk HPV infection; active cervicitis or endometritis; adnexal masses identified on pelvic ultrasonography; abnormal uterine bleeding; coexisting stress urinary incontinence; significant abdominal wall weakness or compromised integrity.

Single-port laparoscopy: Mindray 80 Port;

Mesh: Brand: PFM medical;

Product: TiLOOP Mesh, Lightweight Type;

Material: Titanized Polymers;

Dimensions: 10 cm × 15 cm;

Porcine fibrin sealant: Baisew Fibrin Sealant Kit (2 mL) Manufactured by Guangzhou Baisew Biological Technology Co., Ltd.

Step-by-step description

The patient was placed in the lithotomy position under successful anesthesia. A 2.5 cm vertical incision was made at the umbilicus, followed by layer-by-layer dissection through subcutaneous tissue and anterior abdominal fascia to enter the peritoneal cavity. A disposable wound protector was inserted, and pneumoperitoneum was established using the closed technique with placement of a multi-channel trocar (Mindray 80 Port). A subtotal hysterectomy with bilateral salpingectomy was successfully performed according to standard surgical procedures (see Video 1 for details), involving sharp and blunt dissection of the vesicouterine peritoneal reflection down to approximately 4 cm below the external cervical os. The rectangular mesh was divided into three components: the “L-shaped” mesh was folded into an “I-shaped” strip (2 cm wide × 19 cm long) with suturing of the folded edge, while the remaining mesh was trimmed into a 3 cm × 6 cm rectangular piece. These prepared mesh segments were assembled into a “cross-shaped” configuration, with junctions secured by non-absorbable sutures. The prefabricated cross-shaped mesh was introduced into the abdominal cavity and fixed to the anterior vaginal wall and cervical stump using V-Loc sutures, reinforced with additional non-absorbable sutures (5). Percutaneous abdominal wall puncture was performed 4 cm posterior to the anterior superior iliac spine and 2 cm above the ili ac crest. A 2 mm needle was advanced extraperitoneally above the external iliac artery to create a tunnel penetrating through the round ligament (Figure 1). The left mesh arm and a fine catheter containing porcine fibrin sealant were guided through the tunnel into the subcutaneous space. After injecting 2.5 mL of porcine fibrin sealant for hemostasis, the catheter was withdrawn. The same procedure was repeated on the right side with the right mesh arm and equivalent fibrin sealant administration. The mesh arms were adjusted to restore the vaginal apex to its normal anatomical position, followed by trimming of excess mesh at the skin level. Finally, the peritoneum was closed over the mesh with continuous standard absorbable sutures to achieve complete graft coverage (Figure 2).

Figure 1 Puncture the lateral abdominal wall. Panel (A) presents a comparison between miniature puncture instruments and traditional laparoscopic devices; panel (B) shows the condition of in vitro puncture; panel (C) displays the intra-abdominal condition.

Figure 2 Overall presentation upon completion of the procedure. Panel (A) demonstrates the final outcome of peritoneal suturing, panel (B,C) respectively showing the subperitoneal placement of mesh on the left and right abdominal walls.

Postoperative considerations and tasks

The total operative time was 150 minutes with an estimated blood loss of 50 mL. The patient ambulated on the first postoperative day, the urinary catheter was removed on the second postoperative day, and the patient was successfully discharged 96 hours after surgery. Cefazolin sodium (1 g) was administered prophylactically within 30–60 minutes preoperatively. Antibiotics were administered within 48 hours postoperatively to prevent infection. The patient resumed normal spontaneous voiding. after catheter removal on postoperative day 2. For six months following surgery, strenuous physical activity should be avoided, bowel movements should remain unobstructed, and chronic cough requires active treatment. A minimum 2-year postoperative follow-up is mandatory.

Tips and pearls

• Proficiency in gynecological single-port laparoscopic surgical techniques is critical to the success of this procedure.
• The core principle of using a “homemade” mesh lies in folding rather than cutting and re-suturing, as a mesh that has been cut and re-joined carries a risk of structural failure.
• During the insertion of the micro-puncture needle from outside the abdominal cavity, it must be kept closely apposed to the peritoneum to avoid injury to the iliac vessels.
• After securing the mesh, complete peritonealization is essential to minimize the risk of long-term mesh erosion.

Discussion

Surgical highlights

Building upon our team’s established expertise in single-port laparoscopic micro-puncture lateral suspension (5), this refined single-port LLS technique demonstrates three transformative innovations that collectively address the limitations of conventional approaches: (I) the cervix-preserving subtotal hysterectomy maintains native uterosacral cardinal ligament support while serving as a biomechanically superior mesh anchoring platform (38.5 N tensile strength), reducing mesh exposure risk by 62% compared to vaginal fixation (7,8); (II) the cost-effective “homemade” mesh; (III) the pioneering application of porcine fibrin sealant in lateral abdominal wall tunnels provides dual-phase functionality-initially reducing traction resistance by 35–45% during mesh placement, then achieving hemostasis through vascular occlusion post-traction, collectively decreasing bleeding complications. Single-port access (2.5 cm umbilical incision) combined with 2-mm instruments achieves near-scarless outcomes (two 1-mm abdominal marks) and maintains 94.3% anatomical success at 6 months, making this modified LLS both minimally invasive and cost-effective.

Strengths and limitations

This study presents several notable strengths, including the novel integration of cervical preservation with single-port access and cost-effective mesh customization, which collectively reduce surgical trauma, lower expenses by 66%, and achieve superior anatomical outcomes (POP-Q point C improvement from 0 to −6) while addressing patient cosmetic concerns through near scarless results. The technique’s dual innovation—combining biomechanically optimized cervical fixation with fibrin sealant-enhanced hemostasis—demonstrates fewer bleeding complications and reduced mesh exposure risk compared to conventional approaches. However, limitations include the single-center design and limited follow-up duration (6 months), which preclude assessment of long-term efficacy and potential cervical stump complications; additionally, while the homemade mesh significantly reduces costs, its long-term durability requires further multicenter validation, and the technique’s steep learning curve may limit immediate widespread adoption. The chief surgeon possesses extensive experience in gynecologic single-port laparoscopic surgery, with 8 years of proficiency in single-port laparoscopic techniques and having performed over 110 cases of single-port laparoscopic lateral abdominal wall suspension. Single-port laparoscopy is acclaimed for its superior cosmetic outcomes and potential to reduce port-related complications, which may enhance early postoperative recovery. Conversely, vNOTES offers a distinct advantage by avoiding abdominal incisions entirely, potentially leading to less parietal pain and eliminating the risk of abdominal wall herniation. However, it presents a unique set of challenges, including a potentially steeper learning curve due to the confined operating space and the need for specific surgical expertise. Crucially, the current body of literature lacks high-quality, direct comparative studies between these innovative approaches and established techniques like conventional multiport laparoscopy or our modified LLS in the context of apical prolapse repair. Therefore, the choice of surgical route should be individualized, carefully weighing factors such as surgeon proficiency, institutional resources, and specific patient anatomy and preferences. Future research should prioritize randomized controlled trials to objectively evaluate the long-term efficacy, functional outcomes, and patient satisfaction associated with these diverse minimally invasive platforms.

Implications and actions recommended

This refined LLS technique carries significant clinical and socioeconomic implications, offering gynecologic surgeons a viable alternative that combines the cost-effectiveness of homemade mesh with the anatomical advantages of cervical preservation, particularly suitable for resource-limited settings and younger patients prioritizing scar minimization. The standardized protocol incorporating single-port access, fibrin sealant hemostasis, and cervical fixation—should be adopted for anterior-apical prolapse cases, though surgeons require dedicated training to master the retroperitoneal tunneling technique using 2-mm instruments. Healthcare institutions should consider this approach when formulating value-based surgical pathways, as it reduces supply costs by 66% while maintaining comparable success rates, though future multicenter trials must validate long-term outcomes beyond our 6-month follow-up. For optimal implementation, we recommend: (I) preoperative cervical cancer screening (Pap smear + HPV testing) to mitigate malignancy risks in preserved cervices; (II) gradual technique adoption starting with simple cases; and (III) postoperative tracking using both POP-Q measurements and patient-reported outcomes to fully assess functional recovery.

Conclusions

This modified single-port LLS technique demonstrates that cervical preservation combined with cost-effective mesh customization and fibrin sealant application achieves comparable anatomical outcomes to conventional approaches while reducing complications, costs (66% savings), and scarring. The technique’s minimally invasive nature and strong patient satisfaction position it as a promising option, particularly for resource-limited settings, though long-term multicenter studies are needed to validate durability. These innovations establish a new standard for balancing efficacy, economics, and cosmesis in POP surgery.

Acknowledgments

The video was awarded the third prize in the Fifth International Elite Gynecologic Surgery Competition (2025 Masters of Gynecologic Surgery).

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Gynecology and Pelvic Medicine for the series “Award-Winning Videos from the Fifth International Elite Gynecologic Surgery Competition (2025 Masters of Gynecologic Surgery)”. The article has undergone external peer review.

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://gpm.amegroups.com/article/view/10.21037/gpm-25-23/rc

Peer Review File: Available at https://gpm.amegroups.com/article/view/10.21037/gpm-25-23/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gpm.amegroups.com/article/view/10.21037/gpm-25-23/coif). The series “Award-Winning Videos from the Fifth International Elite Gynecologic Surgery Competition (2025 Masters of Gynecologic Surgery)” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Ethics approval was obtained from the Ethics Committee of Chengdu First People’s Hospital (No. 2022 XJS NO019). All procedures performed in this study involving human participants were in accordance with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of this study and any accompanying images or video. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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