Factors Affecting Vaginal Length in Hysterectomy: A Pilot Study

Objectives: Quantify the effect of pneumoperitoneum and Trendelenburg position on total vaginal length (TVL) to better inform factors affecting mesh tensioning for minimally invasive sacrocolpopexy.


Previous studies indicate mesh tensioning can be a risk factor for mesh complications, such as mesh exposure and pelvic pain after surgery. Increasing tension can lead to longer vaginal lengths, though it is unclear what amount of tensioning is ideal for each patient. We sought to determine whether intraoperative variables, such as Trendelenburg positioning or pressure from insufflation during laparoscopic procedures, can affect vaginal length. It is hypothesized that Trendelenburg may increase length by pulling the vaginal apex more cephalad due to gravity, while insufflation pressure may shorten length by displacing the apex caudally. Quantifying these factors could help understand the necessary compensation for mesh tensioning intraoperatively.

Methods: This is a descriptive study with pilot data and ongoing data collection. This is part of a larger study recruiting women over the age of 18 undergoing laparoscopic hysterectomy for benign indications or women undergoing robotic-assisted laparoscopic sacrocolpopexy with or without concurrent hysterectomy for pelvic organ prolapse. Patients will be excluded who are undergoing anterior colporrhaphy, as this procedure adds an additional variable to the vaginal length.

Subjects were recruited and consented in the preoperative area on the day of surgery. A POP-Q measuring stick was used to measure TVL intraoperatively at the following points:
1. After intubation in level position before procedure start
2. After closure of the vaginal cuff
2a. While the patient was in trendelenburg with pneumoperitoneum
2b. When the patient was in level position with pneumoperitoneum
2c. When the patient was in level position without pneumoperitoneum 

Data analysis included calculating the mean change in TVL to isolate change in TVL with and without trendelenburg and with and without insufflation.

For the patients enrolled undergoing sacrocolpopexy, data will be collected after mesh attachment with and without the variables of pneumoperitoneum and Trendelenburg.

Results: Pilot data for three patients revealed a mean insufflation effect of -0.167 cm (SD 0.289) and mean Trendelenburg effect of +0.5 cm (SD 0) based on a sample size of 3. For this group, the average difference between TVL after cuff closure with both Trendelenburg and insufflation forces present and TVL after cuff closure with both forces absent was 0.333 cm (SD 0.236).

Conclusions: With pilot data collected thus far, Trendelenburg positioning and pneumoperitoneum pressure do appear to have effects on total vaginal length, as hypothesized. This study is ongoing and additional data will be collected to help gain insight on intraoperative factors for patients undergoing sacrocolpopexy as well. This study will help to quantify the intraoperative factors that should be taken into account during mesh tensioning in sacrocolpopexy.