Pelvic floor dysfunctional disease refers to the dysfunction of the pelvic floor tissues and organs, which mainly includes uterine prolapse, anterior and posterior vaginal wall bulge, bladder neck and urethra downward displacement to stress urinary incontinence, and rectal prolapse, etc. The causes of the disease are mainly in two categories, one of them refers to its own tissue and structural defects, and the other one is the injuries (birth trauma and traumatic injuries), and the treatments are mainly using the strategies of structural reconstruction or correction, and the application of laparoscopic surgery has achieved good clinical results. Currently, laparoscopy has been used in this field with good clinical results, and several new surgical methods are introduced below. Laparoscopic surgery for uterine prolapse There are many surgical methods for uterine prolapse, and the ones that can be done laparoscopically with good results include uterine and vaginal sacral capsule fixation, uterosacral ligament folding and shortening, and uterine and vaginal dome and sacrospinous ligament fixation, and so on. Indications and contraindications Uterine prolapse, combined with the anterior and posterior walls of the vagina dilated by conservative treatment is ineffective, and seriously affect the patient’s quality of life, the need for surgical treatment. There are serious lung disease, and chronic cough; chronic constipation and heavy laborers should not be surgical treatment. Those with contraindications to laparoscopy should not undergo laparoscopic surgery. Uterine cervix and vaginal mesh sacral cape fixation (1) separation of the retroperitoneal space: the first separation of the vesicovaginal space or vesico-uterine space, the two gaps in the bladder pillars as the boundary, bilateral bladder pillars in the bladder at the base of the bladder will be convergence, and the ureter is located in the same level, the bladder pillars in the medial midline at the incision and separation. The rectovaginal space is separated by opening the lateral peritoneum, finding the ureter and pushing it away from the sacral ligament. Identify the bilateral sacral ligament junction in the recto-uterine recess, lift the peritoneum, cut the peritoneum of the recto-uterine recess, and separate the rectovaginal space. The scope of separation is required to reach forward and down to about 2cm above the perineal union. The broad ligament is perforated, the uterus is lifted and pushed to the other side, and the posterior lobe of the broad ligament is opened so that the anterior and posterior lobes of the broad ligament are connected, which is used to place the repair mesh. (2) Exposure of the sacral promontory: the best way to expose the sacral promontory is to carefully push away the sigmoid colon and then use the head-down hip-high position, in order to improve the field of view can be fixed in the sigmoid colon in the anterior abdominal wall. To identify the right ureter and common iliac vein, the posterior peritoneum is vertically incised from the sacral promontory, and the ureter is freed and exposed. Continue to separate the posterior peritoneum to the upper lumbar 5 or sacral 1, separate the anterior ligament of the vertebrae, and push away the artery and the median sacral vein within it. (3) Placement of the repair mesh: Mersilene mesh is used because it is strong and stretches better longitudinally than transversely, does not remain fixed, and facilitates laparoscopic operation. If the uterus has been resected, the repair mesh is firstly placed into the posterior, and nylon thread is used to suture the repair mesh to the vagina, and the gap between the repair mesh and the vagina is closed; then the anterior wall of the vagina is covered and sutured to the anterior wall of the vagina. If the uterus is not resected, the repair mesh is placed behind the vagina and fixed to the vaginal part of the uterus and the main ligaments with size 0 non-absorbable nylon sutures. (4) Recto-Uterine Entrapment Plasty: The goal is to raise the rectum into position and pull the vagina posteriorly. It involves closure of the posterior dome and the recto-uterine sulcus with 2 sutures. The uterosacral ligament is closed posteriorly. The ureter is first identified and the main ligament is closed. Finally, the mesh is sutured to the vagina and the opposite side is treated in the same way. (5) Fixation of the repair net: unfold the repair net in the vesicovaginal space. If the uterus has not been removed, the two wings of the mesh are passed through the hole made in the posterior lobe of the broad ligament. A wide knot is tied behind the isthmus, where there is no peritoneum at the time of separation of the rectovaginal space, and the mesh is fixed to the anterior vaginal wall with a 2/0 nylon thread, and the knot is tied. (6) Fixation of the sacral promontory: The anterior and posterior repair meshes were fixed to the anterior ligament of the sacral promontory and the periosteum of the sacral promontory, and only the fibrous layer of the tendon membrane was entered in order to avoid spondylolisthesis and perforation of the spine. The sutures were checked to make sure they were secure. Pelvic peritonization: The incision is made in the front of the vesico-uterine separation, in the back of the rectovaginal separation, and in the middle of the incision from the sacral promontory to the midline of the recto-uterine depression. 2/0 nylon thread and curved sutures are placed in 2-3 stitches, and the incision is closed by knotted sutures, or steel staples can be used. (7) Peritonization of the posterior peritoneum: After the sacral promontory is sutured, the polypropylene mesh is placed in the right pararectal space behind the peritoneum, and the posterior peritoneum is closed. Folding and shortening of the uterosacral ligament (1) Separation of the lateral peritoneum: first identify the course and position of the ureter, open the lateral peritoneum, free and push away the ureter, so as not to injure the ureter when suturing the sacral ligament. (2) Uterosacral ligament folding and shortening: U-shaped folding suture along both sides of the uterosacral ligament, rectovaginal septum and vaginal wall, the uterosacral ligament is shortened, and then successive sutures to the top of the vagina and bilateral sacral ligament junction, and with the vaginal fascia suture fixation, so that the cervix around the fascial ring on both sides and the posterior to be reinforced. (3) Fixation of uterosacral ligament: The folded uterosacral ligament is sutured with non-absorbable No. 0 nylon thread at the level of the cervix, fixed on both sides, and then knotted after the suture is finished. (4) Closure of the uterorectal fossa: The uterosacral ligaments are sutured intermittently with No. 0 nylon thread on both sides to close the uterorectal fossa. If the ureter is twisted after suturing the uterosacral ligament, open the pelvic peritoneum on the medial side of the sacral ligament, free and push away the ureter to make its natural course. Cervical and vaginal vault sacrospinous ligament fixation (1) Separation gap: similar to the vaginal sacral fixation, the first separation of the cervical and vaginal paravaginal gap to expose the fascial tissue above the sciatic spine. Then separate the rectovaginal space, first open the lateral peritoneum, find the ureter and identify its course, and push it off the uterosacral ligament to avoid injury. Identify the junction of bilateral sacral ligaments located in the recto-uterine recess, lift the peritoneum, cut open the peritoneum of the recto-uterine recess, and separate the recto-vaginal hiatus. (2) Separation of the perirectal space: on the medial side of the uterosacral ligament, extend the peritoneal incision of the rectovaginal recess to the anterior aspect of the second and third sacral bones, separate and push away the rectum, expose the bilateral sacrospinous ligaments, the caudal muscles and the sciatic spine. (3)Suture the posterior wall of cervical-vaginal part or posterior vaginal wall on both sides, pass the suture through the coccygeal muscle and sacrospinous ligament 2-3cm from the medial side of the sciatic spine, the suture of sacrospinous ligament on each side should not be more than 2 stitches, and tie a knot to fix the posterior vaginal wall or the cervical-vaginal part to the sacrospinous ligament. Precautions and common complications (1) Traumatic hemorrhage and vascular injury: including traumatic hemorrhage during the separation of the interstices, injury to the presacral venous plexus during the suture closure of the sacrospinous ligament and injury to the uterine artery during the perforation of the broad ligament. Both traumatic hemorrhage and injury to the uterine artery can be hemostatized by bipolar coagulation, and sutures are used to stop the hemorrhage if necessary. As for the injury of presacral vein, it depends on the size of the laceration, if it is a small laceration, only compression or bipolar electrocoagulation can be used to stop the bleeding, if it is a small laceration, it can be tried to be closed under laparoscopy, if it is difficult to close the laceration or the laceration is large, it can be used to perform vascularization by laparoscopic suture or anastomosis. (2) Ureteral injury: If there is ureteral injury, anastomosis of ureter and ureter or ureter and bladder can be performed, and a ureteral stent can be placed after surgery to prevent ureteral stenosis. Generally, the stent is removed about 3 months after the operation. (3) Intestinal obstruction: Due to incomplete closure of the rectal recess, the small intestine enters into the recess, forming an internal hernia of the small intestine, resulting in intestinal obstruction. Mild internal hernia can be relieved automatically by conservative treatment, but in severe cases, intestinal necrosis can occur and surgical treatment is needed. In severe cases, intestinal necrosis can occur and surgery is needed. Therefore, the rectovaginal pit should be closed thoroughly without leaving a gap to avoid intestinal hernia. Surgical evaluation Reproductive tract prolapse is a common gynecological disease, and there are currently more than 30 surgical procedures for the treatment of this type of disease, which is sufficient to illustrate the intractability of this type of disease. Laparoscopy only provides a new means of transabdominal surgery, it can make the separation of the anterior and posterior gaps with better vision, this new procedure combines the traditional vaginal or cervical fixation with a new surgical pathway, and achieves minimally invasive, precise separation of tissues and rapid recovery, which has a good clinical application prospect. However, due to the difficulty of laparoscopic surgery, thus limiting its clinical application, it is necessary to strengthen the training of laparoscopic surgical suturing techniques so that more gynecologic laparoscopists can master the technology and serve in the clinic. Stress incontinence laparoscopic surgery Stress incontinence surgery is also a variety of surgical methods, but the purpose of the surgery is mainly to correct the urethra of the lack of support, in order to alleviate the symptoms of urinary incontinence. Laparoscopic surgery is most commonly used to suspend the bladder neck and mid-urethra, and the results are good. Indications and contraindications Tension urinary incontinence of degree II or above can be treated with surgery if conservative treatment is ineffective or recurrent. Those with contraindications to laparoscopic surgery are not suitable for laparoscopic surgery. Burch bladder neck suspension (1) Separation of the retro-pubic Retzius space: there are two routes, i.e., the transabdominal route and the extraperitoneal route. Transperitoneal route: The peritoneal incision is made from one umbilical artery to the other to fully free the anterior interstitial space of the bladder, and it is advisable to fill the bladder in patients who have difficulty in bladder exposure. The bladder should be filled in patients who have difficulty in visualizing the bladder. Then, the pubic retropubic fascia should be continued downward, and the Retzius hiatus should be opened to expose the pubic bone and bilateral Cooper’s ligaments, and then the neck of the bladder should be reached. The bladder is pushed back medially with a separating forceps, while the vaginal wall tissue is grasped with a grasping forceps on the opposite side to completely separate the bladder from the vagina and expose the anterior vaginal wall. Extraperitoneal route: At the midpoint between the umbilicus and the umbilicus, a 2-cm-long horizontal incision was made to bluntly separate the Retzius space under the rectus abdominis muscle to the Cooper’s ligament on both sides, which could be done by inserting a 1,000 to 1,500 ml balloon into the space or by bluntly separating with a finger. A 5mm trocar is then inserted in each side, and a set of trocars is placed in the pubic bone for retraction. The rectus abdominis muscle is sutured around the 10-mm trocars, and the Retzius space is inflated with low-pressure (8-12 mmHg) air. (2) Suture: Firstly, suture the Cooper ligament, try to pass through the whole layer of Cooper ligament to enhance its resistance to tension, and exit the needle in the direction of its longitudinal axis, and do not force the needle in order to avoid breaking the needle. Insert the middle finger or index finger of the left hand into the vagina to expose the urethrocystic connection and the anterior vaginal wall to be sutured into the needle point, use the finger as a guide to enter the needle and avoid the bladder to puncture the tissue of the anterior vaginal wall, but avoid penetrating the whole layer. Tighten the suture after the needle is released, and tie the knot so that the urethrocystic connection does not form an acute angle. The first suture must be close to the urethrocystic connection, and then the second and third suspension sutures should be closed sequentially, with an interval of about 1cm between each suture. Bipolar electrocoagulation can be used to stop bleeding on the trauma, if necessary, suture hemostasis, rinse the trauma, thoroughly check the inactivity of bleeding, that is, the peritoneum with absorbable sutures intermittent suture. Urethral sling suspension (1) the preparation of the sling: there are two kinds of materials, namely, autologous tissue and synthetic materials, synthetic materials because of infection, erosion and high chance of being rejected by the body, so most of the use of their own tissue materials (autologous grafts) or allogeneic tissue denaturation processed materials (allogeneic grafts). Autologous or allogeneic fascial band tissue extraction: cut the rectus abdominis muscle or thigh quadriceps muscle surface of the strong tendon, about 10cm long, about 1cm wide, after taking out the tendon membrane tissue, local gauze compression bandage to stop bleeding, due to the small incision after the operation the patient does not have obvious discomfort. If the patient’s body is weaker or older, the use of allogeneic tissue as a sling, the effect is the same as autologous tissue. Preparation of synthetic materials: generally used polypropylene mesh or nylon mesh, cut into strips can be. (2) the placement of the sling: through the laparoscopic puncture sheath hole will be placed in the sling into the retropubic space, before the retropubic space through the laparoscopic free and thoroughly hemostasis, separation of the bladder and the ureter, as well as the junction of the ureter and the bladder. At this time in the anterior vaginal wall of the bladder neck position with a scalpel longitudinal incision of the vaginal mucosa and submucosal part of the muscle layer, with a pointed vascular forceps from this incision along the vaginal mucosa inserted, in the bladder neck side penetration straight to the retropubic space, the vascular forceps to grasp the end of the sling, clamping pulled into the vagina; at this time, clamping the vascular forceps from the other side of the sling in the vagina under the mucous membrane through the vaginal wall into the tissue interstitial, in the bladder neck on the other side. Into the posterior pubic space. (3) Suture of the sling: Use No. 0 nylon thread with needle to sew the two ends of the sling to the bilateral Cooper’s ligament, the tension of the sling should not be too great, that is, the urethra can not form a sharp angle. (4) Close the posterior peritoneum and vaginal mucosa, and use absorbable sutures to intermittently suture the peritoneum. Then use absorbable suture to close the vaginal incision. Precautions and common complications (1) bleeding and vascular injury: in the opening of the posterior peritoneum need to pay attention to prevent bleeding from injury to the arteries under the abdominal wall, if any, can be used to bipolar electrocoagulation to stop bleeding; if bleeding in the ligament of the Cooper suture or the vaginal wall, need to be immediately used to bipolar electrocoagulation to stop bleeding, to prevent anatomical relationship caused by bladder or urethra injury; sometimes there is bleeding often need to be intermediate laparotomy, therefore, in the separation of the retrosplenial space should not be too close to the pubic bone, so the pubic bone is not too close to the pubic bone. Therefore, the pubic bone should not be too close to the pubic bone when separating the posterior interspace, so as not to damage the closed vein. (2) Perforation of the bladder or penetration of the suture needle: Firstly, it occurs when incising the posterior peritoneum, due to the confusion of recognizing the edge of the bladder, the bladder can be easily incised; secondly, it is easy to occur when separating the Retzius space and when the suture needle passes through the vaginal wall, for this reason, we can fill up the bladder with methylene blue solution firstly, and if there is any injury, it can be repaired immediately under the laparoscopic procedure. After surgery, a urinary catheter is left in place for more than 7 days. (3) urethral injury also occurs from time to time, such as penetrating injury, removal of stitches can be, such as transverse injury, it is necessary to open the urethral anastomosis, the urethral catheter should be appropriately prolonged after the operation until the urethral anastomosis is completely healed, otherwise it is easy to occur urethral stenosis. (4) urethral obstruction: due to the suspension of the bladder neck angle is too large, can appear difficult to urinate, or urethral obstruction, some with the position. If urethral obstruction occurs, conservative treatment is needed first, including urethral dilatation, change of urinary position and drug relaxation of the bladder neck, etc. If it is ineffective, then it is necessary to remove the sutures and re-suspend until the obstruction is corrected. Evaluation of therapeutic efficacy of tension incontinence surgical treatment methods, including urethral sling surgery and Cooper’s ligament suspension surgery is better. Cooper’s ligament suspension surgery is to raise the position of the bladder neck and urethra, narrow the posterior angle of the urethrocystic bladder, increase the resistance of the bladder neck, so that when the abdominal pressure increases, the urethra is still of sufficient length and the bladder neck can not be opened to improve the control of urinary overflow. The cure rate of 3 months to 1 year after surgery is 71% to 95%. Laparoscopic suburethral urethral sling suspension is suitable for patients with intrinsic sphincter defects of tension urinary incontinence, these patients generally use Burch suspension is not effective. The efficiency of suburethral sling suspension is about 90%, and the results are stable over 6 years of follow-up. Laparoscopic suburethral bladder neck and midurethral suspension has certain advantages over transvaginal surgery, first of all, it can completely stop the bleeding of the wound, and secondly, the position of the sling can be accurately positioned, for different degrees of uterine prolapse, laparoscopic-assisted vaginal hysterectomy and uterine sacrosacral ligament vaginal dome suspension can be used for the treatment of uterine prolapse.