Laparoscopic vaginal sacral fixation has become the gold standard procedure for mid-pelvic defects and has gradually replaced the open vaginal sacral fixation. Due to the improved surgical approach, the indications for the procedure are expanding, and it can correct not only mid-pelvic defects, but also severe bladder bulge or rectal bulge. Long-term clinical outcomes have shown high subjective and objective cure rates, minimal recurrence of apical vaginal prolapse, low postoperative impact on patient quality of life, and mesh-related complications in the acceptable range. Although bowel erosion of the mesh is rare, long-term postoperative follow-up of patients should be emphasized. The long-term efficacy of laparoscopic uterosacral fixation remains to be observed. Laparoscopic sacralcolpopexy (LSC) has gradually become one of the gold standard procedures for patients with mid-pelvic defects due to the improvement of laparoscopic equipment and the widespread availability of laparoscopic surgery, which has gradually replaced open vaginal sacral fixation. Since the warning of the complications of transvaginal mesh placement surgery by FDA in 2008, the scope of transvaginal mesh surgery has been relatively narrowed, while LSC, with its outstanding advantages of low incidence of mesh-related complications and recurrence rate and low impact on sexual quality of life, has significantly increased the proportion of this procedure in Europe and the United States, and has also been more widely used in China in recent years. In 1957, Arthure and Savage first reported that the posterior vaginal vault was fixed to the anterior longitudinal sacral ligament, called sacralcolpopexy (SC). In 1973, Birncf described the normal anatomical position of the vaginal apex and suggested that the normal anatomy of the vaginal apex was at the level of S3-S4, suggesting that the anterior sacral fixation point of the mesh should be on the sacrum at S3-S4. In 1981, Sutton proposed fixation of the mesh on the S1-S2 sacrum through anatomical studies, suggesting that this plane could easily avoid the median sacral artery and the anterior sacral plexus, reducing the risk of intraoperative hemorrhagic injury.In 1991, Snyder and Krantz extended this procedure to patients with low rectal distention, extending the In 1994, Nezhat et al. reported 15 cases of LSC for the first time [1], and this procedure was popularized in Europe and the United States for its high subjective and objective cure rates, low recurrence rate, low mesh exposure, and rapid postoperative recovery; Agarwala N et al. clinical outcomes 2 years after laparoscopic uterosacral fixation, 72 The subjective and objective cure rates were 97% and 100%, respectively, and there was no recurrence in one case. Complications included one case of bleeding and one case of cervical abscess, with an infection rate of 1.4% [2]; however, the follow-up period was still relatively short. 2004 Marco reported for the first time a patient with vaginal vault bulge who underwent robotic-assisted sacral vaginal fixation [3]. Throughout the history of vaginal sacral fixation, LSC has become the leading procedure for sacral fixation, and has gradually replaced abdominal sacral colpopexy (ASC), and the indications and modalities of the procedure are continuously being expanded and improved. 2.Characteristics of the vascular anatomy of the anterior sacral region Understanding the anatomy of the anterior sacral region is very important to reduce the bleeding injury during surgery. The vasculature of the presacral region consists of the anterior middle sacral artery branching from the left common iliac vessels, two anterior middle sacral veins connecting the left common iliac vein, two lateral sacral veins connecting the internal iliac veins, and the transverse trunk veins between the sacral vertebrae connecting with the lateral sacral veins. The anterior sacral venous plexus consists of a venous network composed of the lateral sacral veins on both sides, the middle sacral vein, the transverse trunk vein and the mutual traffic veins, which are located on the deep surface of the anterior sacral fascia attached to the pelvic surface of the sacral vertebra. Since both the vertebral venous system and the vena cava system have no venous valves, the blood of both can flow with each other, and once the veins in the anterior sacral area are injured, the blood of the inferior vena cava system also participates in the process of hemorrhage. When the blood vessels in the anterior sacral region are injured, blood rapidly fills the posterior pelvic cavity, causing intraoperative handling difficulties and can cause fatal hemorrhage. In addition, the variability of arteries and veins in the anterior sacral region is large; therefore, it is necessary to fully understand the characteristics of the vascular anatomy in the anterior sacral region and to evaluate the safe area for surgery in the anterior sacral region according to the type of vessels in the median sacral region [4] in order to reduce bleeding injuries in the anterior sacral region during surgery. 3. indications and contraindications 3.1 Indications The current consensus on the indications for LSC considers symptomatic vaginal vault prolapse (≥ stage II); patients with primary treatment of POP with predominantly mid-pelvic defects (≥ stage III); and some patients with recurrence after POP surgery. Because patients with symptomatic vaginal vault prolapse ≥ stage II usually have lower urinary tract symptoms, lower abdominal cramping, or perineal discomfort, the symptoms are mostly relieved by vaginal vault suspension to correct the anatomy; for patients with recurrent POP, the vagina is often shortened or narrowed, and because LSC is not limited by vaginal length and width, it can be performed in patients with significant vaginal narrowing or shortening The LSC is not limited by the length or width of the vagina. In patients with stage IV anterior vaginal wall prolapse, the anterior mesh should be placed up to the level of the transverse vaginal sulcus; in patients with stage IV posterior vaginal wall prolapse, the posterior mesh should be placed at the rectovaginal diaphragm up to the puborectalis fascia near the perineal body to achieve simultaneous repair of anterior or posterior pelvic defects [5]. 3.2 Contraindications Combined contraindications to laparoscopic surgery, acute infectious phase of the genital tract, and connective tissue disease are contraindications to this procedure, and in addition, those who have not completed childbirth should complete it before reconstructive surgery. Age older than 70 years, the risk of laparoscopic surgery increases, and the difficulty of laparoscopic surgery increases in especially obese patients, which should also be listed as a relative contraindication. 4. Surgical modalities and main steps 4.1 LSC surgery can be broadly classified as laparoscopic vaginal sacral fixation, laparoscopic sacrocervicopexy, and laparoscopic sacrohysteropexy. The surgical routes are divided into fully laparoscopically operated LSC, vaginally assisted laparoscopic sacrocolpopexy (VALS), or robotically assisted LSC. 4.2 The main surgical steps include: identification of the vessels of the presacral region, the right ureter, and the right iliac vascular dissection The mesh of the anterior vaginal wall and the mesh of the posterior wall are sutured either microscopically or transvaginally, and if the uterus is preserved, the anterior vaginal wall mesh is retracted anteriorly by perforating the right broad ligament, and the anterior vaginal wall and posterior wall mesh are sutured separately. The peritoneal incision was closed so that the mesh was completely peritonealized. 5.Evaluation of efficacy It is generally accepted that LSC is a clinically common surgical procedure with positive efficacy in the treatment of apical vaginal prolapse. The current criteria for recurrence of ICS are defined as: POP-Q points above 0, C points below -5, and reappearance of prolapse-related symptoms. %, with an overall recurrence rate of 7%-16% and recurrence mostly in Aa and Ap [5, 7, 8]. Most scholars believe that the cause of recurrence may be related to the shallow placement site of the vaginal end mesh. The rate of apical recurrence is about 1.5%-3% [8, 9]. The results of a prospective clinical trial study suggest that LSC has a higher postoperative anatomic success rate and lower mesh exposure and recurrence rates in patients with symptomatic POP-Q stages II-IV compared with total pelvic floor reconstruction surgery (TVM) with transvaginal mesh [8].Freeman et al [9] randomized controlled study comparing anatomic and perioperative outcomes after LSC and ASC in patients with post-total hysterectomy vault prolapse and found that postoperative anatomic outcomes, operative time, and postoperative apical vaginal improvement with LSC surgery were similar to ASC, with shorter hospital stays and less intraoperative bleeding, hematoma, and postoperative pain medication use in LSC patients.VALS is a minimally invasive, combined treatment for severe uterovaginal prolapse patients. The prolapsed hysterectomy is first performed vaginally, followed by transvaginal placement of a mesh, which is finally suspended laparoscopically at the level of the sacral promontory or first sacral vertebra. The results showed that this procedure significantly shortened the operative time, had high subjective and objective cure rates, and improved vaginal symptoms, sexual dysfunction, and quality of life in all patients [5, 10, 11].Von Pechmann WS et al [11] compared VALS with conventional LSC and found that intraoperative and postoperative complications, incidence of mesh erosion, and postoperative patient POP -Q scores were not statistically different, but the operative time of VALS was shorter than that of conventional LSC.For young patients with uterine preservation requirements, laparoscopic uterosacral fixation can be used, and there are two methods of mesh placement in the uterine region: (i) perforation of the broad ligaments on both sides and fixation of the mesh around the peri-cervical ring; (ii) the anterior mesh is led posteriorly from the perforation of the right broad ligament, and the anterior and posterior vaginal wall meshes are fixed with sutures respectively. The anterior sacral mesh fixation method is the same as that of LSC. Due to the small number of clinical cases and the lack of results of long-term randomized controlled studies, the efficacy remains to be observed. The use of Y-shaped mesh in recent years has reduced the area of intra-abdominal mesh. Whether the mesh weaving technique and the addition of absorbable components can reduce the complications associated with mesh remains to be confirmed by further clinical trials. Mourik SL et al [12] reported robot-assisted LSC with an overall patient satisfaction rate of 95.2% at a postoperative follow-up time of 29 months, but the procedure was expensive and the operative time was relatively prolonged. This procedure is still difficult to be popularized in China. 6, prevention and control of surgical complications This procedure has complications such as intraoperative anterior sacral vascular injury, nerve root injury, postoperative mesh exposure, erosion, infection and pain, and the chance of new stress urinary incontinence and defecation dysfunction after surgery is similar to that of transvaginal mesh pelvic floor reconstruction surgery. The anatomy of the anterior sacral area is fully understood, and suturing of the mesh in the anterior sacral area is performed in the avascular area to avoid cutting the anterior sacral fascia during suturing to prevent injury to the anterior sacral venous plexus. The rate of mesh exposure varies widely among operators, about 3.4%￣11% [5, 7, 8, 11, 13, 14], and may be related to the operator’s surgical technique, the length of time to perform such procedures, whether the uterus is removed at the same time, the intraoperative mesh placement method, and the presence of hematoma or co-infection. Some studies have found that concomitant total hysterectomy for LSC increases the risk of vaginal stump mesh exposure, which may be associated with infection at the vaginal stump site [7, 8]. It is emphasized that the vaginal end mesh needs to be adequately spread and placed tension-free, and the mesh in the abdominal cavity must be completely peritoneal to reduce mesh-induced complications related to erosion, exposure, pain, and bowel obstruction. Laparoscopic subtotal hysterectomy + cervical vaginal sacral fixation has a high success rate, and preservation of the uterus or preservation of the cervix reduces vaginal mesh exposure, especially in relatively young patients, and the authors recommend subtotal hysterectomy if hysterectomy is required when performing vaginal sacral fixation [7]. Two cases of intestinal erosion of the mesh have been reported recently [15-16], and symptoms of intestinal erosion can occur several years after surgery, usually presenting as acute lower abdominal pain and bloody stools, and individual cases can be completely asymptomatic, with only mesh erosion detected during proctoscopy. Although bowel erosion after LCS surgery is a rare case, rectal erosion and bowel obstruction in LSC should be taken seriously, and long-term follow-up of patients after such surgery is emphasized. There is a lack of large sample, long-term, randomized controlled studies on the overall efficacy of LSC surgery, how to reduce postoperative pain and mesh exposure rate, erosion and infection, and the impact of surgery on postoperative bladder and rectal function and quality of life still requires long-term evidence-based medicine.