Introduction
Sacrocolpopexy is considered the gold standard surgical procedure for pelvic organ prolapse, with success rates estimated at 98.6% and mesh complications rates of 4.1%. Since the mid-2000s, robotic-assisted laparoscopic sacrocolpopexy has gained increased popularity due to the ease of dissection and suturing afforded by wristed instrumentation.
The first laparoscopic sacrocolpopexy was described by the Nezhats in 1994. After the US Food and Drug Administration (FDA) approved the da Vinci robotic surgical system (Intuitive Surgical Inc., Sunnyvale, CA) for performance of gynecological procedures in 2005, Elliott et al. published outcomes from the first case series of robotic assisted sacrocolpopexy in 2006. Since then, the percentage of surgeries completed robotically has drastically increased in the United States. ,
Transperitoneal
- 1.
Access, pneumoperitoneum and port placement
- 2.
Positioning in steep Trendelenburg with bowel mobilization and identification of right ureter, aortic bifurcation, and sacral promontory
- 3.
Retroperitoneal dissection along pelvic sidewall via the uterosacral ligament from sacrum to vaginal apex
- 4.
Exposure of anterior longitudinal ligament
- 5.
Identification and dissection of vesicovaginal space
- 6.
Identification and dissection of rectovaginal space
- 7.
Suture attachment of mesh to anterior and posterior vagina
- 8.
Suture attachment of mesh to anterior longitudinal ligament of sacrum with appropriate tensioning
- 9.
Reperitonealization over the mesh
- 10.
Cystoscopy to ensure bladder and ureteral integrity
Indications for robotic sacrocolpopexy
The indications for sacrocolpopexy are for surgical correction of symptomatic apical pelvic organ prolapse (uterus or vaginal vault prolapse after hysterectomy). Sacrocolpopexy can be performed via laparotomy, laparoscopically or robotically. In general, this procedure is reserved for patients who have failed a prior native tissue (non-mesh) repair or those with advanced vaginal vault or uterine prolapse (stage 3 or 4). Sacrocolpopexy can be performed after concomitant total or subtotal (also known as supracervical) hysterectomy or with the uterus left in situ (sacrohysteropexy).
Relative contraindications to sacrocolpopexy include suspected severe adhesive disease in patients with previous multiple abdominal surgeries or patients with chronic inflammatory bowel conditions, in which risk for bowel obstruction or injury or mesh infection may be increased. Absolute contraindications consist of the conditions rendering the presacral area inaccessible, such as the presence of the pelvic or horseshoe kidney overlying the sacral promontory, or known reaction to synthetic mesh such as polypropylene.
Preoperative assessment
Robotic instruments
- •
Fenestrated bipolar forceps or Maryland bipolar forceps
- •
Monopolar scissors
- •
Robotic fenestrated bowel grasper or tip-up fenestrated grasper
- •
Large needle driver
- •
Large or mega suturecut needle driver
Sutures
- •
2.0 polydioxanone (PDS) on SH needle
- •
CV 2-0 Gore-Tex
Lightweight synthetic (usually large pore polypropylene) mesh
Robotic or laparoscopic Lapra-Ty suture clips
AirSeal insufflator
Laparoscopic suction device, Allis graspers, bowel graspers, Kittner dissectors
Operating room and port setup
Patient preparation and positioning
After induction of general anesthesia, a three-way Foley catheter is placed prior to positioning the patient in a low lithotomy position. All pressure points are carefully padded, and the patient is secured to the operating table at the level of the chest with the arms tucked on both sides and with forced-air patient warming (such as “Bair Hugger”) in place. The surgical table is positioned in Trendelenburg position between 27 to 34 degrees, depending on the patient’s body habitus for optimal visualization of the sacral promontory. Oral-gastric tube placement, hair clipping, skin preparation, and draping are performed as usual ( Figs. 38.1 and 38.2 ).
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