Abdominal Sacrocolpopexy

Fig. 9.1

Port placement placement for robotic abdominal sacrocolpopexy (using the 4-arm Da Vinci)

../images/312378_2_En_9_Chapter/312378_2_En_9_Fig2_HTML.jpg — Fig. 9.2

Port in place after insufflation. In this view from the head looking toward the legs, the 10/12 camera port and accessory port are easily distinguished from the three robotic arm port. The third robotic port, the most cephalad of the three, is placed as far lateral as possible to the patient’s left side, approximately 3 cm from the iliac crest and at least 10 cm from the left instrument port, at the level of the camera port

The OR table is lowered and the patient is placed in steep Trendelenberg position to allow bowel contents to retract naturally cephalad and the robot is docked. RASC can be accomplished with traditional docking between the legs at the foot of the bed. However, with the robotic cart side-docked 45° lateral to the patient’s left leg, vaginal access during the procedure is improved (Fig. 9.3) [18, 19]. The bedside surgeon stands on the patient’s right as does the scrub assistant.

../images/312378_2_En_9_Chapter/312378_2_En_9_Fig3_HTML.jpg — Fig. 9.3

(a) Side docking allows for easier access to the vagina and easier manipulation of the vaginal obturator by the bedside assistant (Arm #3, *red*; arm #2, *green*; camera, *blue*; arm #1, *yellow*). (b) Note that arm #3 is almost parallel to the floor

Gaining Exposure

If not already in use, the 0° robotic camera is placed. The abdomen and pelvis are inspected and adhesions are addressed robotically. The sigmoid colon is identified. A fenestrated bipolar forceps can be used in the third robotic arm to retract the sigmoid colon laterally. If one is using the 2-arm robot, then a suture can be used to retract the sigmoid colon. There are several methods for doing this. A Keith needle can be used to pass a retracting suture into the abdomen through the skin. Using the robotic arms the retracting suture is then passed through an epiploic appendage or the tenia of the sigmoid colon and then back through the skin near the entry site. This is gently secured at the skin level with a clamp.

The following structures should be identified: the sacral promontory which is just below the bifurcation of the iliac arteries, the right ureter which is approximately 3 cm lateral to the sacral promontory, the vagina, bladder, and rectum (Fig. 9.4) [20]. To identify the vagina, a vaginal obturator is placed and manipulated by the bedside assistant. A round tipped endoanal, or EEA sizer may be placed transvaginally (Fig. 9.5). Alternatively, a customized handheld vaginal retractor can be used. CooperSurgical (Trumbull CT, USA) manufactures a two disposable Sacro tips that attach to their RUMI® handle, one of which is used for sacrocolpopexy and the other which can be used for sacrocervicopexy.

../images/312378_2_En_9_Chapter/312378_2_En_9_Fig4_HTML.jpg — Fig. 9.4

Pelvic anatomy. Prior to any dissection, one can identify the bladder, iliac artery and vein, and right ureter

../images/312378_2_En_9_Chapter/312378_2_En_9_Fig5_HTML.jpg — Fig. 9.5

Various options to use as the vaginal obturator: (a) EEA sizers, (b) customized vaginal retractor used at the Mayo Clinic, (c) CooperSurgical disposable Sacrocolpopexy tips and Sacrocervicopexy tips for RUMI® System Handle. (Courtesy of CooperSurgical, Trumbull, CT, USA)

With the vaginal obturator in place, the plane between the anterior wall of the vagina and the bladder is developed (Fig. 9.6). The peritoneum over the vaginal apex is incised with cautery applied via the monopolar curved scissors in the right hand and the Maryland bipolar forceps in the left hand. This should be a relatively bloodless plane, and after the initial use of cautery to incise the peritoneum, the remaining dissection is performed sharply without cautery to prevent devascularization of the vaginal wall (Fig. 9.7). The bladder can be filled to help demarcate the appropriate plane, or a cystoscopic light can be introduced into the bladder. This plane should be dissected for a minimum of 3 cm distal to the vaginal apex to allow space for placement of the mesh. The lack of direct tactile feedback can make this dissection challenging, particularly in patients who have undergone prior reconstructive procedures. In a series of 85 cases performed by an experienced robotic surgeon, the rate of inadvertent cystotomy was 4.7% [17].

../images/312378_2_En_9_Chapter/312378_2_En_9_Fig6_HTML.png — Fig. 9.6

Using the third robotic arm to retract the bladder anteriorly, the peritoneum over the vaginal cuff is exposed. Note the grasper in the left hand and the endoshears in the right hand

../images/312378_2_En_9_Chapter/312378_2_En_9_Fig7_HTML.png — Fig. 9.7

The peritoneum overlying the anterior vagina has been disseted allowing a place to develop between the vagina and the bladder. This will be site for the anterior mesh attachment

The rectovaginal space is similarly developed. The peritoneum over the posterior vaginal wall is elevated and the vagina is separated from the rectum posteriorly. An EEA sizer placed per rectum can help to identify the rectovaginal septum.

After adequate vaginal mobilization, attention is then turned to the sacral promontory and to exposure of the anterior longitudinal ligament of the sacrum (Fig. 9.8). The 30° down scope allows for better visualization of the sacrum. The peritoneum overlying the sacral promontory is grasped and incised with the monopolar endoshears. Blunt dissection can then be used to clearly identify the anterior longitudinal ligament in preparation for suture placement. Extreme care is taken to avoid injury to the presacral veins, as this can cause life-threatening bleeding. The magnification and 3-D visualization afforded by the robotic technique provide enhanced visualization of the pre-sacral vasculature. The peritoneal incision can then be extended in a caudal direction towards the posterior cul-de-sac and vaginal cuff to allow for retroperitonealization of the mesh at completion of the procedure. Alternatively, a peritoneal tunnel can be created using blunt dissection from the promontory to the cul-de-sac [17]. This eliminates the need for a peritoneal closure at the end of the case, which can be time-consuming.

../images/312378_2_En_9_Chapter/312378_2_En_9_Fig8_HTML.png — Fig. 9.8

Sacral dissection with the posterior peritoneum incised and the anterior longitudinal ligament exposed

Mesh Placement

Next, two or three nonabsorbable sutures, cut to approximately 7 cm, are placed into the exposed portion of the sacral promontory (Fig. 9.9). These sutures with needles attached are left in the abdomen for mesh fixation. 2.0 Gore-Tex, 0.0 or 2.0 Ethibond, and 2.0 Prolene have all been described [17, 21–24].

../images/312378_2_En_9_Chapter/312378_2_En_9_Fig9_HTML.png — Fig. 9.9

The anchoring suture for the sacral portion of the mesh is placed through the anterior longitudinal ligament

The polypropylene mesh, either in two separate strips (3–5 cm × 12–15 cm) or prefashioned in a Y configuration, is passed into the field through the assistant port and sutured to the posterior and anterior vaginal wall. Several companies have a precut macroporous Y-shaped mesh designed specifically for ASC (Fig. 9.10). Alternatively, the anterior and posterior arms of the self-cut mesh can be sewn together with permanent suture before introduction into the abdomen.

../images/312378_2_En_9_Chapter/312378_2_En_9_Fig10_HTML.png — Fig. 9.10

Macroporous Y-shaped prefabricated mesh. Pictured is the Upsylon™ Y-shaped Mesh. (Courtesy of Boston Scientific, Marlborough, MA, USA)

With the vaginal obturator in place and the endoshears swapped for a needle driver, the mesh is affixed to the anterior vaginal wall with a series of 4–8 interrupted sutures cut to 6.0 inches in length (Fig. 9.11). Placing the distal and lateral corner sutures first facilitates placement of the remaining sutures. Traditionally, nonabsorbable sutures, often 2.0 Gore-Tex, have been used to affix the mesh to the vagina. Because Gore-Tex is a monofilament suture, it is thought to be less likely to extrude vaginally. Recently, the procedure has been described using 2-0 polyglactin suture for this portion of the procedure [24, 25]. In two small series, both of which had 2-year follow-up, the rate of vaginal mesh erosion was less than 3%. It is proposed that polyglactin suture which is completely absorbed in 56–70 days, will retain its strength in the first few weeks while tissue ingrowth incorporates the mesh into the vaginal wall and then absorb, eliminating the risk of suture extrusion in the long term. The effect this may have on prolapse recurrence rates in the long term remains unknown.

../images/312378_2_En_9_Chapter/312378_2_En_9_Fig11_HTML.png — Fig. 9.11

With an obturator in the vagina, the mesh is attached to the anterior vaginal wall

The posterior arm of the mesh is then affixed to the posterior vaginal wall (Fig. 9.12). The third robotic arm can be used to grasp the apical end of the mesh, allowing the posterior arm to drape over the posterior vaginal wall. Excess mesh from the anterior and posterior limbs is trimmed with either robotic scissors or the scissor portion of the SutureCut™ needle driver.

../images/312378_2_En_9_Chapter/312378_2_En_9_Fig12_HTML.png — Fig. 9.12

Using the third robotic arm to retract the sacral portion of the mesh, the posterior arm of the mesh is affixed to the vagina. Note that the vaginal obturator is used to deflect the vagina anteriorly

Finally, the apical portion of the mesh is held in place against the sacral promontory while the console or bedside surgeon examines the vagina to assess the degree of prolapse reduction. The mesh tension should be adjusted appropriately to reduce the prolapse without putting excess tension on the vaginal walls. The previously placed sutures in the anterior longitudinal ligament of the sacrum are then passed through the mesh at the chosen location (Fig. 9.13). Excess apical mesh is trimmed and the mesh is retroperitonealized by reapproximating the peritoneum over the mesh with 2-0 Vicryl suture (Figs. 9.14 and 9.15). Additional sutures can be used to approximate the peritoneum overlying the bladder to cover the mesh near the vaginal cuff. The LAPRA-TY® (Ethicon) device can be helpful in securing the suture for this portion of the procedure.