Abstract
As life expectancy continues to increase, quality-of-life health problems such as pelvic organ prolapse will increasingly demand more attention and treatment from health-care providers. Surgical repair of pelvic organ prolapse has become one of the most common types of procedures performed in women. While the abdominal sacrocolpopexy has often been referenced as the gold standard surgical procedure for correcting pelvic organ prolapse, minimally invasive routes of sacrocolpopexy and other gynecologic procedures are becoming more popular. Technologic advances in minimally invasive surgery have been rapidly adopted, and robotic techniques for prolapse repair have surpassed vaginal repairs in many instances. With both laparoscopic and robotic surgery, surgeons must be aware of the unique set of perioperative considerations and potential complications. In this chapter we will discuss the potential perioperative complications unique to minimally invasive female pelvic surgery and outline specific methods to decrease their incidence.
Keywords
Pelvic organ prolapse repair complications, Complications of robotic and laparoscopic surgery, Minimally invasive prolapse repair, Robotic sacrocolpopexy, Robotics and female pelvic medicine
Chapter Outline
Patient Positioning and Surgical Setup
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Key Points
- 1.
Pre-operative risk stratification for robotic pelvic floor reconstruction should be focused on pulmonary compromise, uterine enlargement or pelvic adhesions, and sacral anomalies such as a horseshoe kidney or sacral bony abnormality in order to minimize operative complications of robotic sacrocolpopexy.
- 2.
Pre-operative assessment of clinical or occult stress urinary incontinence enables the pelvic floor surgeon to properly counsel the patient regarding options for concurrent incontinence procedures at the time of robotic sacrocolpopexy, in order to decrease the risk of post-operative persistent or de novo urinary incontinence.
- 3.
Proper patient positioning for robotic pelvic floor surgery includes attention to Trendelenburg and its potential to cause nerve injury, retinal injury and pulmonary compromise. Anti-skid techniques should be employed to avoid inadvertent patient movement after robot docking.
- 4.
Pre-sacral hemorrhage is the most significant and potentially life-threatening complication associated with sacrocolpopexy. Meticulous attention during sacral dissection must be carried out with particular knowledge of aberrant sacral vasculature. The most common site of vascular injury is the left common iliac vein and its appearance can be distorted by the pneumoperitoneum, often mistaken for the anterior longitudinal ligament.
- 5.
Intra-operative pre-sacral hemorrhage is often difficult to control with pressure, topical hemostatic agents or materials and generally requires conversion to open with vascular surgery assistance. It is imperative to maintain local pressure on the site of sacral bleeding while conversion is undertaken, initially utilizing the robotic arm followed by a laparoscopic instrument. Communication with anesthesia and nursing staff is imperative during the conversion process in addition to preparation of blood products.
- 6.
Cystotomy during robotic sacrocolpopexy can be avoided by placement of a vaginal manipulator such as a sponge-stick, EEA sizer or vaginal stent to facilitate dissection in the proper plane between the anterior vaginal wall and bladder. Cystoscopy is imperative at the completion of the robotic pelvic floor procedure to ensure there has been no injury to the bladder or ureters.
- 7.
Bowel dysfunction is a common post-operative complaint following robotic pelvic floor reconstruction. Dyschezia, obstructed defecation and constipation re the most common types. The average time to first bowel movement post-operatively is 3 days and patients should be made aware of this expectation.
- 8.
While rare, post-operative infection of the disc or sacral bone can occur and be both severe and potentially life-threatening. Severe back pain accompanied by fever or signs of sepsis should prompt immediate lumbosacral imaging. When placing sacral sutures, the surgeon must avoid the L5-S1 disc space and the depth of sutures in the anterior longitudinal ligament should not exceed 2–3 mm.
As the life expectancy of the population continues to increase, so does the prevalence of medical conditions associated with advancements of age. Pelvic organ prolapse (POP) is a common condition associated with aging, menopause, and prior pregnancy and delivery. Surgical repair of POP is currently the most common type of inpatient procedure performed in women older than 70 years, and the incidence of procedures for this condition will continue to increase.
The abdominal sacrocolpopexy is regarded as the “gold standard” procedure for correcting symptomatic pelvic organ prolapse. In many patients, minimally invasive routes of sacrocolpopexy and other gynecologic procedures are preferred and offer advantages both for the patient and the surgeon. Minimally invasive sacrocolpopexy has been compared with the abdominal approach in various studies and has proven to be as efficacious and safe, with the added benefit of decreased morbidity. More recently, two level 1 studies have been published comparing abdominal sacrocolpopexy with a minimally invasive approach. Both trials reveal comparative outcomes between the groups and illustrate that the minimally invasive approach is associated with decreased morbidity, less blood loss, shorter length of stay, dand overall decreased recovery time. These data support the use of minimally invasive surgical approaches to sacrocolpopexy and other POP procedures.
With minimally invasive surgery comes a unique set of perioperative considerations, counseling topics, and both intraoperative and postoperative complications. Surgeons should be aware of these unique components of minimally invasive surgery and should understand ways to minimize potential obstacles whenever possible. This chapter aims to highlight the potential perioperative complications unique to robotic female pelvic surgery and to discuss how to safely handle these problems should they arise.
Preoperative Considerations
When determining surgical candidacy for robotic reconstructive pelvic surgery, the surgeon must gather critical information during the office evaluation ( Table 33.1 ). It is imperative to focus the history and physical exam around factors that could increase the risk of complications unique to robotic surgery. When considering a laparoscopic or robotic approach, the medical history should include questions about the patient’s exercise tolerance, smoking history, presence of cardiopulmonary or chronic renal conditions, and history of prior pelvic surgeries. The surgeon should have a good understanding of the hemodynamic and metabolic effects of intraabdominal CO 2 insufflation on individuals with these conditions. Potential contraindications to laparoscopic or robotic surgery such as an increase in intracranial pressure or baseline hypovolemic state should be contemplated, especially when the operative time may be prolonged. Patients with pulmonary compromise should be particularly counseled on possible conversion to laparotomy if the degree of physiologic strain, such as impairment of pulmonary functional residual capacity, becomes intolerable to the patient during surgery. It is well documented that patients benefit from smoking cessation prior to surgery, and encouraging patients to stop smoking within 8 weeks of surgery can be beneficial. Studies demonstrate improvements in respiratory function and lower risks of postoperative atelectasis and aspiration pneumonia, known risks associated with the inability to tolerate pneumoperitoneum or steep Trendelenberg positioning. While research indicates that pulmonary complications after laparoscopy may be lower than those associated with laparotomy, surgeons should be aware of the specific risks in patients with cardiopulmonary comorbidities, such as chronic obstructive pulmonary disease. Pulmonary complication risk is also found to correlate with older age and longer operative time. These factors should be taken into consideration when deciding upon the route of pelvic reconstructive surgery.
| Patient History and Physical Exam |
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| Patient Positioning and Surgical Setup |
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The physical exam should include assessment of abdominal scars and the presence of any abdominal hernias, particularly if a patient has had multiple prior abdominal surgeries. This will allow for anticipation of potential difficulties with port placement and pelvic adhesive disease when planning a robotic surgical approach. Particular attention should be paid to umbilical hernia as the umbilicus is often utilized as a port site during robotic surgery. Additionally, a bimanual pelvic evaluation to assess uterine mobility and size is necessary. One should attempt to palpate the width of the lower uterine segment (LUS) at its junction with the cervix and assess degree of movement of this segment toward the contralateral pelvic sidewall. In general, lateral mobility of 2 cm or more on each side predicts adequate access to uterine vessels laparoscopically. The presence of obstructing fibroids or pelvic adhesions should also be considered, as these characteristics can limit uterine mobility and preclude successful minimally invasive pelvic surgery. Placing cephalad pressure on the LUS and attempting to elevate the uterus out of the lower pelvis can help with understanding of circumferential space that is present. This technique may be inhibited by patient body habitus. At times, pelvic imaging may be necessary to adequately assess uterine size and other pelvic pathology that may make laparoscopy more difficult.
Obesity itself should not preclude minimally invasive surgery; however, it can make a laparoscopic or robotic approach to pelvic surgery more challenging due to the impact of this condition on both respiratory and gastrointestinal mechanics. Obese patients, particularly with a BMI >40, are prone to poor gas exchange and delayed gastric emptying, increasing the risk of impaired respiratory function and aspiration during and after surgery. Obesity also is commonly associated with increased central adiposity, which can preclude optimal patient positioning, trocar placement, and visualization intraoperatively. It is imperative to consider these risk factors when counseling patients on minimally invasive surgery, and extra time should be allotted perioperatively to ensure optimization of patient positioning.
The surgeon should inquire about any known anomalies of pelvic anatomy. Anatomic variances such as a horseshoe kidney, transplant kidney, or any sacral anomalies could make robotic sacrocolpopexy more difficult or contraindicated. Knowledge of these potential structural alterations should prompt adequate imaging to obtain a clearer understanding of any variations or abnormalities in pelvic anatomy. Surgeons can then plan for any required modifications in instrument placement or surgical technique when performing pelvic surgery.
Screening for stress incontinence is pertinent when performing any prolapse procedure, and if present, discussion of a possible concomitant anti-incontinence procedure is needed. The surgeon should take into account the risks and benefits of added operative time with concomitant procedures and the potential complications this could pose. Conversely, even without the presence of stress incontinence, the possibility of de novo stress incontinence following sacrocolpopexy should be discussed. Ideally, patients should be screened for occult stress incontinence with prolapse reduction preoperatively to allow for proper counseling and surgical planning. Management of expectations is critical, and patients should be made aware that midurethral sling placement at the time of minimally invasive sacrocolpopexy may be associated with lower incontinence cure rates, when compared to sling surgery alone.
Traditionally, preoperative mechanical bowel preparation (MBP) has been used as a way to enhance visualization of the surgical field and improve intraoperative bowel handling. In theory, this practice leads to a decreased incidence of bowel injury and lowers minimally invasive operative times. More specifically, bowel preparation can facilitate sacral visualization during robotic sacrocolpopexy. Recently there has been evidence in the literature refuting the necessity of mechanical bowel preparation in minimally invasive surgery in gynecology. In a recent systematic review of high quality trials across surgical specialties, there were no or few benefits of MBP or rectal enemas and no negative effects on perioperative outcomes were reported. These data should prompt surgeons to contemplate the risk and benefit of MBP when performing minimally invasive prolapse surgery. In surgical procedures where this practice seems beneficial, preparations using magnesium citrate or Miralax combined with 64 oz of Gatorade appear to be the best tolerated. We routinely recommend a modified mechanical bowel preparation preoperatively to enhance pelvic visualization during robotic surgery, minimize the need for bowel manipulation intraoperatively, and improve postoperative return to bowel function. We utilize a clear liquid diet the day before surgery as well as one bottle of magnesium citrate and two doses of oral bisacodyl.
Patient Positioning and Surgical Setup
Intraoperatively there are many techniques that can be adopted to allow a surgeon to decrease the risk of complications when performing robotic pelvic reconstructive surgery (see Table 33.1 ). It is critical to maintain constant communication between the anesthesia and surgical teams when choosing the most appropriate operating room setup, as each case may require adaptations to the arrangement of room layout, instrument choice, and other ergonomic considerations. For both laparoscopic and robotic-assisted prolapse repair, proper patient positioning is imperative to sustain optimal surgical exposure and prevent neuromuscular compromise. One obvious concern with these surgical techniques is sliding of the patient on the operating table during steep Trendelenburg positioning. This can result in skin breakdown and neuropathic injuries, as well as incisional extensions and formation of hernias through port sites due to the overstretching caused by incidental changes in patient position. Nerve injury is increased in obese patients, who most commonly suffer from ulnar and sciatic neuropathies. The surgeon should ensure proper corporeal padding of both upper and lower extremities. The knees should be flexed at a maximum angle of 60 degrees when patients are placed in dorsal lithotomy position. Any greater flexion increases the risk for femoral nerve compression. Arms should be tucked at the patient’s side, and all pressure points should be adequately protected. Leaving the arms extended or the use of shoulder blocks can increase the risk of brachial plexus injury, and these practices should be avoided. Recent evidence illustrates that use of anti-skid materials such as egg crates, surgical beanbags, or gel pads minimizes the risk of shifting and therefore decreases the potential for nerve stretch injuries, even in patients with a BMI >30. After the anti-skid material is placed on the operating table, the patient should be placed directly on this material without intervening bedsheets. This direct contact allows for optimal drag coefficient to keep the patient from slipping and is very effective for steep Trendelenburg positioning during pelvic reconstructive surgery.
The risk of facial trauma and corneal abrasions should also be considered, especially when performing robotic surgery. The patient’s face can be in close proximity to the robotic camera system and instruments, especially when port sites are placed superior to the umbilicus or when using a 30-degree down scope in steep Trendelenburg position. In these instances the robotic camera system may be only a few centimeters away from the face, and facemasks or adhesive eye shields should be used to protect from facial trauma. Direct trauma is known to be the cause of up to 20% of corneal abrasions, and most are thought to be due to lagopthalmos, or failure of complete eyelid closure. To protect this perioperative complication, the eyes can be taped closed after induction of anesthesia. It is important to consider these potential adverse events and discuss ways to minimize risk with the anesthesia team.
Whether performing laparoscopy or robotic-assisted pelvic surgery, the utilization of Trendelenburg positioning is traditionally noted to be essential to achieve adequate pelvic and sacral exposure. Compared with traditional laparoscopy, robotic surgery has been associated with the use of more pronounced Trendelenburg positioning. Although there is no consensus in the medical literature as to the appropriate amount of Trendelenburg used in pelvic surgery, experts have routinely called for “steep” Trendelenburg positioning, usually categorized as 25 to 45 degrees. While this has long been the routine positioning of patients undergoing robotic pelvic surgery, recent data have suggested that gynecologic surgeries can be effectively performed without use of this steep angle positioning, which is often associated with increased morbidity, especially in the elderly or obese populations. In a recent article by Ghomi et al., 20 women underwent robotic-assisted gynecologic surgery for benign disease. The procedures included total and supracervical hysterectomy as well as sacrocolpopexy. Surgeons were blinded to the degree of Trendelenburg used, but were instructed to choose the degree of positioning that would allow them to obtain adequate exposure of the surgical field. Degree of Trendelenburg was measured at the end of each case and results revealed the mean Trendelenburg position used was 16.4 degrees and no patient was placed further than 24 degrees. There were no incidences of conversion, no perioperative complications, and average BMI was 28.5, while median console time was 87.5 minutes. Though the only study of its kind, these data defy the practice of routine adherence to steep Trendelenburg positioning if not absolutely necessary and surgeons should take care to individualize patient positioning for each case in order to minimize complications associated with a considerable degree of Trendelenburg placement. Extra caution should be taken in any patient with retinal disease or prior retinal surgery, as Trendelenburg positioning has been associated with retinal complications in some reports.
Having a clear understanding of abdominal wall anatomy is crucial for proper port site placement, in order to avoid vessel injury during this portion of the case. Both robotic and laparoscopic ports are generally placed in either a W configuration or in a straight line, a minimum length of 10 cm apart, to allow for adequate space and optimal utilization of all ports and to minimize arm collisions. To optimize visualization of the sacral promontory, the camera port should be placed above the umbilicus if the distance from the umbilicus to the pubic symphysis is less than 15 cm. The use of a 30-degree (up) robotic camera to place the four additional ports is often helpful to adequately evaluate the pelvis for any intrusive adhesions and also to position ports properly and ensure avoidance of epigastric vessels. Port site bleeding is noted to occur at an incidence of about 0.7%, and the origin is most commonly due to perforation of the inferior epigastric artery. If perforation does occur it is best to leave the offending trocar in place to denote the location of the injured vessel. If each end of the transected vessel can be identified, cauterization of both ends using bipolar cautery should be attempted. If this is not successful, the method of tamponade using a Foley catheter can be used. A size 10 or 12Fr Foley catheter should be introduced through the 5-mm trocar and inflated with approximately 10–15 mL of sterile water. The trocar is removed only once the balloon has been inflated, and then traction should be applied to allow the balloon to tamponade the port site. Clamping the catheter on steady traction with use of an umbilical clamp or hemostat is helpful, and this can be left in position postoperatively if necessary, until hemostasis is achieved. If neither of these methods will stop port site bleeding, interrupted 0-Vicryl sutures can be placed into the abdominal wall using a CT or CT-1 needle. One suture should be placed on either side of the trocar site and tied externally. These sutures can be removed after 12–24 hours of observation, and the trocar should be left in place during this time.
The use of an 8-mm accessory port is our preference, as the literature reveals a smaller accessory port results in less postoperative pain and decreased risk of port sight hernias when compared to larger accessory ports. In a survey conducted by the American Association of Gynecologic Laparoscopists, port site hernias were found to occur in port sites 10 mm or larger in 86% of cases, while those 8 mm or smaller were associated with only 3% of port site hernias reported. More recently, Paraiso et al. discussed the notion of lower postoperative pain with use of smaller ports when comparing postoperative pain scores in patients undergoing robotic and laparoscopic prolapse surgery. Those undergoing laparoscopy endured fewer and smaller trocar incision sites, which correlated with lower postoperative pain scores. Given this, we routinely use the smallest size ports necessary when performing minimally invasive pelvic organ prolapse surgery. For robotic sacrocolpopexy, once ports are placed and the robot docked, introduction of robotic instruments should be done under camera visualization in a 3, 2, 1 consecutive order to increase efficiency; it can be difficult to rotate the camera to visualize placement of arms 2 and 3 if arm 1 has already been placed. Lastly, each arm’s range of motion should be thoroughly assessed to minimize arm collisions during robotic pelvic surgery. Many of these technical issues have been overcome with the new da Vinci Xi robot, which has a much smaller and lighter weight camera and slimmer arms allowing more range of motion and less problems with clashing.
Intraoperative Complications
Bowel Complications
Unique intraoperative complications associated with robotic pelvic floor reconstruction can be avoided with knowledge and prevention as outlined here ( Box 33.1 ). During robotic sacrocolpopexy, it is our preference to begin with the dissection of the sacral promontory, in order to complete the more difficult portion of the surgery first. The 30-degree (down) camera is preferred by some surgeons, allowing for better visualization of the sacral promontory. This portion of the procedure requires adequate retraction of the sigmoid colon toward the left pelvic sidewall, in order to maintain optimal visualization of the sacral promontory. Prior to mobilization, however, the surgeon should thoroughly survey the abdomen and maneuver the small intestine into the upper abdomen if steep Trendelenburg positioning has not already accomplished this. Bowel injury during pelvic surgery, although occurring in only about 0.5% of cases, most commonly occurs in the small bowel at the time of intraabdominal access (55%), and delay in identification of a bowel injury can result in mortality in an average of 3% of cases. For this reason, it is imperative to be mindful of this complication and take extra time to evaluate for any potential injury during abdominal entry. If a puncture injury of the bowel is identified, a step-by-step inspection of the entire bowel is recommended to ensure no additional injuries are present. The most common cause of nonentry-related bowel injury is usually due to thermal defects, and these are more likely to go unnoticed.
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Port Site Bleeding
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Attempt to cauterize injured vessel with offending trocar in place
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Tamponade can be attempted using a 12-Fr Foley catheter through trocar
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Sutures can be placed at each side of trocar site and tied externally with removal after 24-48 h
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Bowel Injury
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Use of fan retractors, accessory stitch, ENDOLOOP ligature to retract bowel effectively
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If injury detected, Vicryl or barbed suture can be used for repair
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Repair should be performed in two layers with sutures placed on the long axis of intestine to prevent stricture
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Presacral Hemorrhage
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Middle and lateral sacral vessels should be well delineated
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Assess for variability of sacral/iliac vessels, particularly on the left side of anterior longitudinal ligament
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Apply direct pressure with a Ray-Tec or cottonoid as first-line treatment
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Hemostatic agents (Floseal, Surgicel) and laparoscopic vessel fasteners should be readily available
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Urinary Tract Injury/Vaginotomy
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Use of EEA sizers or vaginal stents to allow for proper visualization of vesicovaginal junction
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Dissection of this junction should be bloodless if correct plane has been identified
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25-mg ICG in 10 mL sterile H 2 O can be injected into ureters prior to RASC for ureteral identification
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Bladder/vaginal injury should be repaired in a double, imbricating layer using Vicryl or barbed suture
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Mesh should not be placed directly over vaginotomy site, should one occur
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