Prevention and treatment of complications due to induced pneumoperitoneum , prolonged lithotomy position, and steep Trendelenburg positions have been explored. Although apparently well-tolerated by most patients, the combined effect of the steep Trendelenburg position, which is about 40°, and carbon dioxide pneumoperitoneum during these long procedures, has not been completely defined. In one observational study of robotic endoscopic radical prostatectomy, Trendelenburg position combined with a carbon dioxide pneumoperitoneum significantly influenced cardiovascular, cerebrovascular, and respiratory homeostasis, but variables remained within a clinically acceptable range.

Mean arterial pressure is increased by increased cardiac output, systemic vascular resistance, or both. These changes have been demonstrated by an increased intra-abdominal pressure compressing the aorta and increasing the afterload, possibly further enhanced by humoral factors during laparoscopic surgery [26]. Also, transesophageal Doppler measurements have shown a significant increase in stroke volume when patients are placed in steep Trendelenburg position [27]. Furthermore, regional cerebral oxygenation was well-preserved and the cerebral perfusion pressure remained above the lower limit of the cerebral autoregulation [28, 29].

The assessment of a patient’s cardiac risk in the perioperative period is made during the history, physical examination , and electrocardiogram. Depending on a patient’s cardiac risk, the surgeon should decide if surgery should proceed without further cardiovascular testing, or be postponed for further testing such as stress testing, echocardiography, or 24 h ambulatory monitoring. The planned surgery may have to be changed to a lesser risk surgery, or conservative management may be chosen instead of surgical treatment. In patients assessed to be at increased cardiovascular risk, a referral to a cardiologist for further evaluation may be indicated preoperatively [30].

A history of ischemic heart disease, congestive heart failure, cerebral vascular disease, renal dysfunction, and preoperative insulin treatment all increase the risk of cardiac complications. Studies have shown a 10–30% reduction in cardiac output in Trendelenburg. Parameters including heart rate, arterial pressure, stroke volume, carbon dioxide elimination, and total respiratory compliance have been measured. Using these values, mean arterial pressure, total peripheral resistance, stroke index, and cardiac index were calculated. At maximum hemodynamic strain, stroke index and cardiac index were reduced by 42%, without significant changes in heart rate and mean arterial pressure. Total peripheral resistance was increased by 50–100% [31].

The Trendelenburg position in awake and anesthetized patients increases pulmonary arterial pressures, central venous pressure, and pulmonary capillary wedge pressure. The cardiac index, a parameter that relates the cardiac output from left ventricle in 1 min to body surface, decreased with anesthesia induction and then again further during laparoscopy. Soon after deflation after laparoscopy, the cardiac index returns to pre-insufflation values [32].

Sacrospinous ligament fixation (SSLF) is one of the most frequently performed and well-studied of the hysteropexy/colpopexy techniques. This procedure involves performing an extra-peritoneal dissection until the sacrospinous ligament is identified and exposed. The right sacrospinous ligament is often used due to the left side’s proximity to the rectum. With the use of a reusable ligature carrier or a suture delivery device, the sacrospinous ligament is attached to the posterior cervix, vagina, or possibly the uterosacral ligament using a permanent monofilament suture, delayed absorbable sutures, or a combination of both (Fig. 2.2).

The safety profile, as well as the success of this procedure, has been extensively studied and described in detail in the literature. Generally, there is a low recurrence rate [38], shorter recovery times, less morbidity, shorter operating times, less pain, and a shorter hospital stay when a SSLF is performed without a hysterectomy [39]. In one randomized controlled trial, 71 women either underwent a SSLF without a hysterectomy or vaginal hysterectomy and uterosacral ligament suspension (USLS). There were no differences in quality of life, prolapse or incontinence symptoms, or reoperation rates at 1 year. Although subjectively, prolapse symptoms were the same 1 year postoperatively, 27% of the SSLF group had stage II or greater prolapse on the POP-Q (Table 2.6) compared to only 11% in the vaginal hysterectomy with USLS group. SSLF was associated with shorter hospitalization, shorter recovery with more rapid return to work, and a significantly longer mean total vaginal length of 8.8 versus 7.3 cm than the hysterectomy with apical suspension group (p < 0.01) [40]. Most recently, SSLF was reported to be non-inferior to vaginal hysterectomy with suspension of the uterosacral ligaments for symptomatic recurrent prolapse of the apical compartment. Although the main outcome was POP recurrence at Stage II or higher of the apical compartment, this study also reported no significant differences between anatomical recurrences, functional outcomes, or quality of life [41].

Because this procedure is short in duration, has minimal blood loss, and does not require entering the posterior cul de sac, patients with comorbidities that do not allow for long procedures or patients who have scarring in the cul de sac due to previous surgeries, endometriosis, or pelvic inflammatory disease, may be good candidates.