A thorough history and physical exam is conducted to evaluate for concomitant cystocele, rectocele, enterocele. In patients who have not had a hysterectomy, an evaluation for postmenopausal/abnormal uterine bleeding is carried out with a transvaginal ultrasound if indicated and documentation of pap smear history is verified [4].

During the preoperative visit, particular attention is paid to counseling and informed consent, as this has been shown to improve postoperative patient satisfaction [5]. Risks of the procedure including infection, bleeding, postoperative ileus, and/or possible injury to the bowel, bladder, ureters, and vagina should be discussed. Currently, we quote the likelihood of these complications at less than 1%. The risk of postoperative voiding dysfunction, dyspareunia, and mesh-related complications including erosion or extrusion are also discussed. Finally, the possibility of conversion is particularly emphasized in patients with a body mass index (BMI) greater than 30 kg/m² [6]. Preoperative anesthetic clearance is obtained when indicated. A type and screen is not needed, and we no longer give a laxative the night before surgery.

The robotic system and operative suite is setup similar to the robot-assisted laparoscopic prostatectomy (Fig. 25.2). The surgeon console is in the corner of the room toward the foot of the operating table. The patient cart, when rolled in, should have its center column between the legs of the patient, with the base of the patient cart straddling the base of the operating table. The surgical assistant stands on the right side of the patient which allows access to the perineum during the procedure. The scrub nurse stands across from the assistant on the patient’s left side.

The patient’s legs are placed in cushioned, full supporting Allen stirrups. This keeps the patient in dorsal lithotomy throughout the procedure and allows access to the vagina before and after the patient cart is rolled in (Fig. 25.3). The lower extremity pressure points are padded, with specific attention given to the region behind the knees. To minimize the risk of plexus injuries, ensure that the stirrups do not place the lower extremities at excessive angles. A strap is secured across the chest below the breasts and the patient is then placed in Trendelenburg (between 15° and 20°). After padding the arm’s pressure points, the arms are tucked beside the torso on arm boards. The abdomen below the level of the breasts, pelvis, vagina, and perineum is prepped for surgery. The vagina is left exposed during draping to allow for intraoperative placement of the hand-held vaginal retractor (explained later in the description of RALS ). A nasogastric tube, urethral catheter, and sequential compression devices are placed prior to the start of the case. All patients receive 24 h of perioperative antibiotics.

RALS is performed using the da Vinci^® Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA). The initial placement of the central camera trocar is based on the patient’s pubic symphysis and umbilicus (Fig. 25.4). Generally the initial central camera trocar is placed 12–15 cm above the pubic symphysis but below the umbilicus. All measurements are generalized and can change based on a patient’s body habitus. The placement of trocars is started by placing the 12 mm disposable camera trocar (red trocar in Fig. 25.4). This is placed 12–15 cm above the pubic symphysis but staying below the umbilicus. The right and left da Vinci^® arm reusable 8 mm trocars (blue trocars) are placed 10–12 mm from the central camera trocar below the level of the camera trocar, lateral to the rectus muscles, and two fingerbreadths superior to the level of the anterior superior iliac spine. The assistant 12 mm trocar (lavender trocar) is placed two finger-breadths below the subcostal margin and lateral to the rectus muscle, one hand-breadth (8–10 cm) away from the right robotic 8 mm instrument trocar. This trocar is approximately 10–12 cm from the central camera trocar. An optional assistant 5 mm trocar or possible third robotic arm (purple trocar) can be placed one hand-breadth (8–10 cm) inferior-laterally from the assistant 12 mm trocar at approximately the level of the umbilicus. This trocar is approximately 10–12 cm from the central camera trocar. A bowel retraction suture may be placed in the appendix epiploica of the sigmoid colon to retract it out of the way. Alternatively, this site may be used to employ an additonal robotic trocar for bowel retraction (X).

Initially, standard laparoscopic instruments were utilized in performing the RALS to assist in taking down adhesions and dissecting the vagina from the posterior wall of the bladder. Now all of the procedure, including the dissection of the vagina is done with the da Vinci^® robotic instrumentation . Regardless of the method used, the sacrocolpopexy depends on the correct identification of the vaginal apex and ability to retract the vagina inferiorly during dissection of the anterior vaginal plane. We utilize a specialized instrument engineered at our institution designated the hand-held vaginal retractor to visualize the plane between the vagina and bladder (Fig. 25.5). The laparoscopic and robotic instruments are listed as follows.

RALS is performed using the da Vinci-S^®, which allows three-dimensional visualization and six degrees of freedom of instrument movement to the surgeon through the modulated remote control. Docking the da Vinci^® includes connecting the camera arm to the laparoscopic 12 mm trocar (red circle, Fig. 25.4), and connecting the instrument arms to the laparoscopic 8 mm trocars (blue circles, Fig. 25.4). During the entire procedure, a 30° lens in the downward view is placed via the camera trocar. We have started each description of our steps with an instrument index table which names the instrument used, the trocar used, and the handedness.