Pelvic organ prolapse (POP) is a major public health issue that can have a considerable impact on a woman’s quality of life. Nearly half of the female population in the United States will present with some degree of POP on vaginal examination, and nearly one-sixth of these women will be symptomatic. Because of the distress associated with the disease, 13%–19% of symptomatic patients will undergo surgical repair in their lifetime. Sacrocolpopexy is considered the gold standard for apical prolapse repair and multicompartment POP. The long-term success rates of sacrocolpopexy have been reported to be as high as 85%–97%. Robotic sacrocolpopexy (RSC) has increased in popularity due to improved surgical ergonomics, enhanced view of the pelvis, decreased blood loss, length of stay and morbidity, faster recovery, and better cosmetic results with equivalent efficacy compared with the open approach. RSC is performed via the attachment of the vaginal apex to the anterior longitudinal ligament of the sacral promontory using a polypropylene mesh. The use of synthetic mesh with this surgery was first introduced in 1962 and was marketed as having increased durability capable of withstanding the tension on the vagina. This chapter outlines a step-by-step approach to posthysterectomy RSC.
Indications and contraindications
The indications for RSC are the same as those for an open sacrocolpopexy. RSC is offered to patients with apical prolapse or multicompartment prolapse. In patients with uterine prolapse, the technique for RSC can be slightly modified to perform a sacrohysteropexy (uterine-sparing approach) or the RSC can be performed in conjunction with a supracervical hysterectomy. The supracervical hysterectomy is preferred to a total hysterectomy in this situation in order to obtain more layers of soft tissue separation between the newly closed vaginal cuff and the mesh, thereby decreasing the likelihood of mesh erosion through the site of hysterectomy. RSC is not suitable for patients who have a contraindication to laparoscopic/robotic surgery, including severe pulmonary disease that would prevent adequate ventilation while the patient is in steep Trendelenburg, extensive prior abdominal surgeries, or morbid obesity (ventilation issues). This is also not the ideal approach for frail patients, especially if they do not wish to preserve coital function. POP repair is not generally indicated for patients with a minor degree of prolapse and who are not symptomatic.
Patient preoperative evaluation and preparation
The preoperative evaluation of a patient undergoing RSC is the same as that of an open sacrocolpopexy. As with any prolapse surgery, urodynamic study with and without packing with stress maneuvers can be performed before surgery to assess the risk of occult stress urinary incontinence. Patients can then be offered a concomitant antiincontinence surgery if stress urinary incontinence is demonstrated. Patients with fecal incontinence or defecatory dysfunction can be evaluated with magnetic resonance defecography and anorectal manometry. They can be offered concomitant robotic anterior mesh rectopexy if they are found to have rectal prolapse, rectal intussusception, or obstructive defecatory dysfunction caused by the prolapse.
Routine laboratory tests (comprehensive metabolic panel, complete blood count, urine culture) should be performed. No bowel preparation is required for RSC alone. One can consider an enema preoperatively, especially if it is performed in conjunction with an anterior mesh rectopexy, to decrease rectal distention, which may improve visualization of the vagina during the posterior vaginal dissection.
A single dose of antibiotics is given before incision. A compressive pneumatic device is placed on the patient’s legs during the procedure.
Operating room configuration and patient positioning
The assistant is positioned on the patient’s right side. We use at least two monitors for the procedure. One should be placed directly across from the bedside assistant, just lateral to the patient’s left shoulder; this will be more ergonomic for the assistant by preventing rotation of the neck. The second monitor is located adjacent to the instrument table and is used by the surgical technician. The instrument table is located to the right of the patient at the level of the right leg to allow adequate room for the assistant and surgical technician. The instrument table should also be placed on the right side of the patient. Side docking from the patient’s left side is used in order to have access to the vagina for manipulation during the vaginal dissection and mesh placement. An assistant, typically the surgical technician, can sit between the legs in order to assist with the vaginal manipulation. Conventional 45-degree side docking can be used, or the robot can be placed parallel to the patient’s bed, with the robot being as close as possible to the foot of the bed. It is important to note that if this position is used, the arm of the camera port does not have to be within the “sweet spot” for appropriate arm placement. If using the da Vinci Xi system (Intuitive Surgical, Sunnyvale, CA), conventional side docking is used.
After general anesthesia has been administered, an orogastric tube is placed, then a bladder catheter is placed after the patient has been prepared and draped. A vaginal manipulator is placed in the vagina. For posthysterectomy sacrocolpopexy, an EEA sizer or vaginal stent can be used. For patients undergoing uterine-sparing sacrocolpopexy or a concomitant supracervical hysterectomy, a malleable blade is usually preferred as it can be placed anterior or posterior to the cervix during the dissection of the anterior and posterior vaginal wall. The patient is positioned in low lithotomy with use of Yellofins stirrups (Allen Medical, Acton, MA), and the arms are tucked bilaterally with a draw sheet. Foam is used to protect the pressure points, particularly at the calf and elbows. A chest strap is also placed to prevent slippage of the patient while in steep Trendelenburg position. For draping, we use an under-buttock drape, legging covers, five utility drapes, and an abdominal laparotomy drape that is cut at the midline between the legs and then wrapped around the legs. A Steri-Drape 1016 irrigation pouch is fixed to the perineum.
Access to the abdomen and creation of the pneumoperitoneum can be done with a Veress needle or the Hassan technique. Our preferred approach is to use the Veress needle through the camera port site. The patient is placed in slight Trendelenburg position. The camera port is usually placed two fingerbreadths above the umbilicus. It is important to place the camera above the level of the sacral promontory to ensure enough distance between the camera and the promontory for easy dissection and suture placement on the promontory. Its position can be estimated by locating the anterior aspect of the superior iliac spine. The promontory should be at approximately the same level. Once the perineum access is obtained and pneumoperitoneum is achieved, a 12-mm port is placed under direct vision. A total of five trocars are used for RSC: four for the robotic system and one for the assistant. The robotic ports are then positioned in a classic “W” configuration, similar to a robotic prostatectomy, but placing the assistant on the patient’s right side. Two 8-mm robotic trocars are placed along a line one fingerbreadth inferior to the umbilicus at least 8 cm away from the camera port. These two ports should be lateral to the border of the rectus muscles to avoid the inferior epigastric vessels. The third 8-mm robotic port is placed on the patient’s left side, at the same level as the camera port, at least 8 cm superolateral to the previously placed robotic port on this side. The distance between each port should be between 8 and 10 cm to minimize colliding of the arms. The assistant port, a 12-mm port, is placed in the right upper quadrant, at the same level as the camera. The assistant port (12 mm) and the far left lateral robotic 8-mm port should be medial to the superior iliac spine to have the full degree of motion of the instruments ( Fig. 38.1 ). After trocar placement, the patient is placed in steep Trendelenburg position, at a 23- to 25-degree angle.
The following section describes the steps for RSC.
Sacral promontory dissection
Mesh fixation to the vagina
Mesh tensioning and fixation to the sacral promontory
Retroperitonealization of the mesh
Sacral promontory dissection
The surgery starts with the zero-degree lens. The monopolar scissors is placed in the right hand, the fenestrated bipolar instrument in the left hand, and the ProGrasp forceps (Intuitive Surgical, Sunnyvale, CA) in the fourth arm. All adhesions of the omentum, small bowel, and sigmoid should be taken down to free the deep pelvis and allow easy reduction of the bowel into the upper abdominal cavity. The sigmoid can be fixed to the left abdominal wall for retraction and exposure of the deep pelvis.
The camera is then changed to a 30-degree downward lens to complete the dissection of the sacral promontory. It is preferred to begin with the dissection of the promontory, in order to complete the most difficult portion of the surgery first. Using the fourth arm, the mesentery of the sigmoid is flattened out and the sigmoid is retracted further to the left pelvic sidewall in order to maximize the visualization of the sacral promontory. The promontory is found below the bifurcation of the common iliac arteries. The assistant surgeon can be utilized to help with tactile feedback during the identification of the promontory. A peritoneal window is created over the sacrum, and the peritoneum overlying the sacral promontory is opened using the monopolar scissors using sharp and blunt dissection. The incision should be made over the middle portion of the sacrum, far from the ureter, which can be found on the right side of the sacrum and runs on the right lateral wall towards the pelvis. The adipose tissue is dissected in order to expose the longitudinal ligament of the promontory. The area of the L5 and S1 vertebrae should be completely exposed. The most optimal location of mesh fixation is caudal and distal to the level of the intervertebral disk. This allows a proper reduction of the prolapse and minimizes the risk of posterior prolapse recurrence ( Fig. 38.2 ).