Set-Up for Robotic Sacrocolpopexy

Fig. 5.1

Example of gel pad used to secure patient on the operating table

We recommend the Hug-U-Vac Steep Trend Positioner (Allen Medical Systems Inc., Acton, MA) as it is quick, easy to use, and provides excellent support to the patient’s head, neck, shoulders, and arms (Fig. 5.2). There are also several commercially available, disposable memory-foam systems (The Pink Pad, Xodus Medical, New Kensington, PA or Devon, Medtronic, Minneapolis, MN). Other devices utilize the patient’s posterior neck as a point of stability (Trengard, DA Surgical, Chagrin Falls, OH). A padded strap can be placed across the chest to further secure the patient to the operating table (Alistrap, AliMed, Inc., Dedham, MA). Older techniques, such as those that utilize shoulder bolsters secured to the head of the operating table, are also available, but may increase the risk of brachial plexus injuries [12].

Fig. 5.2

Patient is in dorsal lithotomy and steep Trendelenburg and secured to the operating table using a bean bag device

Patients should be placed in the dorsal lithotomy position with their bilateral lower extremities secured into supportive stirrups. Care should be taken to avoid pressure on the popliteal fossa or lateral knee, and the patient’s heels should be firmly secured in the boot of the stirrup (Fig. 5.3). The patient’s arms should be tucked at their sides with their arms, wrists, and hands in a neutral position and a “thumbs-up” orientation to avoid ulnar and radial nerve injury. Care should be taken to ensure that no undue pressure is placed on the extensor surfaces of the upper extremities. This can be accomplished using disposable foam, though many commercially available devices such as the Hug-U-Vac Steep Trend Positioner (Allen Medical Systems Inc., Acton, MA) do not require additional padding. The patient’s occiput should also be appropriately padded using foam material.

Fig. 5.3

Patient’s bilateral lower extremities are secured in supportive stirrups

Prior to sterile preparation , the patient should be carefully examined to ensure all pressure points are appropriately padded. Additionally, the patient should be placed in maximum Trendelenburg to test that she is adequately supported and does not move excessively on the operating room table. Her vital signs should be briefly monitored in this position to ensure appropriate cardiopulmonary adaptation. Once patient stability and positioning are assured, sterile preparation can be performed. Intraoperatively, care should be taken to avoid extreme flexion, extension, or abduction of the lower extremities to help minimize the risk of neuromuscular injuries.

Port Placement

Abdominal port placement is an essential component of performing a robotic sacrocolpopexy. Visualization and access to the sacral promontory may be compromised if the robotic camera port is inserted too caudally on the anterior abdominal wall. Additionally, if robotic ports are placed too close to one another, arm collisions can occur. A variety of port configurations are reported in the literature, especially to accommodate variations in body habitus. In our experience, different configurations work best for different surgical robotic platforms.

For the da Vinci Si robotic system (Intuitive Surgical, Sunnyvale, CA), we utilize a “W” configuration to facilitate access to the lower pelvis and sacral promontory (Fig. 5.4). After pneumoperitoneum is obtained using a Veress needle and appropriate insufflation is confirmed, the robotic camera is placed through an 8 mm laparoscopic port in the umbilicus. Two additional 8 mm robotic ports are inserted under direct visualization inferior to the umbilicus approximately 10 cm lateral to the umbilical port to maximize access to the pelvis and movement of the robotic arms. The final 8 mm robotic port is placed on the patient’s left side. This port is located 10 cm lateral to the umbilicus. An optional 8 mm accessory port can be placed on the patient’s right side, mirroring the third robotic port. By only using 8 mm ports, we anticipate that short-term increases in postoperative pain associated with robotic surgery, compared to laparoscopy, will be reduced [13].

Fig. 5.4

A “W” robotic port configuration

If an accessory port is not used, the sacrocolpopexy mesh can be rolled and passed into the abdominal cavity through an empty robotic trocar using a laparoscopic needle driver. Newer suture management devices (StitchKit, Origami Surgical) obviate the need to pass needles into and out of the abdomen during stitching. These devices can be passed into the peritoneal cavity vaginally before cuff closure or through an 8 mm port incision before trocar placement. They can be removed at the conclusion of the procedure through one of the robotic port site incisions.

The da Vinci Xi (Intuitive Surgical, Sunnyvale, CA) surgical platform includes several technological enhancements over its predecessor, the da Vinci Si. The da Vinci Xi patient cart has four robotic arms that are mounted on a mobile overhead boom (Fig. 5.5). These arms are thinner than previous platform models and the robotic arm joints can be manipulated to provide greater patient clearance, allowing for closer placement of robotic arms with fewer collisions. For this system, we have adopted a modified “arc” configuration for port placement (Fig. 5.6). After pneumoperitoneum is obtained using a Veress needle and insufflation has been confirmed, the robotic camera is placed through an 8 mm laparoscopic port in the umbilicus. An 8 mm robotic port is initially inserted on the patient’s right side 10 cm lateral and 1 cm caudal to the umbilicus. A second 8 mm port is placed on the patient’s left side located 10 cm lateral and 1 cm caudal to the umbilicus, symmetrically mirroring the port on the patient’s right side. Finally, an additional 8 mm port is inserted on the patient’s left side, lateral to the previously placed left-sided port.

Fig. 5.5

Da Vinci Xi with four robotic arms that are mounted on a mobile overhead boom

Fig. 5.6

An “arc” robotic port configuration

Robotic Docking

The robotic arms are attached to the robotic ports in a process called “docking.” It is important to place the patient in maximum Trendelenburg position prior to docking the surgical robot as this is what allows the bowels to shift out of the pelvis, facilitating access to the presacral space. On the Da Vinci Si system , it is not possible to move the operating table after the surgical robot is docked. If it is discovered that the operating table is not optimally positioned after docking, the patient cart must be undocked before positioning adjustments can be made.

Various docking techniques are described in pelvic surgery. Center-docking, or placing the patient cart between the patient’s legs, is simplest to perform but leads to limited access to the patient’s vagina or rectum for manipulation and hinders cystoscopy. Therefore, we suggest a parallel docking approach, which places the leading edge of the patient cart in direct line with the edge of the operating table (Fig. 5.7). The patient cart may then be advanced along the edge of the operating table until the camera arm reaches the umbilical port. This typically results in an overlap of 5–10 cm between the patient cart and operating table. The robotic arms may then be attached to the previously inserted ports.