The authors routinely begin the procedure with exposure of the sacral promontory. If this cannot be achieved laparoscopically in a safe and timely fashion, then conversion to an open procedure should be considered. In order to visualize the sacral promontory, the small bowel must be retracted cephalad and the sigmoid colon must be mobilized out of the pelvis and retracted laterally (to the patient’s left). Both the small bowel and colon are usually easily retracted unless there are adhesions preventing their mobilization. In this case, it may be necessary to perform lysis of adhesions until they can be adequately retracted out of the operative field. Once the sigmoid colon is retracted laterally, the sacral promontory is typically visualized. Robotic arm #3 can be used to retract the colon and maintain exposure of the promontory (Fig. 6.4a).

After the sacral promontory is identified, the anterior longitudinal ligament must be exposed. The authors use a fenestrated bipolar forceps in the left robotic arm (robotic arm #2) and an electrocautery scissors in the right robotic arm (robotic arm #1). The fenestrated bipolar forceps or a vessel sealing device are preferred for concomitant hysterectomy. The peritoneum overlying the sacral promontory is opened in both the cephalad and caudal directions. Invariably, there is adipose tissue covering the ligament. Obese patients can have significant adipose tissue overlying the ligament, so it may be useful to periodically have the bedside assistant palpate the promontory to confirm its location. Care must be taken to maintain meticulous hemostasis during this dissection as presacral vessels can cause significant bleeding. If bleeding is encountered, the fenestrated bipolar forceps is well suited to hold pressure on the area while the assistant introduces a suction device. On occasion, a second assistant port must be inserted in the right upper quadrant to enable the bedside assistant to perform simultaneous suction while assisting the surgeon. In the authors’ experience, it is extremely unusual to need to convert to an open procedure. The ligament is readily identifiable by its smooth, white appearance (Fig. 6.4b).

The authors routinely cover the colpopexy mesh with peritoneum to reduce the risk of bowel obstruction, although data exists that may indicate otherwise [12]. In their series of 128 patients, Elneil et al. [12] reported no bowel complications following abdominal ASC without covering the mesh with peritoneum. However, we have witnessed bowel obstruction in the setting of mesh left uncovered, and reoperation revealed a closed loop bowel obstruction due to small bowel adhering to the mesh.

The peritoneal opening that originated at the sacral promontory is extended towards the pelvis in a “hockey stick” configuration (veering to the right of the sigmoid colon) directed at the posterior vagina. Care must be taken to visualize the right ureter during this dissection and to maintain adequate distance from the ureter when electrocautery is used in order to avoid thermal injury to the ureter.

The peritoneal edges should be separated as wide as possible to facilitate the subsequent peritoneal closure over the mesh. This is especially important as one dissects distally in the pelvis (at the location of the posterior vagina) as bringing the left edge of the peritoneal opening over the mesh can be difficult when the peritoneum is not well mobilized in this area (Fig. 6.5).

Distal dissection of the vesicovaginal space is a key part of RASC as distal placement of mesh on the anterior vaginal wall can address associated cystocele and obviate the need for anterior colporrhaphy. If sacrocolpopexy is performed at the time of hysterectomy, this tissue plane will have already been partly dissected during the hysterectomy; however, when sacrocolpopexy is performed after prior hysterectomy, there can be significant adhesions making identification of the tissue plane more difficult. Often, the bladder completely covers the vaginal apex.

In order to facilitate dissection, the use of a vaginal stent is critical. A vaginal stent allows the bedside assistant to manipulate the vagina for dissection and aids in subsequent suture placement. The authors use an end to end anastomosis (EEA) sizer, but there are also commercially available stents specifically manufactured for this purpose including a lighted version and one that can be attached to the operating room table.

Exposure for dissection of the vesicovaginal space is achieved by retracting the bladder superiorly with robotic arm #3. The vaginal stent is then pushed cephalad and posteriorly. In doing so, the general location of the tissue plane is identified (Fig. 6.6). Sharp dissection in combination with electrocautery is usually necessary to initiate the dissection, but once the tissue plane is identified, blunt dissection is often adequate to complete the dissection. When a significant cystocele is present, the vesicovaginal space needs to be dissected as far distally as possible to facilitate distal mesh placement. The authors have found that by placing the mesh as far distally as possible, even large cystoceles can be repaired without the need for additional transvaginal repair.

When dense adhesions are present such that the tissue plane is not readily identifiable, the bladder can be filled with fluid via a bladder catheter to aid in identification of the correct plane. Alternatively, a cystoscope can be inserted in the bladder and transillumination can outline the bladder. Any cystotomy that occurs during this dissection is typically small and repaired readily with an absorbable suture. In this scenario, a bladder catheter should remain postoperatively. The duration of catheter drainage and need for cystogram are at the surgeon’s discretion and are dependent on the size of the defect repaired.

The rectovaginal space is dissected and extended distally in a similar fashion as the vesicovaginal space, and distal placement of the posterior vaginal mesh can address posterior compartment defects and obviate the need for concomitant posterior colporrhaphy. When this tissue plane is not readily apparent, a second EEA sizer can be inserted into the rectum to facilitate dissection. It is critical to assure that the rectum is completely dissected from the posterior vaginal wall to eliminate the risk of suturing mesh to rectum.

At completion of the rectovaginal dissection, the peritoneum previously covering the posterior vaginal wall is now mobilized and made in continuity with the peritoneal opening that originated at the sacrum. Maximal mobilization of the peritoneal edges in this area facilitates subsequent mesh coverage following the colpopexy.

In the original description of robotic sacrocolpopexy, a permanent, synthetic mesh was used [13]. Although the Food and Drug Administration safety communications involving mesh specifically addressed vaginally placed mesh [14], some surgeons are still hesitant to use synthetic mesh and opt for biologic grafts such as autologous fascia or xenografts. If the former is used, open sacrocolpopexy should be considered as harvesting of rectus fascia and the colpopexy can be done through a single incision. The authors advocate use of synthetic mesh, as randomized controlled trials have shown objective cure rates significantly higher with mesh use compared with cadaveric fascia lata, 91% vs. 68%, respectively, P = 0.007 [15]. More recently, data has become available regarding use of autologous rectus fascia, but long-term results are lacking [16].