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Service de Gynécologie et Obstétrique, Centre d’Études Périnatales de l’Océan Indien (CEPOI) – EA7388, CHU Réunion, Hôpital Félix Guyon, Saint Denis de la Réunion, France
LSCP is known as an operation that takes time! If we look at literature, abdominal open sacrocolpopexy takes about 3–4 h [1], LSCP 25 min to one hour more [2, 3] and robotic SCP (RSCP) again 40 min to 1 h more [4, 5] bringing it to over 4–5 h average in well trained hands. At least, we suppose they are well trained, because they publish. So we’re afraid to guess how long it may take when a beginner performs it!
The team of Michel Cosson in Lille [6] has assessed the learning curve and found out that operative time for LSCP drops from 251 min average in beginners to 178 min after completed learning curve. How long is the learning curve? In RSCP, operation time drops from 5.3 to 3.6 h and plateaus after the 60 first procedures [7]. Amazingly, learning curve of LSCP seems to be shorter: operation time decreases from 196 to 162 min after 15 procedures for Mustafa [8] and after 18–24 procedures for Wattiez [9]. This may be explained by the fact that LSCP is performed by experienced surgeons, trained to highly advanced laparoscopy and maybe RSCP publications reflect the first experience of the surgeons with the robot. Thus, the learning curve is double: half to learn to use the robot and half to learn the technique of RSCP.
My personal experience is different. My learning curve was longer: it took me about 50 procedures to plateau my operative time which dropped from 4 h to 80 min average. We published results of the 44 first patients with an average operative time of 2 h 10 [10]. But I had nobody to teach me because in the early 90s, Wattiez, Cosson and me, we were the 3 first gynecologists to start with this procedure. Video facilities were poor. Instruments were poor. And the technique was not standardized.
In this chapter, I would like to share with you the tips and tricks I have developed during my surgical experience of the last 16 years to simplify and to make this procedure quicker.
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Avoid suturing when possible
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EndoHernia stapler (Covidien): This endoscopic stapler has been designed in the late 90s to attach hernia meshes during laparoscopic repair. The stapler needs a 12 mm trocar. The 4.8 mm staples are designed for soft tissue like peritoneum, fascia, vaginal wall or even rectal wall. These staples allow fixation of the mesh to the levator ani muscles, to the vaginal wall and to close easily and very quickly the peritoneal incisions. The depth of penetration is calibrated and constant of 2 mm; it’s safe for fixation to structures like the vaginal wall that has a 5 mm thick wall. The 4.0 mm staples are for tough tissue like promontory or Cooper ligaments. The depth of 1.5 mm is secure at the promontory, as the thickness of the prevertebral ligament has been proven to be 1.4–2.3 mm [11]. I spare at least 30 min of operative time using this device.
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Picture: EndoHernia stapler and the additional cartridges of staples: 4.8 mm for soft tissue and 4.0 mm for the promontory
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Securestrap (Ethicon): it’s an absorbable staple with which you can fix the mesh to the levator ani muscles and to the promontory. Its advantage is to be a 5 mm device and to deliver an absorbable implant. But you cannot fix the mesh to the vagina because the depth of penetration is too long and you cannot close the peritoneum with it. But you’ll save at least 20 min of operative time.
Picture: The SecureStrap stapler. The staples are slowly absorbable
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EndoFast Reliant SCP (Allium-medical): this is a very new device that can be used to fix very easily the mesh to the promontory, to the elevator muscles and to the vagina because of its very limited and calibrated depth of penetration. The device is very effective due to the “spider fastener” (see picture) the anchors the mesh in a very reliable way with its six bended arms. It passes through a 5 mm trocar. But it doesn’t help you to close the peritoneum.
Pictures: The EndoFast Reliant SCP stapler can be used for promontory and elevator muscles
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Glue: Interesting idea published by two French teams [12, 13]. The first teams claimed a reduction of operative time and the second found no difference. The glue was used to fix the anterior and posterior meshes to the levator ani muscles and to the vaginal wall only. Not to the promontory and both teams sutured the meshes to the uterine isthmus or to the vaginal vault. Thus, in fact, using glue was more or less an additional step and time sparing could only be due to inserting less sutures. The team that spared time skipped the levator and vagina sutures. The other team did not. None tried to close the peritoneum also with glue, which would be a great step ahead, I think, if it works.
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Tacker: I don’t recommend using the metallic tacker to fix the mesh to the promontory nor to the vagina. This device is very efficient but several case reports of migration into the bladder and spondylodiscitis have been published. It seems that this device is penetrating too deep into the structures, passing through the pre-vertebral ligament into the discus [11]. Thus, in case of infection, it may affect the vertebral disc immediately. If used on the vaginal wall, as it is a metallic smooth device, it may migrate into bladder or bowel.
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Use T-Lift device to expose the Douglas pouch: when the patient is obese or when the sigmoid colon is very long and makes it difficult to expose the dissection area, T-Lift is a very useful device. Push the needle under view control through the sigmoid meso or through a fatty appendix, slide the T-shaped plastic strip through the needle and suspend the organ to the abdominal wall. You can also suspend the ovaries or the uterine body. T-Lift is a cheap device, easy to use and helping greatly to spare operative time.
