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Advantages of Open Sacrocolpopexy With Decreased Morbidity


 

Some surgeons perform the procedure laparoscopically in an effort to decrease morbidity and recovery time, with some success. Overall, however, a laparoscopic approach has not been widely adopted because of the complex suturing and dissection involved, and the subsequently significant learning curve.

Robotic sacrocolpopexy is a new addition to our armamentarium and is an exciting option for me and other surgeons because it combines the advantages of open sacrocolpopexy with the decreased morbidity of laparoscopy.

A robotic approach to the tried-and-true abdominal sacrocolpopexy takes full advantage of all that robotic surgery offers. Instrument articulation, three-dimensional vision, tremor reduction, and improved ergonomics for the surgeon all make managing the mesh and intracorporeal suturing—as well as dissecting in the rectovaginal and presacral spaces—so much easier than would be the case with a standard laparoscopic approach.

Overall, sacrocolpopexy performed with the da Vinci surgical system—the only Food and Drug Administration-approved robotic device for use in gynecologic surgery—offers better access to the pelvis, compared with both the open and laparoscopic approaches.

We can truly replicate what we do in an open approach, but with less postoperative pain, less blood loss and scarring, and faster recovery. Robotic sacrocolpopexy can also be combined with total or supracervical hysterectomy for uterine prolapse.

Outcomes data are emerging. At the American Urogynecologic Society annual meeting last month, we presented our initial short-term data comparing robotic with traditional abdominal sacrocolpopexy for the treatment of both uterine and vaginal vault prolapse.

Postoperatively, based on a 6-week POPQ (Pelvic Organ Prolapse Quantification) examination, there was a similar degree of pelvic organ support in the 73 patients who underwent robotic surgery and the 105 patients who underwent traditional surgery. The length of hospital stay was significantly shorter with the robotic approach (1.3 days vs. 2.7 days), and estimated blood loss was significantly lower (103 mL vs. 255 mL).

The operative time for the colpopexy and all other procedures, including hysterectomy and slings, was significantly longer in the robotic group (328 vs. 225 minutes). This time is expected to decrease, however, as all members of the surgical team, including fellows, residents, and surgical staff, progress through the learning curve.

Patient Selection and Positioning

I now offer the procedure to any patient to whom I would recommend a sacrocolpopexy. In the initial stages of adopting a robotic approach, however, it makes sense to be more selective and to perform relatively straightforward surgeries. This means starting with patients who are relatively thin (with body mass indices less than 30 kg/m

Initial patients should also have a reasonably sized uterus (if present) and few comorbidities. Pulmonary morbidity (emphysema or chronic obstructive pulmonary disease, for instance) is a relative contraindication, especially for initial cases, because these patients may not tolerate the Trendelenburg position, which is required for the surgery.

In addition, although robotic sacrocolpopexy can be used for uterine prolapse, I recommend starting with patients who have vaginal vault prolapse so that the surgeon can focus on a single robotic procedure. As their experience grows, surgeons can easily perform a combined robotic hysterectomy with sacrocolpopexy for the treatment of uterine prolapse. I primarily perform a supracervical hysterectomy in combination with a sacrocolpopexy in an attempt to reduce the risk of mesh erosion.

When the patient is positioned at the start of the surgery, her arms and shoulders and all “pressure points” should be well padded with foam, but I do not find a need for shoulder pads. I typically use an extra-large vacuum bean bag to keep the patient firmly in place while she is in the moderate to steep Trendelenburg position, but the use of a gel pad placed between the patient and the bed is an alternative approach to keep the patient from sliding cephalad during the surgery.

Port Placement, Setup, and Preparation

For robotic sacrocolpopexy, five trocar sites are used with a four-arm robotic system: three for operative robotic arms, one for the camera, and one to be used as the assistant's port for suction and irrigation, assistance with traction/countertraction, and the introduction of suture and mesh. (The bedside assistant is also helpful for instrument swaps, during uterine morcellation, and for any trocar depth repositioning that is necessary.)

Initially, we tried several different port locations. We have found that a “W-like” configuration for our port placement works well. We place the camera trocar at the umbilicus to accommodate the endoscope and the camera arm. This represents the middle of our “W.”

We then place two robotic ports at the two inferior apices of the “W.” The lateral ends of the “W” are each located about 2 cm inferior to the level of the umbilicus. The right lateral port is the assistant's port, which is used to introduce mesh, suture, and the like. The left lateral port is for the third robotic operative arm and is particularly helpful in moving the sigmoid laterally to expose the sacrum.

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