Advantages of Open Sacrocolpopexy With Decreased Morbidity

I use a Y-shaped polypropylene mesh (AMS) and introduce it, trimmed to the appropriate width and length, in the proper anatomical orientation. I place the distal and lateral sutures on the anterior vaginal wall first, and then place several (four to eight) additional sutures to secure the mesh to the anterior vaginal wall. To suture, I use a Mega needle driver in the left hand and a SutureCut needle driver in the right. The SutureCut needle driver is similar to the Mega needle driver, but it also has a cutting mechanism that provides enhanced autonomy to the console surgeon and makes suturing more efficient overall.

Using the third operative robotic arm, I then roll the sacral end of the mesh and lift it anteriorly, which allows the posterior mesh to drape nicely over the posterior vaginal wall. The longer posterior mesh can then be easily sutured to the posterior wall of the vagina. For the posterior vaginal-wall mesh attachment, I usually start at the vaginal apex and work my way inferiorly. Throughout the surgery, I use permanent sutures of CV-2 Gore-Tex.

I then adjust the mesh tension, ensuring that it will be attached to the sacrum without undue tension and with equal distribution of support to the anterior and posterior of the vagina. Once this is determined, the excess mesh is trimmed.

I typically place three sacral sutures to secure the mesh to the sacrum. I place the inferiormost suture first, using a slip (or sliding) knot. This is a one-way knot that allows the mesh to be easily attached to the sacrum without the need for an assistant to hold the mesh against the sacrum while the suturing and knot tying are completed. Two additional sacral sutures are then placed superiorly to allow for adequate visualization of the sacrum during the suturing, and the excess mesh is trimmed.

The mesh should then be retroperitonealized to reduce the risk of small-bowel obstruction. The closure of the peritoneum is facilitated by the extension of the initial peritoneal incision from the sacrum inferiorly in the midline through the cul-de-sac and along the posterior vaginal wall at the time of sacral dissection. An enterocele repair can be accomplished as closure over the mesh obliterates the cul de sac. The peritoneum is closed with a running, locking, braided, absorbable suture.

I typically perform cystoscopy at the end of the procedure to confirm bilateral ureteral patency using intravenous indigo carmine.

Fortunately, presacral bleeding is rare. However, if presacral hemorrhage does occur, it is important to remain calm and remember that pressure can be applied with most available robotic instruments. (For example, even scissors work well if the wrist of the instrument is used.) If the bleeding does not respond to pressure, a bipolar forceps can be used, depending on the location and source of the bleeding. If bleeding continues, then FloSeal—a thrombin matrix that will usually and very effectively stop the bleeding—can be considered.

If the clinical situation warrants additional procedures, such as a posterior repair or a suburethral sling for urinary incontinence, these can easily be performed after the robot is undocked. If necessary, we perform uterine morcellation after undocking the robot.

Our typical patient at Duke has an overnight stay in our 23-hour observation unit and requires minimal oral pain medication.

Dr. Visco is a consultant for Intuitive Surgical Inc.

Port placement: A “W-like” configuration for port placement works well. This configuration reduces any competition between the two left robotic arms. Intuitive Surgical

Presacral dissection: The presacral space is generally best viewed with a 30-degree down scope.

Anterior suturing: A Mega needle driver and SutureCut needle driver are used for anterior vaginal wall suturing.

Mesh to sacrum: The first and most inferior of the three sacral sutures is placed with a sliding knot. Photos courtesy Dr. Anthony Visco

Robotic Sacrocolpopexy

This is the third installment of the Master Class in Gynecologic Surgery dedicated to robotic surgery.

Whether the procedure is called robotic sacrocolpopexy or robotic-assisted laparoscopic sacrocolpopexy, Dr. Anthony Visco's excellent description will help the reader understand how the robot and the laparoscope can be used to modify the standard treatment for vaginal vault prolapse—the abdominal sacrocolpopexy—into a minimally invasive gynecologic procedure that can be incorporated into one's practice.

As Dr. Visco points out, the robotic procedure involves an obligatory learning curve and a need for practiced, efficient teamwork. However, as the surgeon and staff gain experience, robotic sacrocolpopexy can lead to outcomes similar to those of abdominal sacrocolpopexy, but with less blood loss and quicker recovery time.