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Correcting pelvic organ prolapse with robotic sacrocolpopexy

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An experienced surgeon describes key steps in performing sacrocolpopexy with assistance from the robot, modeled after the open procedure, using a mesh graft


 

References

Recent years have seen growing recognition that adequate support of the vaginal apex is an essential component of durable surgical repair of pelvic organ prolapse.1,2 Sacrocolpopexy is now considered the gold standard for repair of Level-1 defects of pelvic support, providing excellent long-term results.3-5

A recent randomized, controlled trial demonstrated the superior efficacy of laparoscopic sacrocolpopexy to a total vaginal mesh procedure in women who have vaginal vault prolapse—further evidence that sacrocolpopexy is the procedure of choice for these patients.6

The advantages of sacrocolpopexy include:

  • reduced risk of mesh exposure, compared to insertion of vaginal mesh
  • preservation of vaginal length
  • reduced risk of re-operation for symptomatic recurrent prolapse
  • reduced risk of de novo dyspareunia secondary to contraction of mesh.

Obstacles. Although a small number of surgeons are able to accomplish sacrocolpopexy using standard laparoscopic techniques, most of these procedures are still performed by laparotomy because the extensive suturing and knot-tying present a surgical challenge. Open sacrocolpopexy has disadvantages, too, including more pain, longer recovery, and longer length of stay.7-9

With the introduction of the da Vinci robot (Intuitive Surgical), the feasibility of having more surgeons perform this operation using a reproducible, minimally-invasive technique is much greater. The steep learning curve associated with standard laparoscopy in regard to mastering intracorporeal knot-tying and suturing is greatly diminished by articulating instruments. This makes robotic sacrocolpopexy an accessible option for all gynecologic surgeons who treat women with pelvic organ prolapse.

In this article, I detail the steps—with tips and tricks from my experience—to completing an efficient robotic-assisted sacrocolpopexy—modeled exactly after the open technique—that utilizes a y-shaped polypropylene mesh graft. Included is capsule advice from OBG Management’s coding consultant on obtaining reimbursement for robotic procedures (see “ Coding tips for robotic sacrocolpopexy”).

Key points: Performing robotic sacrocolpopexy
  • Two proficient tableside assistants are needed
  • Use steep Trendelenburg to remove the bowel from the operative field
  • A fan retractor is necessary in some cases to gain access to the promontory
  • Correct identification of the sacral promontory is key
  • In the absence of haptic feedback, novice surgeons must be aware of the potential danger in dissecting too far laterally and entering the common iliac vessels
  • Y-shaped grafts should be fashioned individually
  • Know the exit point of the needle at the promontory
  • Adequate spacing between the robotic arms is essential to avoiding interference among instruments during the procedure.

Details of the procedure

1. Surgical preparation, set-up

The patient completes a bowel prep using two bottles of magnesium citrate and taking only clear liquids 1 day before surgery. Although mechanical bowel cleansing has not been shown to decrease operative morbidity, manipulation and retraction of the sigmoid colon may be easier with the bowel empty.

Perioperative antibiotics are administered 30 minutes prior to the procedure. Heparin, 5,000 U, is injected subcutaneously for thromboprophylaxis as the patient is en route to the operating suite.

The patient is placed in the dorsal lithotomy position, buttocks extending one inch over the end of the operating table. The table should be covered with egg-crate foam to avoid having her slip down while in steep Trendelenburg position.

After the patient is prepped and draped, a Foley catheter is placed into the bladder. EEA sizers (Covidien) are inserted into the vagina and rectum.

Two experienced surgical assistants are necessary:

  • One on the patient’s right side to assist with tissue retraction and introduction of suture material
  • Another seated between the patient’s legs to provide adequate vaginal and rectal manipulation during surgery.

2. Port placement, docking, and instrumentation

Pneumoperitoneum is obtained with a Veress needle. Five trocars are then placed (FIGURE 1).

Careful port placement is integral to the success of this procedure because:

  • Inadequate distance between robotic arms and the camera results in arm collisions and interference
  • Visualization and access to the sacral promontory may be compromised if the camera is inserted too low on the anterior abdominal wall
  • Bowel retraction may be compromised if the fourth arm of the robot isn’t at least 3 cm above the anterior superior iliac crest.

My experience evaluating the abdomen before trocar insertion is that at least 15 cm is required between the pubic bone and the umbilicus to rely on this landmark for locating the 12-mm camera port.10 If this distance is shorter (as it is in many obese women), insertion above the umbilicus is necessary.

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