Robotic-assisted laparoscopic mesh sacrocolpopexy

Abstract

The current 'gold standard' surgical repair for apical prolapse is the abdominal mesh sacrocolpopexy. Use of a robotic-assisted laparoscopic surgical approach has been demonstrated to be feasible as a minimally invasive approach and is gaining popularity amongst pelvic floor reconstructive surgeons. Although outcome data for robotic-assisted sacrocolpopexy (RASC) is only just emerging, several small series have demonstrated anatomic and functional outcomes, as well as complication rates, comparable to those reported for open surgery. The primary advantages thus far for RASC over open surgery include decreased blood loss and shorter hospital stay.

Keywords: mesh sacrocolpopexy; pelvic prolapse; robotic surgery.

Figure 1.

Patient positioning for robotic docking. Once secured on the bed with beanbag, egg crate foam and wide tape (a), the patient goes from a flat angle (b) to ‘steep’ Trendelenburg (c).

Figure 2.

Side docking of the da Vinci robot, with illustration of robot positioning (a) and advantage of having assistant at foot of bed to manipulate the vagina (b). (Courtesy of Intuitiv Surgical).

Figure 3.

(a) Cephalad view of port placement for robotic-assisted sacrocolpopexy with skin markings and port sites lateral to each other (dotted line). (b) Optional placement of the robotic port lateral and caudal to the camera port, approximately 9 cm apart. (c) Ports in place after insufflation in image (a).

Figure 4.

(a), Identification of vaginal apex with end-to-end anastamosis sizer in place. Maryland bipolar forceps are in the left arm, monopolar scissors are in the right arm. (b), Identification of the anterior longitudinal ligament (ALL, arrow) with palpation by bedside assistant (suction tip). (c), and (d), Views of posterior vaginal apex after dissection of rectovaginal space with placement of 2-0 PTFE suture.

Figure 5.

Laparoscopic view of Y-shaped polypropylene mesh (IntePro) after initial sutures placed in the posterior vaginal wall (a), and at placement on the anterior vaginal wall (b).

Figure 6.

Laproscopic view of peritoneal closure with absorbable suture (a), and at completion of closure (b).