Robotic-Assisted Laparoscopic Sacrocolpopexy

Pelvic organ prolapse (POP) is a medical condition in which female pelvic organs, including the bladder, uterus, vagina, and/or rectum, descend from their normal positions within the pelvis.[1] These organs can sometimes protrude through the opening of the vagina. This condition is common, being symptomatic in approximately 30% of women 50-89 years of age and requiring a corrective procedure in 11% of women by 80 years of age.[2, 3]

POP occurs frequently with normal aging in women who have had vaginal delivery or deliveries or prior hysterectomy, and in those who have increasing body mass index, which predispose these women to weakening of the supporting ligaments and muscles in the pelvic floor.[1]

The prevalence of POP increases with age.[4] Researchers estimate that up to 250,000 surgical procedures to correct POP are performed each year in the United States,[5] and, as the proportion of older women continues to rise, the requirement for these procedures is expected to increase by approximately 50%.[6]

Sacrocolpopexy is a surgical technique used to treat vaginal vault or uterine prolapse, 2 types of POP. The objectives of the procedure are to reduce prolapse and to restore the anatomy and function of the vagina. During the procedure, the apex of the vagina/fundus of the uterus or stump of the cervix is lifted back up to its natural position by attaching a synthetic mesh from the top and back of the vagina to the sacral promontory. The mesh provides the vagina with the right amount of support to keep it in the correct position (see the image below).

No particular criterion standard for POP repair exists, yet the open abdominal mesh sacrocolpopexy has been revered as the main abdominal approach[7, 8] for correction given its cure rates of 85-100% in recent studies.[9, 10] However, when performed via a robotic-assisted laparoscopic (RAL) approach, the procedure is comparable in its clinical results, providing the same long-term durability of open sacrocolpopexy with the added benefits of a minimally invasive surgery, greater precision and control during the procedure, less pain, less blood loss, better cosmesis, and shorter hospitalization.[11, 12, 13, 14, 15, 16] Many surgeons are unfortunately limited in their knowledge of how to skillfully perform sacrocolpopexies laparoscopically, but the assistance from a robotic system can significantly reduce the learning curve associated with laparoscopic sacrocolpopexy.[11]

Indications for robotic-assisted laparoscopic sacrocolpopexy (RALS) are similar to those for the open procedure and include mainly symptomatic pelvic organ prolapse, graded according to the Baden Walker grading system (grade 3-4 genitourinary prolapse, or symptomatic grade 2)[17] or the International Classification of Standards (ICS) classification (stage II-IV).[18] Symptoms include urinary incontinence or difficulty urinating, the latter due to urethral obstruction; difficulty passing stool; and pelvic pressure or the sensation of pulling on the vagina or the lower back. Most patients seek surgical correction when they experience bulging and protrusion of organs with or without voiding symptoms.

An absolute contraindication to robotic procedures, including the RALS, is increased intracranial pressure because of the steep Trendelenburg necessary in positioning.[19]

Some of the general contraindications are the same as those for any other surgical procedure, including bleeding diathesis or a requirement for anticoagulation; anemia; active infection such as cystitis, bacterial or fungal vaginal infection, pelvic inflammatory disease, or active sexually transmitted disease; uncontrolled hyperglycemia; and active venous thromboembolism.

Some relative contraindications, because an exaggerated Trendelenburg position is required, include severe cardiac disease, severe emphysema or other chronic respiratory/pulmonary disease, glaucoma, history of stroke or aneurysm, and pregnancy.[19]

Some contraindications specific to sacrocolpopexy include cancer of the cervix, vagina, or uterus that is untreated or that cannot be treated due to advanced stage; vesico-vaginal, vesico-uretero, urethral, or recto-vaginal fistulas; and prior POP repairs with infected or exposed foreign material and erosions.

Complication Prevention

Rare but serious perioperative complications include urine leak, bowel obstruction, and peritonitis[20, 21] from failed detection of injury to the bladder, bowel, dehiscence, or infection during the procedure. Being mindful of the potential for these rare complications is important. In addition, although rare, delayed bleeding must be high on the differential in a patient who develops hemodynamic instability.

Postoperative complications can be prevented by awareness and understanding of the risks of surgery, including the risks of bleeding, infection, and injury to adjacent organs, as well as the risks of anesthesia, mesh and other implants, and positioning. For example, appropriate positioning and adequate cushioning of pressure points can prevent neurapraxia. Peroneal nerve injury can occur from compression if a stirrup is not appropriately padded and positioned. In the modified lithotomy position used for sacrocolpopexy, a position that permits simultaneous operative exposure to the abdomen and the perineum, femoral nerve injury can occur by hyperextension at the hip.

In addition, calf compression in this position increases the risk of venous thromboembolism (VTE) and compartment syndrome. The duration of a procedure was found to be the most consistent factor contributing to the development of compartment syndrome.[22] VTE results from alterations in blood flow caused by general anesthesia, positioning, and surgical manipulation, including retractor compression of great vessels.

Prevention of VTE may be achieved with use of modified Krauss arm supports as stirrups during the procedure;[23] in addition to pneumatic compression devices; prophylactic doses of Lovenox, heparin, or low-molecular weight heparin in patients at increased risk for VTE; and early postoperative ambulation. Overall, a reduced operative time will likely reduce the amount of time a patient is in a particular position that can increase injuries to the nerves and other structures.

Mesh erosion, in which the bladder or vagina are exposed to synthetic material, is a late postoperative complication with a reported rate of 3-7.6%.[24, 25, 26] Erosion is reported to occur within the first 5-14 months post-procedure.[24, 27] Symptoms include vaginal discharge, often malodorous, vaginal bleeding, and dyspareunia.[24, 27] Concurrent hysterectomy[24] and smoking are modifiable risks associated with mesh erosion.[24, 25] Monofilament polypropylene mesh has been found to have lower rates of erosion.[24] Conservative management of mesh erosion, including use of vaginal estrogen cream, antibiotics, and mesh trimming, often fails.[28] However, treatment is often not necessary because these will granulate well. Partial or complete removal of the graft via transvaginal excision is known to be more successful.[25]

In one study, Akl et al described the technique and learning curve for RALS,[29] which was performed in 80 patients with stage III-IV prolapse. They found that the mean operative time for RALS was decreased from 179.9 minutes in the first 30 cases in the study, to about 167 minutes in the last 30 cases.

Elliot et al[30] evaluated 30 patients with posthysterectomy vaginal vault prolapse who underwent RALS. The mean follow-up was 24 months, with 21 out of 30 patients having had a minimum of 12-months of follow-up. The success rate was 95% (19 out of 20) based on physical examination, with 1 recurrent vault prolapse and 2 vaginal extrusions of mesh. Ninety-five percent of patients were satisfied with the outcome, assessed with asking the patients whether they would recommend the procedure to others.

Geller et al compared RALS with open abdominal sacrocolpopexy via review of 73 patients who underwent RALS and 105 patients who underwent open abdominal sacrocolpopexy.[20] They demonstrated that the operative time was significantly longer for RALS, although the estimated blood loss and length of hospital stay were significantly less. The 2 techniques had similar short-term vaginal support, in addition to comparable overall complication rates: 17.8% for RALS and 11.4% for open abdominal sacrocolpopexy.

Barboglio et al reviewed RALS complications in 127 patients and found that mesh extrusion occurred in 3 (2.4%) patients. Other complications reported were bowel injury (2.4%), readmission rate (2.4%), wound infection (1.6%), and postoperative hernia at port site (1.6%).[31]

Patient Instructions

One to two weeks before the procedure, the patient must complete a preoperative assessment with a physician, or the nursing staff, to make sure they are able to tolerate anesthesia and that they are in optimal health for surgery. Blood may be drawn, as well as urine collected, for evaluation. An EKG, which is a recording of the heart’s electrical activity, or a chest radiography might also be performed.

The patient will need to shave the pubic hairs along the bikini line before coming in to the hospital the day of your procedure. If the patient does not remember to do so, a nurse will be available to assist.

The patient should not have any food or water 6-8 hours before the procedure. The patient may be asked to have nothing to eat or drink after midnight the night before.

Elements of Informed Consent

A sacrocolpopexy is a procedure to treat vaginal vault prolapse, in which the upper part of the vagina slips downward. This might occur in women who have had children by vaginal delivery or in those who have had a hysterectomy. The procedure is designed to return the vagina to its natural position and function by lifting the vagina back up to its natural position by attaching a synthetic mesh from the top and back of the vagina to one of the bones at the back of the pelvis (sacrum bone).

The procedure can be performed through an open incision, or through a less invasive laparoscopic (with or without use of robotic assistance) incision through the abdomen. During the laparoscopic approach, with or without robotic-assisted assistance, a small needle is inserted through the belly button and gas is gently blown into the abdomen. The gas slowly expands the abdomen for clear visualization of the vagina and other pelvic organs. A small camera (laparoscope) is then inserted through the belly button, and 2 or 3 more tiny cuts are made low down in the abdomen to perform the operation. The cuts may need to be sewn up, which is often unnecessary since the cuts are often so small.

The procedure requires general anesthesia, which means the patient will be asleep during the procedure. The procedure usually takes 2-4 hours.

The patient will have an IV in his or her arm, which will provide the patient with fluids until they are able to drink normally after the procedure. A Foley catheter may be inserted into the bladder through the urethra to help the bladder drain during the procedure, and it may be kept in place for a few days afterwards; there may be difficulty with urination after the procedure. A small drain may be placed in the wound to remove the excess blood and/or fluid if necessary.

The patient will be asked to sign a consent form, which will give permission to perform the operation. Risk and benefits of the robotic-assisted laparoscopic procedure will also be reviewed. Risks include bleeding, infection, damage to nearby organs, ie. the bladder or bowel, failure of the procedure to reach its goal, erosion of the mesh through the vaginal mucosa or bladder, formation of prolapse in another part of the vagina, formation of blood clots in the veins, worsening bladder control, slow return of bladder or bowel function.

Equipment

See the list below:

• 2- 12 mm trocars

• 2- 8 mm robotic trocars

• Pair of robotic scissors

• Pair of robotic graspers (ie. Maryland, Prograsp, or Blunt)

• Robotic needle drivers

• 2-0 Vicryl sutures (ie. Polyglactin)

• 2-0 permanent sutures (ie, Novafil)

• Meshed polypropylene Y-graft

Anesthesia

The anesthesiologist will discuss risks of general endotracheal anesthesia, which is required for robotic-assisted laparoscopic sacrocolpopexy, given the requirements of pneumoperitoneum and steep Trendelenburg positioning; the anesthesiologist will also answer patient questions.

Positioning

The patient is placed in a modified, low dorsal lithotomy position, with her arms tucked and padded at the patient’s sides. Well-padded stirrups should be used to secure both legs and allow for adequate exposure to the abdomen and vagina. Shoulder pads can keep the patient from sliding on the table. Once the patient is secured from slipping, she should be placed in a very steep Trendelenburg position for preparation and sterile draping (see the image below).

The patient should be discharged with the appropriate set of postoperative care instructions, especially limitations to activity. Any strenuous activity or heavy lifting greater than 10 lbs should be avoided in the first 6-8 weeks after surgery so as not to disrupt the healing process. Bicycle riding and other activities that cause perineal strain or trauma should be disallowed. Sexual intercourse and the use of tampons or applicators into the vagina should also be avoided during healing. Follow-up appointments with a physician should be scheduled at approximately 2 weeks, 4 weeks, 6 months, and 1 year after the sacrocolpopexy procedure.

The key component of robotic-assisted laparoscopic sacrocolpopexy is the suspension of the anterior and posterior vaginal wall to the sacral promontory in a manner that re-creates the natural anatomic support provided by the uterosacral and cardinal ligaments. This is accomplished by dissecting the vagina from the bladder and rectum followed by interposition of a mesh graft attaching the vagina to the sacral promontory.

The patient is placed in the low lithotomy position and in padded stirrups. Pressure points are well padded, and 3-inch silk tape is placed in an ‘X’ pattern across the anterior chest. She is carefully secured to the table for positioning in very steep Trendelenburg. A Foley catheter is inserted under sterile conditions. The patient is draped using sterile technique. An intravenous prophylactic antibiotic is administered.

Laparoscopic instrument ports are placed in the abdomen. Initially, a Veress needle is placed immediately supraumbilically, which is subsequently replaced with a 12-mm camera following intraperitoneal insufflation. Under direct vision, two 8-mm robotic trocars are placed laterally and inferiorly to the camera port. These 2 robotic trocars are placed approximately 1 handbreadth away from the camera port to prevent collision between robotic arms. If needed, a third 8-mm robotic trocar is placed inferiorly and far to the left to be used by the fourth arm for retraction. A 12-mm robotic trocar is placed superiorly and on the far right near the iliac crest to be used by the assistant surgeon.

The robot is docked between the patient’s legs, although side-docking is possible and preferred with the new version of the robotic platform. Supracervical robotic-assisted hysterectomy is performed, during which the bladder is dissected away from the uterus and vaginal cuff by first incising the overlying peritoneum. Dissection is then performed inferiorly and laterally through this peritoneal incision to separate the uterus from the bladder.

Once the outline of the uterocervical junction is visualized, the uterus is removed via electrocautery. The cervical stump is left in place. The uterosacral ligaments are also spared to maximize pelvic organ support. The proximal end of the cervical stump is oversewn in a simple interrupted fashion with 2-0 polyglactin suture. The excised uterus is then placed in the right pericolic gutter to be morcellated following completion of RALS.

The sacral promontory is then identified posterior to the sigmoid colon, and the overlying tissue is dissected away; multiple 2-0 nonabsorbable monofilament sutures are preplaced in the periosteum for eventual fixation of the graft. Approximately 4 cm of the sacral promontory is exposed in a longitudinal direction. A polypropylene Y-graft (ie. AMS, Minneapolis, MN, Bard, Boston to name a few) is placed through the assistant port and trimmed to the appropriate tension- free length. Because this length is different per patient, it is determined by placing the cervical stump in an anatomically appropriate position using a hand-held vaginal retractor and trimming the graft to the length that will maintain this position.

One arm of the Y-graft is fixed to the posterior aspect of the cervical stump in a simple interrupted fashion with approximately six to eight 2-0 polyglactin sutures. The other Y-graft arm is fixed to the anterior aspect of the cervical stump in a similar fashion. Exposure for this portion of the procedure is aided by a vaginal retractor. The tail of the Y-graft is then fixed to the sacral promontory with 2-0 nonabsorbable monofilament suture in a simple interrupted fashion. The graft is retroperitonealized by closing the peritoneum over the graft with 3-0 polyglactin suture in a running fashion.

General Information on Robotic-Assisted Surgery

Robotic-assisted surgery was developed to enhance a surgeon’s abilities in performing open surgery, as well as to help overcome some limitations encountered during minimally invasive surgical procedures.

The da Vinci Surgical System, which includes a surgeon’s console, a patient-side robotic instrument with 4 arms (one to control the camera; 3 to manipulate the surgical instruments) controlled by the surgeon, and a high-definition 3D vision system at the surgeon’s console, is the most commonly used system to date (see the image and video below). This system also has intuitive motion control in which it senses the surgeon’s hand movements from the console and translates these movements electronically into delicate movements that allow the robotic arms to manipulate the tiny instruments. In addition, it detects and filters out tremors in the surgeon’s hand movements so that these unwanted movements are not duplicated robotically.

Over the last several years, the popularity of this procedure has exploded. As such, there are many articles referencing the success rates that have remained durable long term.[32, 33]