Approach Considerations
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.
Robotic-Assisted Laparoscopic Sacrocolpopexy Procedure
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]
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Patient positioning
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da Vinci Robotic Instruments
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da Vinci Robotic System
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Diagram of the surgical mesh repair
