Robotic Sacrocolpopexy

Table of contents

1. Operative Note
2. Postoperative Considerations
3. Patient Education
4. Implants & Devices

Operative Note

_ indicates a section that needs to be reviewed or completed.

After informed consent was obtained, the patient was taken to the operating room and placed in the dorsal supine position. She then underwent an uncomplicated induction of general anesthesia. She was repositioned in dorsal lithotomy with her legs in Allen stirrups and she was on the hug-u-vac stabilizer. The vagina and abdomen were prepped and draped in the normal sterile fashion. A surgical time out was performed and a foley catheter was inserted into the bladder.

_The umbilicus was everted and injected with bupivicaine. It was then incised and direct entry with an optical trocar was was achieved. The abdomen was insufflated with CO2 gas and an intra-abdominal survey revealed findings noted above.  The patient was then placed in steep Trendelenburg.

A series fo 8mm incisions were then made after injection of bupivicaine in a horizontal line in the same plane as the umbilicus. Each of these were approximately 8cm apart, two on the left and two on the right. 8mm trocars were then inserted without difficulty under laparoscopic visualization. The assistant port was on theh patient’s left between the umbilicus and the most lateral port.

The bowel was folded out of the pelvis and the DaVinci robotic system was docked without difficulty on the patient’s _right side.

We turned our attention to the sacral promontory. The bowel was swept to the patient’s left to ensure adequate exposure. Peritoneum overlying the sacral promontory was then grasped, elevated, and incised vertically with monopolar scissors. The anterior longitudinal ligament was then identified and cleared. The peritoneal incision was then carried down along the right pelvic sidewall to the posterior vagina with care to stay medial to the right ureter. The deaver retractor was then placed in the vagina. We made an incision in the overlying peritoneum on the proximal posterior vaginal wall and carefully dissected the rectum off the posterior vagina down to the perienal body. With the lucite rod in the vagina, we then dissected the bladder from the anterior vagina using a combination of monopolar scissors, cold scissors, and blunt dissection.

A piece of Restorelle polypropylene Y-mesh was then introduced into the abdominal cavity. The anterior leaf of the mesh was then affixed to the anterior vaginal wall using _ interrupted sutures of 2-0 PDS. The posterior leaf of the mesh was affixed to the posterior vaginal wall using _ interrupted sutures of 2-0 PDS. The excess mesh was trimmed anteriorly and posteriorly. Final anterior mesh length was approximately _cm. Final posterior mesh length was approximately _cm.

The peritoneum overlying the mesh on the vagina was then closed with a running stich of 2-0 delayed absorbable barbed suture.

We then placed two 2-0 Prolene sutures though the anterior longitudinal ligament at the sacral promontory and appropriately tensioned the mesh. The sacral sutures were brought through the tail of the mesh and tied down. The excess tail of the mesh was trimmed and the peritoneum was reapproximated over the remaining mesh using a running 2-0 delayed absorbable barbed suture. Good hemostasis was noted.

We then performed a cystoscopic evaluation. The entire bladder was inspected in a clock-like and systematic fashion. There was no evidence of bladder injury, foreign body, or stone. Bilateral ureteral orifices were normal in appearance. Brisk ureteral jets were noted bilaterally.

We then replaced the Foley catheter and undocked the robot. The trocars were removed and the pneumoperitoneum was evacuated. Skin incisions were closed with 4-0 delayed absorbable suture.

_

Attention was then turned to the posterior repair following the injection in the perineal body and posterior vaginal wall with 1:800,000 dilute epinephrine solution. An inverted triangular incision was made along the perineal body and carried up to the posterior vaginal wall. The vaginal epithelium was dissected off the underlying endopelvic connective tissue in the midline using the Metzenbaum scissors. The excess vaginal epithelium was excised. The epithelium and underlying tissue was plicated in the midline using an 0 Vicryl. We then dissected out laterally to reach the fascia of the levator muscles at the level of the hymen. This was plicated in the midline using 0 Vicryl in an interrupted fashion. We then reapproximated the perineal body using a 0 Vicryl in an interrupted fashion. The perineal skin was then reapproximated using a 3-0 Vicryl in a running subcuticular fashion.

Sponge, lap, and needle counts were correct. The patient tolerated the procedure well and was taken to the recovery room in stable condition.

Postoperative Considerations

Patient Education

Preop

Postop

Implants & Devices

• Coloplast Restorelle® Y Mesh