Sacrocolpopexy

The current gold standard treatment for posthysterectomy vaginal vault prolapse is abdominal sacrocolpopexy. This technique involves suspending the vaginal vault anteriorly, posteriorly, or by closing the levator hiatus by an abdominoperineal approach. These open procedures are associated with significant morbidity and extended hospital stays. A vaginal approach was developed in an attempt to decrease morbidity associated with sacrocolpopexy; however, the success rates are consistently less than the abdominal technique (24). Laparoscopic sacrocolpopexy was developed to mimic the open procedure while decreasing the accompanying morbidity. Unfortunately, these procedures have been performed with significant difficulty and lengthy operating times, especially early in the learning curve (25). DiMarco et al. reported the first series of five robot-assisted laparoscopic sacro-colpopexies (24). The attempt was to reap the minimal invasive benefits of laparo-scopic sacrocolpopexy while simplifying the procedure and decreasing operating room time.

Robotic sacrocolpopexy is indicated for vaginal vault prolapse after hysterectomy. Currently, the procedure has only been performed in grade 3-4 apical prolapse and grade 2-4 anterior prolapse. The preferred patient has had no or minimal prior abdominal surgeries. A transperitoneal approach is utilized after placement of five laparoscopic ports (Fig. 2). Robotic sacrocolpopexy follows similar operative steps as those performed with laparoscopic sacrocolpopexy (25). Retraction of the sigmoid colon and a steep Trendelenburg position provide exposure of the sacral promontory and vagina. Using the Cadiere forceps and the hook electrocautery, the anterior vagina is dissected from the bladder. A customized vaginal retractor aids in dissection (24). Next, the peritoneal reflection is incised posteriorly to further mobilize the

FIGURE 2 ■ Port placement for robotic-assisted sacrocolpopexy. The 12-mm port for the camera is placed at the umbilicus. A 12-mm assistant port is placed sub-costally lateral to the rectus and a 5-mm assistant port is placed one handbreadth inferior-laterally. The 8-mm robotic ports are placed lateral to the rectus two finger-breadths superior to the iliac crest.

FIGURE 2 ■ Port placement for robotic-assisted sacrocolpopexy. The 12-mm port for the camera is placed at the umbilicus. A 12-mm assistant port is placed sub-costally lateral to the rectus and a 5-mm assistant port is placed one handbreadth inferior-laterally. The 8-mm robotic ports are placed lateral to the rectus two finger-breadths superior to the iliac crest.

vagina. Anterior and posterior dissection is then carried out distally toward the introi-tus. The sacral promontory is now exposed by incision of the posterior peritoneum. Care should be taken to avoid injury to the sacral veins. A Silastic Y-graft is brought into the abdomen through a 10 mm port. Using the da Vinci robot system, the graft is sutured to the posterior vagina and then the anterior vagina using 1.0 Gore-Tex suture. The use of a 30° lens maximizes visualization. The tail of the graft is then sutured to the sacral promontory. There should be minimal tension on the vagina. The ureterosacral ligaments are then plicated and the posterior peritoneum closed over the graft.

In the initial series of five patients, DiMarco et al. reported an average operating time of 225 minutes. Hospital stay was 24 hours for all patients and none had recurrent prolapse at four-month follow-up (24). One complication of persistent vaginal bleeding was reported; however, this was attributed to a concurrently performed pubovaginal sling. While the technique of robotic sacrocolpopexy is now standardized, additional clinical experience is needed to fully understand the indications and limitations of the technique. This procedure is still in its infancy and as of yet long-term results are not available. Nonetheless, initial results have shown promise for robotic sacrocolpopexy and the technique appears to have important clinical implications in the future.

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