Robotic Sacrocolpopexy
Counseling
Technique
- Place patient in dorsal lithotomy position, prep/drape abdomen and genitals, give cefazolin or culture-specific antibiotics
- Insufflate abdomen and place ports in transverse line at level of umbilicus: midline camera, R/L hand, 4th arm on L side, assist port on R side
- Dock robot, place bipolar in L arm, scissors in R arm, prograsp in 4th arm
- Examine pelvis, place silk traction stitch on bowel if needed to keep out of pelvis, perform hysterectomy if needed
- Identify sacral promontory, incise peritoneum in midline over sacrum avoiding aorta and iliacs, cut down until longitudinal ligament is identified
- Track incision distally towards vagina, stay medial to ureter (usually safe to travel along uterosacral ligament)
- Place blade/spacer in vagina and push into abdomen, then dissect anterior peritoneum off vagina, taking care not to enter bladder or vagina, ensure adequate space for mesh
- Track posterior incision approx 1 instrument length distal to vaginal apex on posterior side, then connect incision with uterosacral incision, widen posterior space without entering vagina or rectum
- Insert mesh, start with anterior vaginal portion, place 2-0 PDS interrupted stitches x6-8 to anchor mesh, ensure it is anchored distally, then perform the same on posterior side
- Adequately tension mesh (usually halfway between maximum tension and fully relaxed), then place 2-0 prolene x2 anchoring mesh to sacral ligament
- Close sacral incision with 2-0 vicryl with hemolok clip on the end, place new clip at the end and tie to anchor
- Place another vicryl stitch in purse-string fashion to close peritoneum over the mesh
- Remove instruments/robot, close ports, place vaginal packing