Robotic Sacrocolpopexy: Salvage Procedure After Failed Open Sacrocolpopexy

Abstract

Introduction: Pelvic organ prolapse (POP) affects 130,000 women annually, and this number is likely to rise as our population increases in age. Approximately 11% of women will undergo a surgical procedure for the treatment POP or urinary incontinence by the age of 80.1 Surgical procedures for repair of POP have varied from transvaginal approaches to transabdominal and from addressing a single compartment to addressing a comprehensive repair at one time. In this video, we describe a technique for robotic sacrocolpopexy in a woman who underwent a previous open sacrocolpopexy 10 years earlier that failed within 3 months. Comprehensive repair of POP through open sacrocolpopexy has a high success rate, but as this case demonstrates, without proper identification of anatomical landmarks such as the anterior longitudinal ligament (ALL) and appropriate dissection of the anterior and posterior vaginal walls, the procedure will fail. Materials and Methods: This patient presented with a POP-Q stage IV prolapse having failed prior open sacrocolpopexy. A da-Vinci S robot was used with side port docking, one right arm and two left arms and one assistant port. Robotic instruments included the monopolar cutting scissors (right arm), plasma kinetic dissecting forceps (left arm), and prograsp instrument (left arm). The mesh from the previous procedure was completely excised. An assistant grasper and end-to-end anastomosis (EEA) sizer are utilized throughout the case. Surgery steps are as follows: (1) excision of the old mesh; (2) proper identification of the sacral promontory and dissection of the ALL; (3) placement of two individual Gore-tex sutures in ALL; (4) dissection of the anterior vaginal wall and fixation of one arm of the Y-mesh using double-armed 0 polydiaxanone monofilament synthetic absorbable knotless tissue-closure suture (14×14 cm); (5) dissection of the posterior vaginal wall and fixation of the other arm of the Y-mesh using double-armed 0 polydiaxanone monofilament synthetic absorbable knotless tissue-closure suture; (6) the posterior portion of the Y-mesh is pulled to the sacrum and cut to the appropriate tension; (7) anchoring of the mesh to the ALL; and (8) closure of the peritoneum so that no mesh is left exposed and no areas are at risk for herniation. Results and Conclusions: Total robotic console time for this procedure was 123 minutes and the patient had complete reduction of prolapse. The Foley catheter was removed within 12 hours and the patient was discharged home on postoperative day one. The robotic repair has been durable at 9 months follow-up without any de novo incontinence. Robotic sacrocolpopexy is a highly reliable treatment for women with POP, providing a comprehensive repair of POP with precision, durability, and less morbidity than the open procedure. This video demonstrates the importance of proper identification of anatomical landmarks and shows the steps required for successfully salvaging previous failed surgeries for POP. No conflicts of interest. Run time: 7 mins 42 secs