V269: Robotic-assisted Sacrocolpopexy: Salvage Procedure after Failed Open Sacrocolpopexy

Video

Introduction and Objectives
In this video we describe a technique for robotic sacrocolpopexy in a woman who underwent a previous open sacrocolpopexy ten years prior that failed within 3 months. Comprehensive repair of pelvic organ prolapse (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.

Methods
This patient presented with a a Grade 4 Baden/Walker POP despite a 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 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 and the new Y-mesh was fixed to the vaginal walls with a running Quill suture. The ALL was attached to the mesh with two Gore-Tex sutures and the peritoneum was closed leaving no poritons of the new mesh exposed.

Results
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 post-operative day one. The robotic repair has been durable at 9 months follow-up without any de novo incontinence.



Surgery steps:

1) Excision of the old mesh.

2) Proper Identification of the sacral promontory and the anterior longitudinal ligament (ALL).

3) Placement of two Gore-tex sutures in ALL.

4) Dissection of the anterior vaginal wall and fixation of one arm of the Y-mesh using double-armed quill suture.

5) Dissection of the posterior vaginal wall and fixation of the other arm of the Y-mesh using double-armed quill 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.

8) Closure of the peritoneum so that no mesh is left exposed and no areas are at risk for herniation.

Conclusions
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.

Funding: None