V270: Knot-LESS Sacrocolpopexy: A novel technique for Laparoendoscopic Single Site Sacrocolpopexy.

Video

Introduction and Objectives
The main limitation of laparoendoscopic single site surgery (LESS) is the lack of triangulation, with limited surgical space between the surgeon and assistant. This may complicate the intracorporeal knot in reconstructive surgery, like the LESS sacrocolpopexy (LESS-S) for pelvic organ prolapse (POP). Here we introduce a new technique with Hem-o-lock that may facilitate the learning curve, may improve operative time and avoid the intracorporeal laparoscopic knot during LESS-S. 6 surgical steps are described in this video.

Methods
A fifty nine year old female presented with POP Stage III, including an apical and posterior defect. She showed no evidence of clinical or occult stress urinary incontinence (SUI), and underwent LESS-S. We used a GelPoint (Applied Medical, Rancho Santa Margarita, CA) that was positioned through a 3-cm umbilical incision. For vision, we used a 5-mm Olympus endoscope, EndoEye-Flex with a bariatric laparoscopic scissor (this improves the surgical space between the surgeon and assistant.) We used 10-mm Hem-o-lock clip appliers (Teleflex Medical, Research Triangle Park, NC) to secure the non-absorbable suture to the vagina and mesh. This allows us to avoid the intracorporeal knot. We used Polyform mesh (Boston Scientific, One Boston Scientific Place, MA), 3cm wide and 9cm long, one posterior mesh. We fixed the mesh to the sacrum promontory with a 5mm Pro-Tack, Non-absorbable (Covidien, New Haven, CT.) We closed the peritoneum with a 2-0 Vicryl and this is secured with the Hem-o-Lock clips to avoid an intracoporeal knot. At the end we did a cystoscopy to evaluate the right ureteral efflux and we placed a vaginal pack for 24 hrs.

Results
The LESS-S was performed. Total operative time was 210 minutes, with a blood loss of 100mL. The patient experienced no intraoperative or postoperative complications. She went home on post-operative day two. We were able to correct the POP Stage III with one posterior mesh to the sacrum promontory. She is six months post-op and no evidence of recurrence, erosions or SUI. She is sexually active and denies dyspareunia.

Conclusions
This Knot-LESS technique using Hem-o-Lock clips allowed us to improve our operative time, and may overcome the difficult learning curve of LESS intracoporeal knot in reconstructive pelvic surgery.

Funding: None