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Robotic-assisted Laparoscopic Sacropcolpopexy
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Robotic-Assisted Sacrocolpopexy
Patrick Culligan, MD, FACOG, FACS Director Atlantic Health Division of Urogynecology & Reconstructive Pelvic Surgery
Professor of Obstetrics Gynecology & Reproductive Science Mount Sinai School of Medicine
Key Components of Sacrocolpopexy
Sacrocolpopexy - History
Sacral Colpopexy first described by Lane in 1962
“Modern Version” described and refined by Addison in the 1980’s and 1990’s
Dubbed the “main abdominal approach to prolapse surgery” in a systematic review article 2004 (Nygaard et al)
That status solidified by a Cochrane review in 2005 (Maher et al)
“Tried & True”
3 studies including greater than 200 patients & long-term follow-up: Sullivan et al Dis Colon Rectum 2001. Culligan et al. Am J Obstet Gynecol 2002. Lindeque et al. S Afr Med J 2002.
Objective Anatomic Success Rates
85 – 100%
PATIENT SELECTION
My progression to robotic surgery
Does the patient have a uterus?
YES vaginal hysterectomy +
additional vaginal procedures
NO OPEN Sacrocolpopexy
2002 – switched to laparoscopic Sacrocolpopexy
2005 First daVinci Sacrocolpopexy
Now I frequently combine supracervical hyst and daVinci sacrocolpopexy
My Current Approach to Prolapse Surgery
What is the age and activity level of the patient?
“Younger” “Very Active”
“Older” “Less Active”
Laparoscopic Sacral Colpopexy (+ / - supracervical hyst)
Vaginal Mesh Placement
(probably no hysterectomy)
Severe Uterovaginal Prolapse (before and after robotic sacrocolpopexy)
45 year old
G2 P2 Athletic Very active (physically , sexually, etc…)
But.... Should this patient have a laparoscopic surgery?
78 year old
G5 P5
Significant co-morbidities
Not sexually active
Patient Positioning: # 3 arm comes in from patient’s LEFT
Patient’s Skin Directly Against “Megadyne” Gel
Pad
Shoulder Pads
Use side-docking when patient does NOT have a uterus
Port Placement - always the same...
Camera port - 12mm long bladed disposable Assistant port - 11 or 12 mm disposable (“Excel”) - size depends on whether you need to morcellate 4th arm port - WAY lateral and WAY high (a few cm lower than costal margin)
Instrumentation
Monopolar shears Maryland Bipolar SutureCut
Large Needle Driver
PK Dissector
Tenaculum ProGrasp
Comparison of Type-1 Polypropylene Mesh Products
Brand Name Pore Size (mm) Density (g/m2) Thickness (mm)
Alyte Y-mesh (CR Bard)
2.8 x x1.3 17.67 0.29
Restorelle Y (Coloplast)
1.8 x 1.8 18.96 0.31
IntePro Y-graft (AMS)
1.6 x 2.1 52.4 0.53
Gynemesh (Ethicon)
2.5 x 1.7 42.38 0.42
Polyform (Boston Scientific)
1.8 x 1.5 40.19 0.16
Novasilk (Coloplast)
1.5 x 1.7 18.66 0.25
SACROCOLPOPEXY steps of the procedure
First Steps
Supracervical Hysterectomy Why supracervical as opposed to TOTAL hyst...?? Probably decreases incidence of mesh erosion Cuts down or eliminates need for vaginal instrumentation
Anterior Dissection No Vaginal Instrumentation
Key Aspects: Have a specific goal in mind for each patient Create “fingers” by pushing most of tissue Use small amount of cautery when cutting these fingers
Posterior Dissection - No vaginal or rectal instrumentation
Key Points: Get in “the room” Have a specific “length goal” in mind Keep scope right on top of the action Maintain traction / counter-traction with each move
Posterior Dissection off to a bad start
Suggested Vaginal Instrumentation
Lucite Dilators available from: Progressive Medical Instruments, Louisville, KY (800) 775-7644
If there is no uterus / cervix to grab... Lucite Probe helps Side-docking helps
If there is no uterus... Try to leave “dome” of peritoneum intact at apex....
Doing so may cut down mesh erosion risk
Long, Wide Briesky retractor helps with posterior dissection
Vasculature in Pre-Sacral Space
Middle Sacrals: Standard Hemostatic Measures Work Well
Lateral Sacral Plexus Be Afraid !
Sacral Dissection Find “window of opportunity” at promontory Dissect at least 1/2 way down paracolic gutter Use minimal cautery Usually no need to cauterize middle sacral vessels.
More Sacral Dissection
Sacral Bleeding
Sacral Bleeding
Similar case...better result
Mesh Placement
Plan specific lengths of the mesh - i.e. have a goal in mind
When using Y-Mesh, place a loose suture to fold anterior portion back out of your way
Start with Posterior mesh
In the Posterior compartment - It’s helpful to place sutures BETWEEN mesh and vaginal tissue – working your way from the perineum to the vaginal apex
Mesh Preparation
Posterior Mesh Placement
Anterior Mesh Placement
Peritoneal Closure: Step 1...Purse string
Sacral Suturing Key Aspects: You only need to expose enough of the ligament to allow suture placement Usually minimal cautery needed Usually no need to change from zero degree to 30 degree scope
Mesh Tensioning / Sacral Suturing
When setting mesh tension at the sacrum: No substitute for experienced hand Either you or your assistant should place hand in vagina
during tensioning step Goal - normal vaginal axis...not too tight...not too loose
Peritoneal Closure: Step 2 - paracolic gutter to sacrum (after sacral suturing)
Tricky Situations
Prior Abdominoplasty
Lung or Heart Disease
Prior abdominal prolapse repair
High BMI
Very small women
OUR RESULTS
A Double-Blind Randomized Trial Comparing Porcine Dermis & Polypropylene Mesh for
Laparoscopic Sacrocolpopexy
OBJECTIVE To compare objective and subjective outcomes ≥ 12 months after laparoscopic sacrocolpopexy using organic or synthetic graft material
Methods
Randomization on the day of surgery
Surgery = Laparoscopic Sacrocolpopexy
Approximately 80% were robotic
All outcome measures collected by one research nurse
PATIENTS & RESEARCH NURSE were blinded as to their graft material throughout the study period
Definitions of Cure
“POP-Q Cure” (both criteria required) All POP-Q points ≤ Stage 1 Point C -5 or better
“Clinical Cure” (all 3 criteria required) All POP-Q points < ZERO Point C -5 or better NO POP symptoms on PFDI / PFIQ
Sample Size Calculation Based on “POP-Q Cure”
(aka NIH definition)
Culligan et al 2004
Randomized trial comparing cadaver fascia lata and synthetic mesh for OPEN sacrocolpopexy
91% “cure” for mesh versus 68% “cure” for fascia lata (23% difference)
With 57 patients per group we had 90% power to detect a difference of 23% (α = 0.05)
Enrollment period 2005 - 2008 Patients eligible for study
N = 184
Patients declined enrollment N = 64
Patients randomized to receive either organic or synthetic mesh N = 120
Organic Group N = 57
Synthetic Group N = 62
Lost to follow-up N = 0
Lost to follow-up N = 4
One patient converted to vaginal case on OR table (organic group)
Completing 12 month trial N = 57 (organic)
Completing 12 month trial N = 58 (synthetic)
12 Month “POP-Q Cure” (i.e. stage 0 or 1)
Porcine Dermis 80.4%
Synthetic Mesh 84.1%
p = 0.29
No Apical Failures
12 month “Clinical Cure”
Porcine Dermis 84.2%
Synthetic Mesh 84%
p = 0.96
No Apical Failures
Point C over time (pre-op to 12 months)
Point Aa over time (pre-op to 12 months)
Point Bp over time (pre-op to 12 months)
Single-Arm Cohort Study
120 patients Robotic Sacrocolpopexy using Restorelle Y-Mesh
Perioperative details (120 patients)
Mean operative time 140 minutes (range 80-225)
Defined as incision time to removal of trocars
Mean EBL 49 mL (range 5 - 300 mL)
No conversions to laparotomy
One cystotomy ; No Rectal Injuries
No Erosions
No Transfusions
All patients discharged on POD # 1
“POP-Q Cure” 89% (i.e. stage 0 or 1)
“Clinical Cure” 95%
No Apical Failures
Text
Cure Rates at 12 Months
Current Study (150 patients) Alyte Y-Mesh (CR Bard)
Our
Interesting Situations
Patient with prior (failed) anterior vaginal mesh “kit”
“Gap Failure” (prior mesh kit)