Robotic Vaginal Prolapse Repair

Robotic da Vinci Sacrocolpopexy for Uterine or Vaginal Vault Prolapse

120,000+ cases of uterine and vaginal vault prolapse are surgically treated each year in the U.S. Prolapse (or falling) of any pelvic floor organ (vagina, uterus, bladder or rectum) occurs when the connective tissues or muscles within the body cavity are weak and unable to hold the pelvis in its natural orientation.

The weakening of connective tissues accelerates with age, after child birth, with weight gain and strenuous physical labor. Women experiencing pelvic organ prolapse typically have problems with urinary incontinence, vaginal ulceration, sexual dysfunction and/or having a bowel movement.

Figure 1 shows the vaginal apex (top) falling out of the vaginal opening. The view is from the side like a banana in a banana split. The bladder is in front, the vagina is falling out in the middle and the rectum is in the rear. The backbone is seen in the far right.

Treatment withh da Vinci® Sacrocolpopexy

Dr. Owens recommends sacrocolpopexy, you may be a candidate for a new surgical procedure called da Vinci Sacrocolpopexy. This procedure uses a state-of-the-art surgical system designed to help your surgeon perform a minimally invasive surgery through small incisions.

Operating Room Configuration

The robot consists of a main unit with four arms (a camera and three operating arms), and a surgeon’s console. The robot arms articulate like the human wrist and are controlled by the surgeon at the console. With 3-D optics, the surgeon is virtually inside the patient while the OR crew watches on video monitors in the room. There is a surgical assistant to pass and retrieve items from the surgical field, a scrub nurse to pass instruments, and anesthesia to monitor you during the case.

Sacrocolpopexy is a procedure to surgically correct vaginal vault prolapse where mesh is used to hold the vagina in the correct anatomical position. The term literally means lift the vagina to the pelvic bone (sacro-the portion of the back bone in the pelvis, colpos- vagina, pex-to suspend or lift up). This procedure can also be performed along with a hysterectomy to treat uterine prolapse to provide long-term support of the vagina. Long-term cure rates are about 90% as this procedure provides complete support to the vagina, especially to the top/front of the vagina that is the area most likely to prolapse. For more information click here.

Figure 2 shows the completed sacrocolpopexy. The mesh supports the anterior apex of the vagina (weakest part of the vaginal support), as well as the posterior (back) vagina. The mesh essentially places the vagina on a leash such that it can only fall as far as the tether allows. The bladder sits on the anterior (front) mesh while the rectum gets support from the posterior (back) mesh.

For most women, da Vinci Sacrocolpopexy offers numerous potential benefits over a traditional open approach:

Significantly less pain
Less blood loss and need for transfusions
Less risk of infection
Less scarring
Shorter hospital stay
Shorter recovery time
Quicker return to normal activities

As with any surgery, these benefits cannot be guaranteed, as surgery is patient- and procedure- specific.

Sacrocolpopexy has traditionally been performed as an open surgery. A 6-12 inch horizontal incision is made in the lower abdomen in order to manually access the inter-abdominal organs, including the uterus. Robotic surgery is carried out through five small incisions and the robot learns where it is in space so that the abdominal wall is not tugged on during the case. This allows for much less soreness after surgery. Most ladies in the practice go home the next day after an overnight stay in the hospital.

Surgery Details

After placing the instruments into the abdomen, a form is placed into the vagina to help identify organs and aid with dissection. In this case, the patient has already had a hysterectomy some time in the past and the vaginal cuff is seen. The first step is to separate the bladder from the vagina.

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Warning:

Images in this section are of a graphic nature and include surgery and actual surgery photos. If you are under 18 years old (or 21 in some countries or regions) and/or if it is illegal in your community to view these photos, do not continue. Continuing further means that you accept full responsibility for your actions, and release Advanced Pelvic Surgery from any and all liability.

This view is as you are looking down at yourself. The abdominal wall is at the top of the screen. Right is right and left is left. The bladder is in the left grasper and the form is in the vagina at the bottom of the picture. The scissors are used for the dissection.
We are looking down at the backbone where it fuses with the pelvis. The presacral space is cleared to expose the fixation site. The peritoneum (thin filmy covering of the abdomen and organs) is opened from the sacrum down to the vagina. This will be used to cover the mesh after the colpopexy is completed.
The mesh is then sewn to the anterior (front) vagina. The vagina is distended with the form to help with suturing. The bladder then sits on the mesh, which prevents it from falling
The mesh is then attached to the posterior (back) side of the vagina. This prevents the rectum from falling through the vagina.
Tension in the mesh is adjusted to make sure everything is properly lifted. The instruments are holding the mesh at the sacrum that was previously cleared.
The mesh is then attached to the sacrum with permanent sutures. The sutures are passed not into the bone itself, but into the anterior longitudinal ligament. Think of it as the tough inner bark of a tree.
The peritoneum is closed over the mesh to prevent bowel from slipping under and getting obstructed. The mesh tether is in the center of the screen and the vagina has been covered with peritoneum.