(Video Poster 02) Optimizing Efficiency in Robotic Sacrocolpopexy: Tips and Techniques

Objectives: To present intraoperative techniques that streamline SCP by improving visualization, access, retraction, and closure while maintaining sterility and minimizing operative delays.

Methods: Entry: Palmer’s point entry facilitates safe access in all patients, not just those with suspected adhesions. Ports and Pneumoperitoneum Optimization: Use 5 mm specimen bags and robotic trocars in all ports to enable port hopping. An adapter on an 8 mm robotic trocar supports low-pressure insufflation and multi-port functionality. Camera: Placing the camera port in the midline just below the umbilicus improves sacral access and simplifies robotic fascial closure. Vaginal Manipulation: Use of a mounted vaginal manipulator provides controlled exposure of the vaginal apex, anterior and posterior vaginal walls. Double-draping improves efficiency by minimizing re-gloving and maintaining sterility when transitioning between the console and vaginal access. Rectosigmoid Decompression: Temporary decompression using a bulb syringe or a 36 Fr Foley catheter inserted into the rectum facilitates safer posterior exposure. Redundant Bladder Retraction: Retracting the bladder with a Keith needle into the suprapubic abdominal wall can enhance visualization of anterior dissection planes and free up an instrument or your assistant. Retrograde filling the bladder with air: To help delineate planes, a 30cc syringe can be used to instill air through the catheter into the bladder. Bowel Retraction: Large bowel is retracted using a Keith needle through the abdominal wall. Small bowel manipulation and retraction: The small bowel is flipped against its mesentery. Once it is laying fanned out, it is retracted and kept in place using 4X4 sponges passed through the assistant port early in the case while the bowel is still moist from the peritoneal fluid. Peritoneal Closure Efficiency: Begin closing the peritoneum before sacral tacking to allow access to the distal most parts of the cul de sac that would be inaccessible after the mesh is tacked. Mesh Trimming Strategy: For vaginal cuff suspension, trim mesh to 6 cm anteriorly and 8 cm posteriorly; for cervix-preserving SCP, trim to 7 cm anteriorly and 9 cm posteriorly to account for the cervix. Robotic Fascial closure: This can be done robotically at the end of the case due to optimized initial port placement. Cystoscopy Visualization: Administering phenazopyridine preoperatively enhances ureteral orifice identification during cystoscopy.

Clinical Relevance: These practical techniques, refined through high-volume robotic SCP experience, can significantly improve procedural efficiency, enhance safety, and optimize surgical outcomes.