LAPAROSCOPIC DA VINCI ASSISTED SACRAL COLPOPERINEOPEXY

J. Maceda, D. Hale  

Methodist Hospital, Indianapolis, IN

OBJECTIVE:  Demonstrate the feasibility of the laparoscopic Da Vinci assisted sacral colpoperineopexy.
MATERIALS AND METHODS:  This retrospective case series involves patients who underwent a laparoscopic Da Vinci (Intuitive Surgical, Sunnyvale, CA) assisted sacral colpoperineopexy from May 2003 to September 2004.  The records of 35 patients were reviewed.  Descriptive statistics were applied. The mean age was 61.3 (range 42 to 80), and mean body mass index was 25.9 (range 19.3 to 35.9). The number of patients with POPQ Stage 3 or greater prolapse of the anterior, posterior or vaginal vault compartments was 17 (48.6%), 17 (48.6%), and 13 (37.1%) respectively.  The procedure began with a vaginal rectocele repair when indicated.  The rectovaginal septum was dissected off the vaginal epithelium and the posterior cul-de-sac entered.  A 6x15 cm piece of Prolene Soft (Ethicon, Summerville, NJ) polypropylene mesh was attached to the proximal 8 cm of a Pelvicol (Bard, Murray Hill, NJ) porcine collagen graft (4x12 cm).  This was attached bilaterally to the levator fascia and to the perineal body distally.  The vaginal incision was closed, and a perineoplasty performed.  Laparoscopic lysis of adhesions was performed if necessary, and the vesicovaginal space was developed.  The presacral dissection was extended into the rectovaginal space.  The Da Vinci system was used to suture the posterior graft to the posterior vaginal wall.  A second piece of soft prolene (4x15 cm) was attached onto the anterior vaginal wall.  The grafts were sutured together, and the longer one was then attached to the anterior longitudinal ligament with permanent sutures.  The graft was retroperitonealized, and cystoscopy performed.
RESULTS:  The sacral colpoperineopexy was completed laparoscopically in 34/35 cases.  Overall mean operative time was 273.6 ± 46.6.  Mean operative time for the first ten cases and last ten cases was 301 minutes and 255.3 minutes respectively.  This included cases with some adjunctive procedures.  During 14/35 cases, significant time was spent performing adhesiolysis, and the mean time was 42.5 ± 22.3 minutes.  Average hemoglobin change was 2.8 ± 0.7 gms/dl.  The average length of hospitalization was 2.9 ± 1.4 days.  There was one major intraoperative complication that involved presacral venous bleeding and required laparotomy.  One patient presented postoperatively with vaginal discharge and a suture through the rectal wall was removed without complication.  There were no failures of the robotic technology.
CONCLUSION:  The Da Vinci robotic system can be adjunctively used to facilitate laparoscopic completion of a sacral colpoperineopexy.  The procedure is safe, and the robotic technology is reliable. This technology may allow more patients to undergo minimally invasive surgery for their pelvic organ prolapse.  Long-term outcome data and an economic analysis are needed.

Key Words:  sacral colpoperineopexy, laparoscopy, Da Vinci

Disclosure – Consultant: D Hale, Gynecare.