Page 41 - Jourmal of World Association of Laparoscopic Surgeon

WJOLS

Laparoscopic vs Robotic-assisted Sacrocolpopexy

folded into the shape of a U and sutured to posterior cervix. DISCUSSION
Now, the suture is passed through the loop of the U or bite According to the study results tabulated (Table 1) by Jason
is taken and attached to the anterior longitudinal ligament. P Gilleran, the overall rates of success for the lap procedure
The uterus is kept elevated during this step. It is checked range from 75 to 98% with follow-up mostly around 1 year.
that the round ligaments are horizontal. This ensures the The success rates of RSC are comparable to LSC in short-
uterus is pulled up just adequate. Peritoneum is closed. term follow-up. 25
No. 1 Dacron or PTFE has high strength and is used for the The lowest time required to complete the procedure was
procedure. Drain is placed.
97 vs 186 minutes in the study. Study by Paraiso et al showed
the time taken as 199 vs 265 minutes. 26
Vault Prolapse
Suturing is aided by the robot whereas handling suturing
When the procedure is done for vault prolapse, Y-shaped in the region of sacral promontory is difficult ergonomically
mesh is not required. Instead, 2 long strips are taken. Here, and a tracker is preferred in LSC.
dissection is begun by incising the peritoneum over the Olgaraam et al say that quicker recovery time is
sacral promontory. Then anterior dissection is started. associated with minimally invasive procedures. Level III
A ribbon retractor placed in the vagina and pushed up data suggest that early outcomes of robotic sacrocolpopexy
facilitates the separation of bladder. are similar to those of open sacrocolpopexy. A single
Posterior cul-de-sac is separated on either side of the randomized trial has provided level I evidence that robotic
rectum. Pararectal dissection is carried out till the and laparoscopic approaches to sacrocolpopexy have
ischiorectal pad of fat is crossed and the levator ani is similar short-term anatomic outcomes, although operating
reached. times, postoperative pain and cost are increased with
Posteriorly, the mesh is sutured to either side of the robotics. 6
levator ani fascia and vaginal fascia. Middle of the mesh is Improved visualization and dexterity is afforded by the
sutured to the uterosacrals. The other end is sutured to the robot and may decrease learning curves associated with
anterior longitudinal ligament. Redundant mesh is cut. conventional laparoscopy, leading to broader adoption of
Anteriorly, bladder is separated and bites are taken on the minimally invasive techniques. Likewise, robotic surgery
vaginal fascia and the mesh. Then both parts are sutured has several unique limitations not encountered in laparos-
with three knots on either side with Dacron or silk. Partial copic or open surgery. Surgeons do not get haptic feedback
reperitonization is done. or sensation when operating robotically; therefore, visual
If the procedure includes a vaginal assisted hysterec- changes in tissue blanching and movement must be used to
tomy, a sagittal posterior colpotomy incision is given and compensate for tactile differences in tissues and structures.
the specimen is removed. Culdotomy is closed and further Patient satisfaction and long-term outcomes of both
surgery proceeds. robotic and laparoscopic sacrocolpopexy are insufficiently
studied. Existing studies rarely report outcomes beyond
Robotic-assisted Laparoscopic Sacrocolpopexy
1 year after prolapse surgery and are limited by retrospective
Patient is placed in lithotomy position. The shoulders are study designs, small sample sizes, inconsistent nomen-
padded and the patient is secured. clature, nonstandardized prolapse quantification, lack of
Laparoscopic instrument ports are then placed in masking, and lack of validated symptom and quality-of-
the abdomen. Veress needle is placed supraumbilically. life measures. The cost per procedure was $8.508 for robotic,
A 12 mm camera is placed following intraperitoneal $7.353 for laparoscopic, and $5.792 for open sacro-
insufflation. Two 8 mm, robotic instrument ports are placed colpopexy (Table 2).
approximately one handbreadth away from the camera port Patient selection was comparable in both the procedures
to prevent collision between robotic arms. A third 8 mm but RSC included women with more severe condition in
robotic instrument port is placed inferiorly and far to the few studies. 27,28
left to be used by the fourth arm for retraction, if needed. According to the Table 3 data we can say that robotic
A 12 mm port is placed inferiorly and on the far right near surgery offers the advantage less blood loss, fewer
the iliac crest to be used by the assistant surgeon. complications but is more expensive and takes longer.
The robot is docked between the patient’s legs or side- From Table 3 we can say that disadvantages of the robot
docking is done to facilitate vaginal manipulation. 6 include its clinical limitations, not being cost-effective at
The technique is almost similar to lap surgery. Tacker present, increased operating time and being redundant where
may or may not be needed. precise dissection is not required.
World Journal of Laparoscopic Surgery, January-April 2013;6(1):42-46 43