Task Analysis Of Sacrohysteropexy

1. After giving general anesthesia to pt, position her in a lithotomy position with head 30˚ down.
2. Cleaning, painting, and draping of the abdomen and vagina should be done.
3. Bladder to be catheterized.
4. The surgeon should stand on the left-hand side of pt, one assistant at the right-hand side and one assistant at the vaginal end.
5. Give a 2mm stab incision on the infra-umbilical crease after lifting it up on either side by Alli’s forceps.
6. Insert the Veress needle through the incision and appreciate two clicks.
7. Confirm intra-abdominal position by injecting 5ml of NS through the needle, suctioning the air out and by hanging drop test.
8. Insufflate the abdomen with gas up to 12-15mm Hg of pressure.
9. Pull the needle out and enlarge the 2mm incision to 10mm.
10. Insert a 10mm trocar and cannula with guarded screwing movements and enter the abdomen.
11. Remove the trocar and insert the telescope after having white balance and focus checked.
12. Under vision insert one 10mm and one 5mm on contralateral sides, each 7.5cm away from the umbilical port (making use of Baseball Diamond concept).
13. One supra-pubic port to be inserted parallel to optical port at least 5cm above the upper border of the pubic symphysis.
14. Take a 15× 3 cm polypropylene mesh, pleat it and introduce it through 10mm cannula without the reducer.
15. Unfold the mesh with grasper and Maryland in the abdomen.
16. The vaginal assistant should insert a uterine manipulator with colpomotizer and lift the uterus to an acute anteverted position at 12’o clock position.
17. Take a nonabsorbable suture (silk/Dacron no 1) and take a bite on the vaginal part of one uterosacral ligament, passing the needle from out to in.
18. Care should be taken of not taking the cervical canal or vagina into the bite. 
19. Ask the assistant to hold one end of the mesh. Pass the needle from one corner of the mesh.
20. Tie a knot (square or Weston knot). The square knot is pushed with the help of Clarke’s knot pusher and 3-4 knots are taken in a square knot. Cut the suture.
21. Repeat the procedure on other side uterosacral ligaments.
22. Ask the assistant to hold the free end of mesh against the posterior surface of the uterus.
23. Take a bite 2cm above the previous 2 knots through the mesh and seromuscular layer of the uterus, come out through the mesh and tie an intracorporeal surgeon’s knot and cut.
24. Take another bite in a similar fashion 2cm above the previous knot.
25. The knots should be placed in uterosacral ligaments, isthmus, and the corpus of the uterus in chronological order (it should not reach the fundus of the uterus).
26. Now move the bowel up.
27. Stretch the peritoneum over the sacral promontory, to the right of the rectum, pull and cut it, using harmonic or monopolar scissors.
28. Do the blunt dissection and let the air enter the retroperitoneum space.
29. Keep cutting the peritoneum until 2cm below the fimbrial end of the tube on the right side.
30. Blunt dissection is to be done and separate the areolar tissue.
31. Expose the anterior longitudinal ligament over sacral promontory which is shiny and pearly white in color.
32. Be careful of median sacral vessels medially (towards left).
33. Ask the assistant to push the uterus inside the abdomen so that the cervix is at least 9cm from the introitus.
34. Place the mesh over the anterior longitudinal ligament.
35. Using contralateral or suprapubic port either fire a tacker (Protack) or take a bite and tie a square knot. Be careful of slipping off the tacker or breaking the needle at this point.
36. Usually, one tacker or a bite should suffice.
37. Trim the extra mesh.
38. Carefully insert the mesh into the peritoneal tunnel.
39. Approximate the cut end of peritoneum on right and cut end of mesorectum on the left side with vicryl no 1, using Dundee jamming knot, continuous suture, and Aberdeen termination, and close the peritoneal tunnel, so that mesh is now in retroperitoneum.
40. Inspect the whole abdomen.
41. Remove the uterine manipulator.
42. Remove the 5mm ports under vision. 
43. Port closure of 10mm ports to be done by Veress’ or Cobbler’s needle.
44. Remove the optical port after having a final look at the port exit.
45. Dressing of the wound to be done.