Transumbilical single port laparoscopic sacrocolpopexy using standard instruments

We describe in this video our technique of single port sacrocolpopexy using standard instruments, the 0-degree, 10mm laparoscope, and the SILS™ Port by Covidien. The procedure is performed as usual with intra- or extracorporeal knot tying and tackers. The operative time is 130 min without blood loss. We do not need to place any additional trocar or instrument. This technique is safe and reproducible by any trained surgeon.

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Transumbilical single port laparoscopic sacrocolpopexy using standard instruments

Authors

Abstract

We describe in this video our technique of single port sacrocolpopexy using standard instruments, the 0-degree, 10mm laparoscope, and the SILS™ Port by Covidien. The procedure is performed as usual with intra- or extracorporeal knot tying and tackers. The operative time is 130 min without blood loss. We do not need to place any additional trocar or instrument. This technique is safe and reproducible by any trained surgeon.

Classification

single port, contribution

Keywords

Transumbilical single port laparoscopic sacrocolpopexy, standard instruments

Media type

Surgical video

Duration

10'00''

Publication

2011-07

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E-publication

WeBSurg.com, Jul 2011;11(07).
URL: http://www.websurg.com/doi-vd01en3384.htm

Transumbilical single port laparoscopic sacrocolpopexy using standard instruments

1. Trocar placement 00'19''

We report in this video our technique on sacrocolpopexy using transumbilical single port access and standard instruments. We’ve been performing this procedure since October 2009 representing a review of 26 patients. The incision through the umbilicus is 25mm long. The access to the peritoneal cavity is easy and at direct vision. We are using the SILS™ port from Covidien. The SILS™ port is shoehorned into the previously made incision and can be easily rotated as needed. Three 5mm trocars are placed into the SILS™ port and the insufflation can begin. Then we replace one of the 5mm trocars with a reusable 10mm one. Cold light source and video connection will not interfere with the surgeon’s movements.

2. Exposure and promontory dissection 01'19''

A 0-degree, 10mm laparoscope is introduced into the 10mm trocar. We reported the first 16 cases of this first and unique series of sacrocolpopexies using standard instruments during the last congress of the French Urological Association. In our experience, the existence of a past history of pelvic surgery does not contraindicate single port procedures. We often need to hang sigmoid and uterus up on the abdominal wall for a better view. Then, we perform the sacrocolpopexy as usual and the sacral promontory is exposed. We do not use any bended or articulated specific instruments. From the promontory, the tunnel is made under the peritoneum.

3. Rectovaginal dissection 02'43''

The tail end of this tunnel is located and dissected to help introduce the meshes. The rectovaginal dissection is gently performed, a grasper in one hand for exposure, and monopolar scissors in the second. We use the zooming function of our digital camera to limit the clashing of the instruments against the laparoscope.

4. Introduction, fixation and management of the posterior mesh 03'48''

Once the levator ani has been exposed, the posterior mesh is introduced through the 10mm trocar and will be fixed using tackers. The posterior mesh is placed into the previously made tunnel. The peritoneal incision is closed to cover the mesh using running suture and intracorporeal knots. As you can see, performing intracorporeal knots is technically feasible with a single port access.

5. Anterior dissection and management of the anterior mesh 05'33''

The flat instrument is inserted into the vagina to help the dissection, and this anterior dissection does not pose any problem. We do not use any laparoscopic aspirator and the average blood loss is non-significant. There is no compromise on quality. In case of difficulty, it is very easy to convert this minimally invasive surgery into a traditional laparoscopy by inserting an additional trocar. This single port technique is safe and reproduces our exact standard laparoscopic procedure. The mesh is inserted in the peritoneal cavity through the 10mm trocar. This mesh is sutured to the anterior vaginal surface with extracorporeal knot-tying. The vaginal instrument is very helpful to present the vaginal surface to suture. Due to the lack of triangulation, intracorporeal knots are harder to perform and need specific techniques. We choose this extracorporeal solution to reduce operative time. Needles up to 23mm long pass easily through the 5mm trocar. Zooming in and out is nevertheless useful. Finally, the end of the wires is cut off. This mesh is placed in the previously made tunnel. The SILS™ port may be difficult to use in case of obese patients with BMIs over 36. The thickness of the abdominal wall is the limiting factor.

6. Fixation of the meshes to the promontory 08'00''

Here, you can see the two meshes being fixed to the sacral promontory using tackers. And now, all the peritoneal incisions are closed with tackers or running sutures and intracorporeal knots.

7. Abdominal wall and umbilical repair 09'04''

The abdominal wall is firmly repaired in very good conditions and with an excellent view. The operative time is about 130 minutes. Mean hospital stay is less than 3.5 days, and no complications during or after these procedures have been reported. The final scar is hardly visible. The transumbilical single port laparoscopic sacrocolpopexy is an important step towards a less and less invasive surgery. This technique is safe and reproducible by any trained laparoscopic surgeon. We think that minimally invasive procedures will develop in the future due to the high level of satisfaction of the patients.