Good evening and welcome to today's webinar. I'm Dr. Christina Lewicki-Gaup and I'll be moderating today's webinar. Before we begin, I want to share that we will take questions at the end of the webinar, but you can submit them at any time by typing them into the question box on the left-hand side of the event window. So today's webinar is titled, Laparoscopic Sacral Copal Plexus Tips and Tricks, and we have the pleasure and the honor of having Dr. Peter Rosenblatt here with us. Since 1995, Dr. Rosenblatt has been the director of urogynecology and reconstructive surgery at Mount Auburn Hospital in Cambridge and actually started the FPMRS fellowship there in 1999. He's an assistant professor of OB-GYN at Harvard Medical School and is board certified in both OB-GYN as well as FPMRS. He has an active clinical practice and specializes in laparoscopic reconstructive pelvic surgery and minimally invasive treatments for pelvic organ prolapse as well as for urinary and fecal incontinence. He has served on the board of directors of the American Urogynecologic Society and is the current president of the Society of Gynecologic Surgeons. So, Peter, on behalf of Gary Sutkin, myself, and the rest of the educational committee, we thank you again and take it away. All right, Christina, thank you so much, and I appreciate the invitation to do this webinar this evening. I'm very excited to present tips and tricks of laparoscopic sacrocobalpexy. I'll be mentioning, I'll be talking mostly about straight stick sacrocobalpexy, although there are a few references to robotic sacrocobalpexy as well, but primarily I do want to talk about straight stick sacrocobalpexy. So these are my disclosures. And just to discuss the learning objectives for today, I want to start out by discussing how we evaluate patients preoperatively and discuss the different types of sacrocobalpexy that might be required for different clinical situations. It seems that one of the more difficult pain points that people have is exposing the sacral promontory, especially in obese patients, and I do want to discuss some different ways that we might use different techniques to expose the sacrum in a very safe and efficient manner. Then, you know, probably the thing that takes the most time in any kind of sacrocobalpexy is the suturing, and I do want to talk about ways to improve that efficiency and safety of both suturing and knot tying. The hot topic in the last couple of years has been whether we should do uterine sparing sacrohistropexy. So I do want to discuss a few techniques that have been employed, and you'll be hearing about that, I think, more in the future. So to move on and talk about vaginal prolapse, there are a lot of papers out there, but it has been shown that sacrocobalpexy really is considered still the gold standard, and this was a quote from Chris Mars as lead author of the Cochrane Database in 2016, that sacrocobalpexy is associated with a lower risk of awareness of prolapse, recurrent prolapse on exam, repeat surgery for prolapse, postoperative stress incontinence and dyspareunia, than a variety of vaginal interventions, and by vaginal interventions, he was really talking about uterus sacral ligament suspension and sacral spinous fixation. This is one of the studies by Nygaard and others that is often quoted, came out a couple of years ago in JAMA, and this was a follow-up of the CARE trial. As you know, CARE trial looked at copalpexy and efforts to reduce stress incontinence, either with a BIRCWH or without a BIRCWH procedure, but the long-term outcome, they followed both pelvic organ prolapse and incontinence failure, and what they found is that over time, those rates gradually increased, although there was a low re-operation rate. The other thing which raised a lot of eyebrows was that if you looked out at seven years, the mesh erosion, but that really was referring to exposure, exposure in the vagina rate, was over 10%, which is really, really high, and I think a number of people look at this that, you know, these are the types of rates that are even higher than transvaginal mesh procedures, and so that did raise a lot of eyebrows. Looking at this next chart, this showed the entomic cess over time, over seven years, did decrease kind of significantly, and so did symptomatic success. The counterargument or rebuttal to this, especially with the mesh exposure, was that these were done mostly open, and they used a variety of different meshes, including Gore-Tex and heavier weight polypropylene that may not be really relevant today. This is a study that just came out by Culligan. It was just published in the most recent journal of FPMRS, and it was a large study, a prospective study of consecutive patients, over 300 patients, and they defined success as meeting all of these criteria, no retreatment for the prolapse, no prolapse beyond the hymen, you couldn't have any apical descent below minus five, and the patient couldn't have any prolapse symptoms. What they found was that of the 316 patients, consecutive patients, 253 or 80 percent of them did come back for an exam and subjective assessment after five years, and the success rate, which we saw with the definition of before, was 89 percent, with absolutely no apical failures. 4.4 percent did meet the criteria for objective and subjective failure, and there were 16 women who were considered failures, but strictly by subjective criteria. In other words, on examination, they did not have prolapse beyond the hymen. Their apex was well-supported, but they had a subjective feeling of a bulge. So, in general, and only a very small percentage of the women, 4 percent elected to undergo any subsequent prolapse repair, and these anterior and posterior repairs were native tissue repairs. I think very importantly, though, is that there was not one mesh-related complication. There were no mesh erosions and no mesh exposures, and that is with now the new lightweight meshes that are available. So, if we go on and look at the selection criteria, I want to talk about two things. One is vaginal vault prolapse, which is the classic sacrocopalpexy, and then uterine prolapse as well. And what we can do with vaginal vault prolapse is basically reassign, I'll tell you what I mean by this, the vaginal apex, and you can also address, I believe, perineal descent very effectively, and we'll talk about the uterine prolapse in a minute. So, this is a diagram from an online website called Pelvic Floor Institute, and it shows a complete vaginal vault prolapse, and the star I put at where the apex is. Now, if you were to push this in with a probe, the apex, where the star is, is exactly at the top of the vagina, and so when you put mesh down in this area, you see that this is the classic sacrocopalpexy, and the sacrocopalpexy restores the vaginal apex in this situation. What happens, though, if we now look at a situation where this is mostly vaginal vault, sorry, anterior wall prolapse, and the star is where the cuff would be. If we replace this patient, you can see that the star is located where the apex, or the vaginal cuff, is located on the posterior vaginal wall. It doesn't really affect, though, where we put our mesh, so we are reassigning where the vaginal apex is by dissecting the bladder off the vagina and then putting the mesh on the front and back, so where the apex is doesn't matter. Now, if we were to now do this in a situation like this, a patient, as you can see, when this patient bears down, she has significant perineal descent. It almost looks like she is crowning. I don't know if you can see that. Now, that patient, if we did a classic sacrocopalpexy, as shown in the next slide, we may not prevent that perineal bulging from taking place. So in these patients, and if you look carefully as I advance it, you'll see that now there's an extension of the mesh, the single piece of mesh, though, all the way to the perineal body. Now, many people who first look at this go, oh, that sounds dangerous, I don't know if I can get all the way down to the perineal body. I can tell you with straight stick laparoscopy, and I had one of these cases today, it's a lot closer than you think. Once you enter the posterior rectovaginal space, you can, if you're doing straight stick, put your finger on the perineal body and bring an instrument, a blunt instrument, and touch it, and you'll see that it's very, very close. So it is not a difficult dissection to get down to the perineal body. What about uterine prolapse? We have a couple of different options, and we have to think about, because we can't really reassign the apex as much, so we have to think about how much anterior and or posterior descent do we have. So one thing you can do is you can reduce the prolapse by pushing in, having the patient bow salvo, and seeing which comes down more. If you have complete resolution of all the compartments, to me, that would be a perfect patient for a hysteropexy, not doing any hysterectomy, but just re-supporting the apex, which would be the uterus. If you support the cervix and you still have a ballooning anterior wall segment, then you might consider an LSH, supracervical hysterectomy, and sacroscervical pexy with preferential attachment of the anterior wall, or some people would use two separate meshes rather than a Y-shaped mesh, and the opposite is true for a ballooning posterior segment. You could perform a posterior repair, certainly, but you could also use two separate meshes and do an adjustment, also with LSH as well. So here's a good demonstration. I had a patient like this and pushed up the apex and everything disappeared. This patient was a very good candidate, I thought, for a hysteropexy, and I'll show you later on in this presentation how that patient did. So now we have the situation where you have an LSH was just performed. We're looking at the cervical stump, and she has some sort of equal prolapse of both the anterior and posterior vaginal walls, and we put a Y-mesh on this patient. It supports everything very well. But I do want to call your attention to this situation where you have a ballooning anterior wall segment where you have a ballooning anterior wall segment and maybe not as much prolapse. This is the best drawing that I could show that would show this. If you don't do anything, if you did the same operation, dissect the bladder down and lift up with the mesh, you will get an unsatisfactory support, especially to the anterior vaginal wall. It will be lined with mesh, but it will not be well supported. So we need to do something to fix that, and I'm going to show you a little bit later on what I would do in that situation. So a couple more tips and tricks. Patient positioning. You definitely want to have the buttocks slightly off the end of the table. I'm going to show you what we use, but there are some nice commercially available devices that are on the market. I think our anesthesiologists at this point, 20 years later, have gotten used to us tucking both arms, which I think is sort of essential. I think most people have gone to some type of adjustable, like yellow fin stirrups and steep Trendelenburg. Those are all very important. This is the inexpensive method that you can use with a pink pad, not a pink pad rather, just a egg crate, and using these sheets to wrap the arms around to tuck the arms with these foams. So this is an inexpensive way to do this. It does permit access for the anesthesiologist to get to the hand for the IV, and it really is not a problem. Occasionally with obese patients, we will have to use a toboggan, but most of the time this works very nicely as it's tucked under. So also in terms of, let me make sure this goes. So this is basically the position when you're all ready to perform the surgery with the bear hugger in place. Now let's talk about trocar strategy. You know, we always like to try to make our trocars cosmetic. We do have to think, though, that we're not just operating in the pelvis because we're also operating at the sacrum. So we have to think about that because if the trocars are too low, as in where a phantom steel incision would go, you're going to have difficulty getting up to the sacrum because the thighs might get in the way. So we do want to maximize exposure. We want to separate our trocars to provide as much triangulation as possible. I would encourage you to think about a single midline suprapubic port in addition to the lateral ports, and that could be your one large port where all the ports could be five millimeters except for the suprapubic port, which might be a 10 or 11, which is how we get our mesh and our needles in. And actually I'll show you an exception to that as well in the future. So this is kind of a typical strategy for a post-hysterectomy sacrocopalpexy, a five-scope, two lateral fives, and an 11 in the midline. I did want to show this. This is fascinating. This patient, we did an LSH sacrocervicopexy with a five-millimeter scope, but those little areas, those little dots are three-millimeter instruments. And three-millimeter instruments, I really do believe, might be the wave of the future. They are becoming much more robust, very good needle drivers, graspers, scissors, even a bipolar. What they don't have in the three-millimeter instrument, as far as I know, is a bipolar cutter like you might use typically for like an LSH. But it is possible to use this. And this was a case where we actually did remove the uterus, but we removed it through a posterior colpotomy. So we can get pretty small with our instruments and have very good cosmetic results without compromising patients. So other ways to avoid complications and have good visualization, one is to restore normal anatomy, although occasionally with license of adhesions. Sometimes the rectal sigmoid may be stuck over to the left pelvic sidewall, and you can use those adhesions to gain access and visualization. Right at the beginning of the case, I think it's really important to identify both ureters, bladder reflection, rectum, and sacrum. Over time, things tend to get a little bit opacified if you wait too long. So I think early identification is really important. And looking at the sacrum itself, these are the anatomic structures we need to be aware of. We're going to talk about the L5-S1 disc space, middle sacral vessels you can see there, the left common iliac vein, which lies medial to the arteries and doesn't stand out as well, the bifurcation, the right ureter, and we need to be aware of anatomic variance. So this is what the promontory might look like before we get started. And I'll just put the labels on to show you the various structures that you should be able to identify. So let's take a look at a quick video of what this might look like in real time. And you can see the area of the sacral promontory, but if you go back a little bit, a little higher up, you can see where my instrument was touching of kind of a floppy area. We refer to that as the waterbed sign, and that's the area of the left common iliac vein, which absolutely positively needs to be identified, and that area needs to be avoided. Here's an interesting case where we have a little bit of an unexpected finding where when we move the bowel, the rectum out of the way, you can see where the sacrum is, but you can also see this kind of bony prominence, which was just that. So we did not use it. We didn't attach the mesh to it, but it did give us a little pause because that's kind of unusual. So you do find anatomic variants, especially of the blood vessels in this area, and need to be aware of that. Now, this is a case I had done a sacral copalpexy, and a colorectal surgeon had come in to do the rectopexy on this patient who also had a rectal prolapse and did a very beautiful dissection. But as you can see here, did not identify the anatomy when he was using a tacker device to tack down the rectum to the promontory. This is a very disturbing case. It was one of my cases. And you can see this should never happen. This is a never event. And the point of this is just to show that it is so important to identify anatomy. Several bad things happen here. You can see that first a sucker is brought in. That's not very helpful. I mean, for small amounts of bleeding, that can be helpful. But you're basically just not really identifying anything. The right thing to do here would have been put in maybe a sponge, some pressure. Ultimately, a laparotomy was made in this woman. But the other mistake I believe happened here is without identifying where the bleeding was coming from, they brought in a ligature bipolar instrument to try to control the bleeding without seeing it. And that is another big mistake. So this is this woman received a massive transfusion protocol and ultimately did well. But that's why it's so important to identify the anatomy of the sacrum and all the potential variants of that. The reason I'm showing this MRI, you can see the area of the L5 and then S1. The L5, the five is there is a little S that you can see, but you can see the significant drop off of L5 and S1. And I had done a sacrocopalpexy on a woman years ago. And for some reason, I think maybe it was defecatory dysfunction. We did get an MRI and I want to show you what it looked like. This is what it looked like. And you can see the mesh heading right to the L5 S1 disc space. I'm convinced that for the first probably eight or 10 years that I was doing this procedure laparoscopically, I was unknowingly attaching the mesh to the disc, hopefully just picking up the anterior longitudinal ligament on the disc. But nevertheless, you know, fortunately, it's very rare to get a discitis. I've had one in my in my career and I hope I never have one again. And I hope no one listening to this webinar ever has a discitis because it's a very disturbing, very, very difficult for the patient. So we're going to talk about a little bit later how you might avoid that area when attaching to the sacrum. Other tips for getting exposure, vaginal and potentially rectal probes can be very helpful. There are a variety of them that I'll show you for patients that still have a uterus. A uterine manipulator can be very useful and retracting the rectal sigmoid. I see so many people putting in extra trocars just to put in a either a FAM retractor or or a grasper. And there are other things you can do. There's a device called T-Lift. You can suture the epiploica. And the question is whether a bowel prep can help. So let's talk about there are a couple commercially available devices that are that can be used, such as these. I've used all of them. I think they're all pretty good. Very simple uterine manipulators I find for hystereopexies and LSHs are very useful. And then this is a device which automatically holds your device, your uterine manipulator, and can be adjusted by pushing down on the pedal, which unlocks this this device. And you can position it and then release your foot and it holds it steady. Very nice device. I don't I have trialed it. I have not. I don't own it in my hospital, but I do like it a lot. This simple device, very inexpensive, that comes out of France called the T-Lift is really useful. I want to show you a little video of how we use that. You come in, it's about a one point, maybe eight millimeter, I believe, needle. You go through epiploica, almost like a shish kebab. And once you have several epiploica in the right area, not just any epiploica, you release this plastic that comes out through the end that has a little T on it and then pull back the needle. It just leaves the plastic T in place. And then there's a little blue tab like for an IV. And it provides wonderful, wonderful exposure of the sacrum. And I use that on on almost every case. I've never regretted putting in one of these devices. You could just suture with suture the epiploica. But that is very useful. This was a study done in my center by one of our fellows with the lead author, Dr. Adelowo, looking at mechanical bowel preps in reconstructive surgery, mostly sacrocopalpexy. Bottom line, it showed that we were blinded as surgeons, is that it didn't really help at all. The only difference was the patients were less miserable who didn't have the bowel prep. So in terms of the surgeon's view, it really didn't make much of a difference. So we have stopped doing bowel preps. We just have patients do an enema the night before surgery and the morning of just to remove any significant stool contents that they might have before getting started. Now, in terms of the sacral dissection, once we have it all dissected, it's important to lift the peritoneum away from the sacrum. The middle sacral vessels will not come up with you. They stay down attached to the sacrum itself. I personally use monopolar scissors on COAG. You could use cutting too, but I do use COAG, being very careful to avoid significant lateral spread. I've never had an injury using that. And then kind of dissecting down and allowing the CO2 to create the space to open the space up and then exposing the anterior longitudinal ligament. There usually is some fatty tissue overlying the ligament that needs to be dealt with. You can cauterize the middle sacral vessels if they're in your way, and that doesn't seem to cause any problems. But the other thing is when you lift up, often you can identify the sympathetic nerve trunks, and rather than cutting through them, which could lead to constipation, just sort of pushing them over to the side, I think, is a very good idea. And I think early on in my experience, we probably did cut through some nerve tissue as well. The anatomic line marks you want to be aware of, obviously, is the right ureter. If you stay medial to the right uterus sacral ligament, you will not get the ureter. And on the medial side is the rectum. So those are your anatomic landmarks as you're opening up the pelvic sidewall. Anterior vaginal dissection, I would strongly encourage people to put in a Foley catheter, and we use a three-way Foley catheter so we can backfill the bladder, and we use a methylene blue stain fluid. Very often, especially post-hysterectomy, the bladder is often tacked up very high, even may come over to the opposite side, to the posterior side. So using backfilling is very useful. And the fascia, the white fascia, has a very distinct appearance. There have been times when, you know, you might see sort of crossing fibers, and you can try to convince yourself that that's fascia and it's not. You're cutting into detrusor muscle. So if you start, if you get started and you see these crossing fibers, you might want to stop, reevaluate, and go higher, even possibly starting posteriorly and kind of pulling the bladder over the apex. We try to dissect down as far as the bladder neck, but we'll go what we think is, we'll go as far as we think is safe. This is a view of the posterior dissection, which we continue with the pelvic sidewall dissection. And the important point here is that when you first run into fat, the fat belongs on the rectum. It does not belong on the vagina. So as long as you stay above the fat, you will never get a rectal injury. You should get into this kind of cotton candy, a realer tissue, and it should just go down without hardly any cautery. We talked about going down potentially to the perineal body, which is not that far again. And if there's any question of where the rectum is, getting a second probe, like an EEA sizer, or specifically made rectal probes can be very helpful in that situation. It also can be helpful with straight stick laparoscopy for the surgeon to use their other hand to either place in the vagina, even with a probe in place, or against the perineum so that you can feel that instrument. By the way, we do not routinely change our gloves when we go from the vagina back up. We prep the vagina, we wipe our hands off on those cloth towels, and then we don't touch the ends of the instruments. And fortunately, we've never had any infections to speak of. It's a very clean method of doing this. So we talked earlier, how do you deal with that ballooning anterior segment? Well, there are a couple of different ways of dealing with it. One is to placate laparoscopically before you put the mesh on. This is what I would do with longitudinal sutures, although you could do horizontal sutures. You might do a paravaginal pair if they have a paravaginal defect, or you could perform an anterior coporaphy at the end of the case and see how much is left. This is another method that some people will do is that if they have a large anterior ballooning segment, let's say it's 12 centimeters long, they'll cut the mesh to maybe about like six centimeters. And they kind of gather up the vagina to fit onto the mesh. So that's one method. This is the method that I've been employing, which is I've got a big ballooning anterior segment. I believe I have a Breisky-Navratil retractor right here in the anterior vagina. And I'm just gathering up the epithelium with polyglycolic acid, so Vicryl-type sutures in a longitudinal fashion to shorten the anterior vaginal wall, and then bring these down with extracorporeal knots. So, and we'll do a series of these. So we may take, again, an anterior vaginal wall that's let's say 12 centimeters, reduce it to six centimeters before, and then we put our mesh on and do a standard repair with permanent, I like to use permanent sutures like Gore-Tex. So, every one of these cases is different, unique, and you have to think of, how do I bring that either anterior or posterior wall back to a normal size before we put our mesh there? So we'll move on and talk about a couple other things here. Let me see. So, preparing the mesh. We prepare the mesh by rolling up the sacral extension and placing a suture to keep it in place and out of the way. Not to make it unruly, I roll up the sacral portion of the mesh and loosely tie a suture so that it just stays out of the way. And I personally like to do the anterior segment first, suturing it down. I know there are people that will do the posterior segment first, and that's fine, but that's just a very simple method of dealing with all these different arms of the leg. Everyone likes their own needle drivers. I happen to like the self-writing needle driver, but standard needle drivers are terrific as well. What I would encourage you not to do, obviously, is to use things like graspers, like Maryland graspers or bowel graspers to do suturing. It just doesn't work very well. And people have their preferences. I, like many people, like very narrow-gauge cortex sutures, polypropylene sutures. More people are going to the late-absorbable, like PDS. And some people are using barbed suture, and I think as long as the mesh lays down flat, that's fine. Extracorporeal knot tying is wonderful and easy, and I'll show you a quick little video of how we do that. I personally like to start at the apex of the vagina, either anteriorly or posteriorly, and working more distal to flatten out the mesh as much as possible. This is a device which I think our robotic friends should know about. It's a little capsule that goes down through a 12-millimeter port and has six cortex sutures already in it and cut to a very nice length. So you don't depend on an assist, a bedside assist, introducing and removing sutures. You do this all yourself, and it really does improve efficiency and decrease time. And you can see from here, on the one side, on the upper side, it has the six sutures. On the lower side, it's sort of like a sharps container. So you can put your used needles in this area. It's a very clever device, and I know a lot of robotic surgeons who really like it. You know, in terms of how many sutures should you put down, the bottom line is, you know, the more, the better, because the more sutures you have, within reason, the less tension there is on any one stitch, and that's why you can lay down on a bed of nails, because if you have one suture, you have 100% of the tension on that suture, but if you have 10 sutures, you only have 10% on each one of the tension on the sutures, so less likely to fail. So think of the bed of nails when you're putting your sutures in. Now, this was, I just wanna talk about suturing. This was an interesting case. I believe it was a hysteropexy. This surgeon is doing a very nice intracarporeal knot-tying technique, but you can see they're not paying attention. They're paying attention to the knot, but as they tighten the mesh, they are not looking at the pelvic sidewall and get into bleeding, which required them to open, so that's the external iliac. That can't happen. That's why we have to be very careful with our laparoscopic suturing. So here are a couple things I hear myself saying to my fellows and residents whenever they're suturing. First of all, you can throw a needle into the abdomen. Throw it, nothing will ever happen. The moment you pick it up on a needle driver, it is a lethal weapon. So I think it's so important. I ask the surgeons, do not look away from the needle when the needle is loaded on a needle driver, and I kind of kid with them. I say, don't even blink. It is so important that you are always aware of where the needle is. You can't look down for a foot pedal, et cetera. That's safe suturing skills number one. Safe suturing skills number two, grab the needle when you're grabbing the needle from someone else, perpendicular to the needle driver, not parallel to the tip. That way you're going to prevent barbing. And especially if you grab the needle at the very tip itself. And if you're working with someone else, it's important to make sure that you only move one at a time and to communicate with the other person. It's very important. So this is just a simple video of how we do extracorporeal knot tying, which takes very little time. It's important to kind of separate the knots by about a centimeter or two, make all the knots together. And then usually we would put a hemostat on the end and then carefully guide the knot pusher onto the one end of the suture, untwist as you get low and then insert the knot. And this takes just seconds to do and is a very nice method of doing extracorporeal knot tying. Whereas robotic, you normally would do intracorporeal. So for intracorporeal knot tying, it's really important to either turn the, unlike the video that we saw earlier, turn the needle towards the knot as you pull away, or better is to just let go of the needle, pick up the suture and not tighten with the needle itself. I think that's probably the best way to do that type of intracorporeal knot tying. We talked earlier about avoiding the L5-S1 disc space. There are patients that have very steep angles between L5 and S1 and using a 30 degree or even 70 degree scope can be helpful. Tensioning, my personal method is to push in all the way with the probe and then back off a little bit. And that usually is the right amount of tension. Tacking is possible. And we'll talk briefly about transcervical suture placement. There are centers that do a lot of tacking. I don't do a lot of it. I don't think there's anything particularly wrong with it. The only issue is that when you tack, you do need to put the mesh down first. So you might lose your orientation of where the middle sacral vessels are. And you can put several tacks like we're doing here. This is a tack that has sort of a plastic cap on it. And it can maybe save some time and it doesn't seem to go very deep into the tissue. So I think it's a valid method of doing attachment. But you can see here from an article several years ago that shows the prominence of the disc space and why we probably were putting our sutures in the disc for a long time before we became aware of these anatomic principles. And you can see here, you really need to go over the cliff in a way to get to S1, which you may need an angle scope or some other methods that have been used. So very important to get, there's a lot of anatomic variations. You can see that almost 90 degrees down to kind of a sloping 53 degrees. These are very different anatomic variants that you really won't know until you get in there. In terms of re-perinatalization, which I think is important, you can do interrupted or running. The other day we used Laparotai clips with suture. Barb suture I use routinely. And as long as you double back and cut the barb very close so that the barbs don't get caught on any bowel, that's important. And be very aware of the right ureter and the rectum when you're repairing, because you could get injuries to those structures as you repair. This is what a Laparotai closure would look like, a running stitch with several Laparotais, which are basically delayed absorbable clips. This is a full sacral copepaxi. And I'll just go through this briefly. We are exposing the anterior longitudinal ligament. Very important that if there is fat overlying that area that you do dissect down to the ligament itself. In this case, the bladder was kind of far down, but I am scoring the area and dissecting the bladder down more. Basically, so I can get an edge to close over the mesh when we're done. This is a lightweight polypropylene mesh that we're using. You can see that I like to use the self-righting needle driver. And these happen to be GORE-TEX CV3, although you can also use CV4, using an extracorporeal knot tying technique. And in this case, starting toward the apex and working more distally. And we are, you know, again, how many sutures do you put down? As many as it takes without getting too close to the bladder edge and then cutting the mesh away. As we get very close to the bladder, we might work backwards toward ourselves just to avoid injury to the bladder. Obviously, it's mandatory, I believe, to do cystoscopy following the procedure so that to rule out, number one, unintentional injury to the bladder, but also make sure the ureters are functioning well, especially the right ureter. These are the sutures that are placed into the sacrum. And then after determining proper tension, they're brought up through the mesh. And again, extracorporeal knot tying is performed. Usually two sutures is plenty, although occasionally we might put a third. And then closure with barbed suture. That can either be started in the cul-de-sac and working back up toward you, although I find it fine to start at the apex and work away. But it's a very nice closure at the end. And typically these cases go just fine. I'll just mention briefly, and then we'll leave time for some questions. LSH sacroscervical pexy is one of the special situations which I find very useful. It does maintain the cervix for good apical support without getting too thin vaginal walls. And we believe it does decrease the risk of mesh exposure. There are several ways to remove the corpus of the uterus itself. In-bag morcellation, often done, many people will do this through the umbilicus. I find that a posterior copony can be very useful in this situation. Below the area of where the mesh is, I'll just show very briefly. I think this might be the last slide that we can allow time for a question. But the mesh has been placed anteriorly. I use, as you can see here, it's a little unusual, but I use a crowbar that's placed through the cervix, which we've cored out, we've cored out the cervix. And then below the mesh, in other words, closer to the perineum, we use a bipolar spatula to make a posterior copony. We bring our uterus, which has been removed earlier, and put it in an endoscopic bag. We close the bag off, and we bring the suture and feed it to a surgeon who reaches up and grabs the suture in the posterior copotomy. As you all know, most of the time the uteruses are small. Obviously, this could not be done with a large fibroid uterus, but it is amazing how much space you can get in the posterior copotomy. We've removed 12-week, 14-week-sized uteruses through a posterior copotomy with no difficulty at all. The incision, the posterior copotomy, can be closed from above as shown here, in this case, a barbed suture, but it can also be closed by a surgeon who is between the legs and can do it that way as well. The sacral mesh is now unrolled, and appropriate tensioning is determined to provide adequate apical support. After the mesh is cut to the correct length. And I won't show that because we've already shown that before. And by the way, people often ask about that trocar. When we take that out, we put a purse string around the cervix transvaginally. The other thing that can be done is sacrohystorpexy, which we mentioned briefly. There are different ways of doing it, as shown here in the picture. You can do it with a posterior strip. I'll show you the Cleveland Clinic method very briefly, where they go through the broad ligament, attach the mesh to the cervix, and then attach that to a strip that runs posteriorly up to the sacrum. That can be done. This is a video of, I think we saw this patient earlier, where I reduced the prolapse. And this is a procedure I perform called a cerclage sacrohystorpexy, which I don't believe we're gonna have. I'll show you the beginning part of this, but I think we'll wrap up after this video. We make small incisions in the posterior broad ligament, and just kind of open that area up. And then we take down a bladder flap, just like we would with a hysterectomy or a supracervical hysterectomy. And dissecting on either side of the cervix, we have a strip of mesh that has a loop in it. And then we go through the broad ligament from anterior to posterior, hugging the uterus, which is medial to the uterine vessels, pulling this strip through, and then encircling it by going on the other side as well. We've done this, we have a series of about 130 or 140 cases so far, and it's like a noose. So we go through the loop on the end of the mesh, and then it's brought up to the sacrum with sutures, which I won't show. Is this for every patient? No, but this is for patients that have primary uterine prolapse that reduces well, excuse me, well in the office with support. All right, so then the question comes up, do we do a peroneoraphy for these patients? And if they do have a gaping introitus, if they have complaints of vaginal laxity, then we will do it. Some patients will have discomfort, obviously. It's rare to have long-term post-op dyspareunia. But sometimes the copepexy itself may correct, and I put in quotes there, the situation. And I think of this like Chinese finger handcuffs, that when you pull on them, the opening sort of gets tighter. So often it's really just not necessary, I find, to do the peroneoraphy. And so anyway, just to conclude, sacral copepexy, it's important to have a preoperative game plan, but also have a plan B in case nothing, in case things don't work out the way you think about it. Exposure seems to be kind of a very common pain point that all of us have. And I think we've talked about different ways to get exposure. Identify anatomy early and often. Make sure you expose the sacral ligament and have the right tools for the job, including the right needle drivers, the right knot pushers, the right type of retraction. And then I do think it's important to distribute the tension as much as possible. Don't compromise on the amount of sutures you put. And personally, I believe that it's important to cover our work, meaning reperitonealizing. So I will stop there. We have about 10 minutes left, and I'll hand it back to you, Christina. Thanks so much, Dr. Rosenblatt, Peter, for your presentation. We do have a couple of questions, but I want to remind everyone that you can type in questions right now on the left-hand side of the window. Our first question is, can you describe how you get to the perineum posteriorly with straight stick laparoscopy? I find it harder to get to the perineum this way compared to robotics, so I would like to be able to get lower. So, by the way, I apologize. Apparently, I couldn't hear it, but there was some audio playing, and I did not realize that. So I apologize for that, and I hope that wasn't too disturbing. Christina, can you ask me that question one more time? Absolutely. So one of our listeners was asking if you could please describe how you get to the perineum posteriorly with straight stick laparoscopy. They write that they find it harder to get to the perineum this way compared to robotics, but they wanna be able to get lower. Right. So I've done robotics in the past, by the way, and I actually, I gotta, my personal experience is that I think it's easier with straight stick. I think important to define that fat layer and always stay above it. With straight stick, if you're standing on the patient's left side, so your right hand has an instrument, and your left hand can't, even with a probe in the vagina, can be posterior to the probe, and you can see your finger, and you can just work down on your finger. And it always impresses me how close we are already, as soon as we make that posterior incision in the peritoneum, how close we, we're not far from the perineal body. So just kind of peel the fat off the roof, work along your finger, make sure you're in an avascular plane, so you're not splitting the vagina, because I think most of us, if you had to error, you'd rather split the vagina than split the rectum, but it's actually a pretty open space unless it's scarred with a previous repair. And you will find you can get down to the perineum pretty easily. We have another question. When you shorten the anterior vagina with longitudinal sutures, could you comment on how you tie them? Yeah, so I tie that with extracorporeal knot tying technique. So I will put usually two sutures in before tying, one bringing the suture in through the right lower quadrant trocar, and hold it. And then just to not limit my access, I'll put another suture from the left lower quadrant. So now I have both sutures that are untied, and then I tie them down using an extracorporeal knot tying technique. Now I have, I'm lucky. I work with very talented fellows, and I know not everyone has an assistant that can do this. So, but I can rely on my fellows or resident to put, but usually fellow, to put these extracorporeal knots down so we can alternate back and forth. Another question is, do you have any photos or videos that show the nerve plexus at the promontory? I do. By the way, I'm gonna encourage everyone here listening to record every, if you have a DVR in your OR, record every case, record every case. You never know when you're going to get some great footage. I promise to answer the question, Christina, by the way. And you also, like the one I had of that horrible complication, that bleeding complication, you just don't know when you're gonna have a complication. And I'd rather record that for presentations and to review with colleagues, what did we do wrong, et cetera. And so I do have videos that I don't have any to show tonight, but when you open up that space, you can usually sort of use your grasper and pull, and you'll see a cord that's running down longitudinally along the anterior sacrum. That cord is the plexus. I hope that makes sense. If you pick it up and it's just fatty, you will not find a cord, but if you pick it up and you see that it's, you're basically like tethering a clothesline, don't cut that, that's the nerve plexus. Well, along those lines, another one of our listeners is asking if you do need to identify the neurovascular bundle before taking the sacral promontory stitch, and if you yourself have had any experience in injuring the hypogastric plexus. Yeah, and by the way, yes, I have. And I believe I did for years before I became more aware of what these areas are. I used to clear off the entire sacral promontory, and then sometimes there's, the patients have no side effects at all, but sometimes, and I'm sure all of us have had those patients who've complained of constipation. That's usually the major complaint. I've never had anyone have loss of sensation, perineal sensation, et cetera, it's usually constipation. So I think the important thing is we don't have to clear off the entire sacrum. The important thing is to dissect down to the anterior ligament, identify if possible the middle sacral vessels, and anything else that's there, just push to the side. Have an assistant or yourself retracted to the side. We do not need to cut through everything. But the other thing that I think is important, which brings up the point, is that some people will open up the peritoneum, and there's this fatty layer, and they won't clear it off, but they'll put their sutures through this fat, hoping they'll get the anterior ligament. I've seen too many very large vessels. I've seen the, think about this, the right common iliac vein should be lateral to the right common artery. Occasionally, it's not. That's one of those anatomic variants. And so it's basically, if you don't clear off that fat, it is as if you are blindfolded when you're passing that suture or that tactor. So I don't think that's a good idea. I think it's important to slowly allow that CO2 to dissect in that area, but get down to the ligament and expose it before putting a suture through it. I think we have time for one more question. And the question is, do you have a BMI cutoff for doing a laparoscopic sacrocopalpexy? I often find that ladies with a BMI of greater than 30 have more presacral fat, and thus opt to do them robotically rather than straight sticks for better exposure. Yeah, I've heard that. I do have to have a confession here. My confession is that I work in Cambridge, Massachusetts, and we don't have an abundance of very, very high, I mean, do we have obese patients? Sure, but I'm very fortunate that we often don't get above 30. I'm also kind of surprised, pleasantly surprised, that often you get into that area in an obese patient and you don't see a lot of presacral fat. That said, I had a case either, I think it was last week, which only happened, it probably happens once every five years or so, where we had a really hard time retracting the small bowel. We got the large bowel up with the T-lift, but no matter, you know, I couldn't put her in that much Trendelenburg because of ventilation and anesthesia issues, and I did bail. In other words, I could not feel comfortable identifying the sacral anatomy and dealing with a small bowel. So I think it's important in these patients, yes, I've heard the same thing, that robotic, you know, may be better for that. I'm not really sure I understand why it would be better, and I did my share of robotics, but I do think it's important in the obese patient to have a plan B and to talk patients, you know, will you open her or should you do a vaginal repair if you cannot safely perform the sacral copepaxi? Well, on behalf of the Oggs Education Committee, I'd like to thank you, Peter, Dr. Rosenblatt, and everyone for joining us today. As a kind of future marker, our next webinar is gonna be titled Flaps and Neuro-Ventrologic Surgery, and will be presented by Dr. Martha Matthews on April 15th. So thank you again, everyone for joining us. Thanks again, Dr. Rosenblatt, and all of the webinars will be on the Oggs website. Have a good night, everyone. Good night.

laparoscopic sacral copal plexus

tips and tricks

suturing techniques

uterine sparing sacral coprohistropexy

vaginal prolapse

patient positioning

anatomical structures

exposure tips

suture types