This video presents the anatomic landmarks that are pertinent when performing a laparoscopic or robotic-assisted laparoscopic sacral copopexy. Sacral copopexy was first introduced by Lane in 1962 and has become the gold standard procedure for apical prolapse. Approximately 34,000 sacral copopexies were performed in the United States in 2010, which constituted 11% of all prolapse surgeries. There are several intraoperative and postoperative complications that may occur with sacral copopexy. Knowledge of the anatomic landmarks should decrease the chances of their occurrence. Looking at the publications on robotic-assisted laparoscopic sacral copopexy from 2006 to 2014, the intraoperative complications are vaginotomy, bladder injury, ureteral injury, and bowel injury. Postoperative complications include bowel obstruction, port-site hernia, abscess and peritonitis, cuff dehiscence, and mesh erosion, which can occur 0-8% of the time, with higher rates when a vaginotomy had occurred or a total hysterectomy was performed. These rates were also higher when a standard weight polypropylene mesh was used as opposed to a lightweight mesh. Our patient is a 56-year-old gravid 3 para 3 with a stage 3 apical and anterior prolapse. She did not want to use a pestry and elected to proceed surgically, and the decision was made to proceed with a supracervical hysterectomy, sacral cervical pexy with deep and wide anterior and posterior dissection to address all three levels of vaginal support. As can be seen here, she has significant apical and anterior prolapse with perineal descent and a gaping contritus. After the supracervical hysterectomy is performed, the cervical stump is lifted up and one can follow the uterus sacral ligaments along the green arrows from the sacrum to the cervix. The ureters are also outlined here with the blue arrows from the pelvic brim into the pelvis. Peritoneum on the posterior aspect of vagina is then grasped and entered, and a dissection is done in the rectovaginal space to the level of the perineal body. The levator ani muscles are exposed on the left hand side as can be seen here. The same is done on the right hand side. The levators can clearly be seen here with the rectum at midline. The green arrows indicate the location of the levator ani muscle dissected out. The peritoneum overlying the sacral promontory is entered and this dissection is carried down to meet our dissection from below in the cul-de-sac. The middle sacral vessels are shown here with the red arrow. Dissection is now done in the vesicovaginal space to the level of the triangle. The right ureter is again identified and followed into the pelvis. We begin our anterior lateral dissection to identify the right uterine artery and the right ureter as it courses under the uterine artery shown here with the red arrow for the vessel and the blue arrow for the ureter. The same is done on the left hand side. Again, the left uterine artery shown with the red arrow and the left ureter with the blue arrow. One can follow the course of the ureter under the uterine artery as it enters the bladder at the level of the trigon which is shown here with a hollow blue circle for the foley bone. Once the dissection is complete, the lightweight Y-mesh is attached to the puborectalis fascia on either side of the rectum as shown here with the blue circles. It is also attached at midline at the level of the perineal body as shown here with a blue circle. Now the mesh is lifted up and the attachments can be visualized. At least 2 centimeters of vaginal epithelium is uncovered by the mesh laterally shown here in blue indicating the necessity for a wider mesh. The remainder of the mesh is sutured posteriorly with CB4 cortex sutures. Attention is now turned to the anterior vaginal wall and midline sutures are thrown through the anterior aspect of the vagina just under the foley bone indicated here with a hollow circle. Several more sutures are used to attach the mesh to the anterior aspect of the vagina. At least 2 centimeters of vaginal epithelium is uncovered anteriorly as shown here in blue indicating the necessity for a wider mesh. Such attachments should take care of the level 2 support after scarring. The sacral portion of the mesh is then attached to the anterior longitudinal ligament at the level of S1 lateral to the midline sacral vessels as shown here with a blue circle. The whole area of the mesh is then retroperitonealized with zero monocle suture with laparotide device at each end. The post-operative exam shows good apical support with no perineal descent since the mesh is attached to the perineal body and there is no need for a perineuropy. I'd like to thank my collaborators on this video Dr. Nestor Villa-Irata and Diego Villa-Irata and Animated Images provided courtesy of the Visible Body AMS Pelvic Anatomy App. Thank you.

laparoscopic

robotic-assisted laparoscopic sacral copopexy

apical prolapse

complications

anatomic landmarks