This is a video presentation of a robotic-assisted laparoscopic tracheolectomy in a patient who underwent a robotic supracervical hysterectomy and sacrocervical pexy in the past. Sacral copepxy was first introduced by Lane in 1962 and has become the gold standard procedure for apical prolapse. Over 34,000 sacral copepxies were performed in the United States in 2010, which constitutes 11% of all prolapse surgeries. Traditionally, when a uterus is present, a total abdominal hysterectomy is performed before proceeding with the sacral copepxy. With the advent of laparoscopic sacral copepxy, a total vaginal hysterectomy or total laparoscopic hysterectomy was performed before proceeding with the sacral copepxy. More recently, a supracervical hysterectomy has been the preferred mode of hysterectomy, secondary to the presumption that the cervix provides a barrier to reduce the chance of mesh erosion. Tan Kim et al. published on 188 patients who had a sacral copepxy for apical prolapse. They found a 5% erosion rate on their post-hysterectomy patients, 5% rate on their supracervical hysterectomy patients, and a 23% erosion rate on a total vaginal hysterectomy was performed before proceeding with the copepxy. Similarly, Osmundson et al. found a 0% erosion rate when a supracervical hysterectomy was performed and a 14% erosion rate when a total hysterectomy was performed at the time of robotic sacral copepxy. With more surgeons performing supracervical hysterectomies at the time of copepxy, there is greater concern with the need for trachelectomy in the future should there be a new onset of cervical pathology or undiagnosed uterine and or cervical pathology before the surgery. The easiest approach for a trachelectomy would be the vaginal route as reported by Managlia et al. However, there is the concern of compromising the repair since significant traction on the cervix is necessary to perform this procedure. We are presenting a video on a robotic-assisted laparoscopic trachelectomy. Our patient was a 65-year-old gravity 2 para 2 with stage 3 prolapse with no history of cervical pathology. She underwent a supracervical hysterectomy, bilateral sublingual phrectomy, and sacral cervical pexy. 22 months after the surgery, she had an abnormal pap smear of high-grade SIL with a positive high-risk HPV. The biopsies were consistent with mild dysplasia, and a decision was made to proceed with robotic-assisted laparoscopic trachelectomy. This is the configuration of the Y-mesh attached at the time of sacral cervical pexy. A small amount of bowel adhesions noted are taken down sharply. The Y-mesh can be seen attached to the cervix and the sacral plumbatory, covered mostly by the peritoneum. An incision is made anteriorly. The anterior aspect of the Y-mesh can be visualized. This dissection is continued until the lateral aspects of the mesh are visualized. The dissection is then carried laterally on either side to circumferentially expose the mesh around the cervix. The Gore-Tex sutures that were used to attach the mesh to the cervix are identified and removed. The cervix and the mesh are then grasped with a tenaculum on the third arm of the robot, and the mesh is carefully separated from the cervix. The Gore-Tex sutures used to attach the mesh to the cervix are identified and removed. The mesh is then pulled to the left, and the cervix is grasped with a tenaculum with the third arm of the robot. The mesh is then separated further from the posterior and anterior aspects of the cervix. The uterine vessels are then sclerotized and cut. The cervix is then amputated with monofilocotam. A manipulator may be used for better cervical identification. The cervix is then removed vaginally. The cuff is closed with vacal suture in interrupted fashion, followed by an embroidering running The cervix is then amputated with a manipulator, followed by an embroidering running, followed Retroperitonealization is then done with monocle suture. We have seen the patient one year post-operatively, and there were no signs of erosion or recurrence of her prolapse. I'd like to thank my collaborators for this video, Dr. Nestor Villairata and Diego Villairata, and animated images provided courtesy of the Visible Body AMS Pelvic Anatomy app. Thank you.

robotic-assisted laparoscopic trachelectomy

cervical pathology

uterine pathology

sacrocervical pexy

Y-mesh configuration