We would like to present a video about tips and tricks in laparoscopic sacral copopexy. We start first with the entry at the umbilicus after infiltration with lidocaine solution and an incision made inside the umbilicus. After that, using a 10 mm OptiView trocar, we make our entry under visualization. First, we tunnel to the left side through the subcutaneous fat above the rectus muscle. This will allow us an entry with a zigzag fashion into the abdominal wall preventing any further hernia. Once above the rectus muscle, we go with the right angle entering first through the anterior rectus sheet as we can see. We keep on going through the rectus sheet. Once the trocar pass through the sheet, we are going to tunnel down parallel to the rectus muscle fibers. After tunneling and fixation of the trocar through the fascia, we pull back the trocar slightly and go with the right angle through the rectus muscle. And here we can see the posterior rectus sheet. Then we tunnel down parallel to the rectus fibers down to the arcuate line. Then we can withdraw slightly the trocar and pass through the peritoneum into the abdominal cavity under visualization. Once that happens, insufflation is done in the standard fashion. Next, we would like to describe the accessory trocar entry. Once we infiltrate again with lidocaine epinephrine, notice that we go down with the needle for mapping and for infiltration of the peritoneum and creation of a bulla. That will help us guiding the trocar as well as help preventing any injury. The trocar is entered through the abdomen, right angle to the floor, not to the patient abdomen. Once the trocar pass through the fascia, we orient the trocar down toward the pelvis and entry is done under visualization by a scope. After placement of the trocars, identifying the anatomy, the sacral promontory, the ureter, internal iliac vessel, external iliac vessel. As we can see here, the peristaltism on the right ureter. Next, we would like to describe opening of the broad ligament. Notice the wide dissection that will give us extra peritoneum to cover the mesh after the sacral colopexy. This was done by push and spread technique. As we notice, it's a nice avascular plane. We're pushing the fat away to create a large dissection. Now, we would like to describe uterine vessel skeletonization. Once the vessels are identified after opening the broad ligament, a grasper is placed posterior to the vessels and another grasper is used to push down the posterior sheet of the broad ligament. Notice the size of the space between the uterine vessel and the broad ligament. Next, we would like to describe opening of the posterior sheet of the broad ligament. Notice the size of the space it's created posterior to the vessels as well as the avascular plane. This is repeated again anterior to the vessels using one grasper to protect the vessels and using the second grasper pushing it up on the anterior sheet of the broad ligament. Next, we would like to describe adequate skeletonization of the uterine vessels for cauterization. Once skeletonization is adequate, using a bipolar energy, cauterization is done while bouncing on the cervix assuring a complete grasp of the uterine vasculature. Here we can see complete desiccations of the uterine vessels. Next, we would like to demonstrate the amputation of the uterus using an insulated wire endoloop. Once the endoloop is introduced through a 5mm trocar, it's taken down toward the lower uterine segment and the endocervix. Once we are assured that there's no bowel or other structures entrapped, activating the monopolar energy would amputate the uterus without any difficulty with excellent results on the cervix and hemostasis. During sacral copopexy and after dissecting the pubocervical space and the rectovaginal space, we use a sterile measuring tape to cut the proper length of the Y-graft. Another trick using the Balchez uterine manipulator or the Pelosi manipulator, the graft is cut in the midline and that is used to pass the manipulator through that will stabilize the mesh at the vaginal cuff for easy suturing. Next, we would like to discuss suturing and needle handling. If we are using a 5mm trocar, the needle can be passed through the port site without any difficulty. Once the needle holder is through the port site, then the trocar is passed in. Once the needle inside the abdomen, the needle is held with the left side and the needle dance can be done to adjust the needle orientation. Once the orientation is adequate, the needle is grasped and brought down to the camera to check for orientation. Another way of handling the needle with one hand is to lay it down on the tissue, then grasp it and pushing it down, that will rotate the needle adequately. Once the needle is rotated, you can bring the needle down to the camera again to check for orientation. Next, using the Pro-Q, the Pro-Q manipulator is used to adjust the length of the Y-graft. Next, using the Pro-Lean double-armed barbed suture, one needle is secured to the abdominal wall, keeping it away from the surgical field. Once the needle is loaded in the right way, it's brought down to the tissue with a flat surface, and then the back rotation is done until the needle is perpendicular to the tissue, and then it will be passed without any difficulty. Once the passage is done, we can see the needle tip, which will be protected with the other needle holder, and the needle is kept right above the graft surface to be reloaded again. After that, we would like to demonstrate the tacking of the mesh to the sacral promontory. This is done using the Pro-Tacker auto-suture, securing the mesh to the sacral promontory without any difficulty. Alternatively, this can be done using the Pro-Lean sutures. After the completion, we use the PDO barbed suture to close the peritoneum above the mesh to prevent any further adhesions or bowel obstruction. Once the needle is passed through the tip of the closure, it's taken back to secure the suture and to prevent any exposure of the barbed suture to the bowel. In conclusion, these tips will help the surgeon ultimately to have more tricks in his armamentarium to accomplish the surgical repair. Thank you. www.ottobock.com

laparoscopic sacral colpopexy

umbilicus entry

rectus muscle tunneling

insufflation

surgical repair enhancement