The adoption of laparoscopic surgery over the last 10 years has reduced the length of admission, pain, and complications previously associated with open sacral copepaxy. When compared to laparoscopy, a robotic-assisted approach has been criticized due to longer operative times and higher cost, although outcomes such as complications and prolapse recurrence are similar. Suturing and knot tying have previously been identified as a time-intensive component of minimally invasive gynecologic surgery. When used for vaginal cuff closures, barbed suture has been found to decrease suturing time without increasing complications such as vaginal cuff dehiscence. Barbed suture has also been shown to be safe and efficacious for mesh attachment during minimally invasive sacral copepaxy. A previous study with a small sample size demonstrated that barbed suture for mesh attachment decreased operative time when compared to an interrupted suturing technique. We sought to evaluate two types of vaginal mesh attachment techniques, one using a continuous barbed suture and the other using interrupted suture, among a cohort of women undergoing robotic-assisted sacral copepaxy. Our primary hypothesis was that a barbed suture technique for vaginal mesh attachment will have a shorter operative time than an interrupted suture technique during robotic-assisted sacral copepaxy. In order to compare this technique to traditional interrupted sutures, we performed a retrospective analysis of all robotic-assisted sacral copepaxies between February 2013 and December 2017 at a large academic institution. We compared continuous barbed delayed-absorbable suture with traditional interrupted delayed-absorbable suture for vaginal mesh attachment. Outcomes were compared using Wilcoxon Rank Sum and Chi-square with multivariable regression. This video will demonstrate a technique for using continuous barbed suture for mesh fixation in a robotic sacral copepaxy. Our surgical demonstration begins following the anterior and posterior dissection. A vaginally placed manipulator is positioned in the anterior vaginal fornix to provide a flat surface for mesh attachment. A preformed Y-shaped polypropylene mesh is laid flat on the anterior vagina. We used two 14-centimeter bidirectional delayed-absorbable barbed sutures for mesh fixation. An initial stitch is placed approximately 1-2 squares from the edge of the distal midline. This suture is gently pulled through until mild traction is felt at the midline of the suture where the barbs change direction. We have a needle driver in arm 1 and a needle driver with suture cut in arm 2. Our third arm is being used to deflect the bladder. The barbed suture is run in a counterclockwise direction with care to remain approximately 1-2 squares from the edge of the mesh. The orientation of the barbs on the suture help to evenly distribute tension and eliminates the need for knot tying. However, we choose to secure our suture by changing the angle of the needle placement and locking the final suture at the midline. Once our suture has been secured, we leave the needle temporarily attached and turn our attention to the other half of the barbed suture. This half is run continuously in a clockwise direction and similarly locked when past the midline. Minor areas of pleading will be tamponotted as the suture is pulled through, similar to the effect that is achieved by tying a knot when placing interrupted sutures. Both arms are active throughout the suturing process, with one arm driving the needle and the other arm simultaneously flattening the mesh. We secure this end of the suture when past the midline. The ends of the suture can be grasped and cut, then handed to the assistant as the second suture is brought in. This efficiently removes both needles while preparing for the posterior mesh attachment. A continuous barbed suture used for anterior mesh attachment allows the mesh to lay flat against the tissue without any knot burden. The vaginal manipulator can be rotated and anteverted to facilitate visualization of the posterior vagina. The posterior mesh is laid flat and the second barbed suture is loaded. We secure the posterior leaf of the mesh in a similar fashion as we did the anterior leaf. The third arm is assisting by elevating the cervix towards the anterior abdominal wall while the second needle driver continues to flatten the mesh as the barbed suture is placed. The second half of the posterior mesh is attached in a counterclockwise fashion, with the suture secured at the midline, as was done anteriorly. Both needles can be cut and removed together once mesh attachment is complete. The mesh is attached to the sacrum using permanent suture and the vaginal manipulator is slowly removed. This has been a demonstration of continuous barbed suture for mesh attachment during a robotic sacrocolpopexy. Our primary outcome was operative time. Secondary outcomes include interoperative complications, prolapse retreatment, prolapse recurrence, and mesh exposure. Prolapse retreatment includes all cases of surgical retreatment and those managed by a pessary. Prolapse recurrence was defined as the leading edge at or equal to zero on the most recent POPQ exam. Interoperative complications include bowel or bladder injury, conversion to open procedure, or blood transfusion. In total, 212 robotic-assisted sacrocolpopexies were included. Barbed and interrupted cases were split evenly. Mean age was 62.3 years and mean BMI was 27.8. Most women were Caucasian and had stage 3 prolapse. 68.4% underwent a concomitant hysterectomy and 32.1% had lysis of adhesions. Fellows were involved in 72.2% of the cases. Operative time and interoperative characteristics were similar between groups with the exception of concomitant adnexal procedures. The barbed group was more likely to undergo salpingectomies and less likely to undergo oophorectomy. The barbed group had a shorter follow-up time with a median of 19.5 weeks and a median follow-up time for the interrupted suture group of 31 weeks. Our primary outcome was operative time. We found that operative time in the barbed suture group was 149 minutes compared to 142 minutes in the interrupted group. There was no significant difference between groups. There was one interoperative complication in each group. Both groups had two cases of prolapse retreatment with one managed surgically and one managed via pessary in each group. The barbed suture group had 12 cases of recurrence while the interrupted suture group had 7 cases during the follow-up period. There was one case of mesh exposure in the barbed suture group and three cases of mesh exposure in the interrupted suture group. None of these differences in our secondary outcomes were significant. In the adjusted analysis, we found operative time was not associated with mesh attachment suture type. When controlling for adnexal surgery, operative time increased above the mean baseline of 131 minutes by 13.8 minutes with fellow involvement and 0.36 minutes for each milliliter of blood loss. Mesh attachment with continuous barbed suture had similar operative times when compared to interrupted suture during robotic-assisted sacrocopalpexy. We found no differences in interoperative complications, surgical retreatment, prolapse recurrence, or mesh exposures, and our small sample size was short follow-up. Further longitudinal studies are needed to support our findings.

laparoscopic surgery

robotic-assisted surgery

sacral colpopexy

continuous barbed sutures

interrupted sutures