To date, there are no standardized robotic dry lab training resources that include pre-sacral dissection with vaginal and sacral mesh attachment for robotic sacrocopalpexy. Therefore, our objective was to create a pelvic simulation model to resemble the anatomy encountered at the time of robotic copalpexy. Additionally, we sought to outline the necessary tasks and subtasks required to complete a robotic copalpexy by performing a hierarchical task analysis. First, we obtained a bony pelvis including L4 and L5 vertebrae. The anterior longitudinal ligament was created by placing a piece of surgical tape over the pre-sacral space. In this image, you can see the middle sacral artery, left common iliac vein, aorta and its bifurcation, and ureter. Next, quilt batting was placed over the vasculature and ureter to simulate the areolar tissue under the peritoneum. The vaginal cuff was prepared by previously closing it with a running barbed suture and it was secured at the pubic arch. Next, the peritoneal layer was placed and secured with binder clips attached to the periphery of the bony pelvis. The pelvic model was then placed into the robotic exercise kit. According to our hierarchical task analysis, the first subtask at the time of robotic sacrocopalpexy is survey of the pelvis. The pre-sacral dissection begins with the visual inspection of the ureter at the bifurcation of the right common iliac artery. Medial to this, the sacrum can be palpated and the peritoneum overlying the pre-sacral space is grasped, elevated, and opened. Extending this incision both caudally and cephalad exposes the pre-sacral space. The areolar tissue is then dissected away to identify the location of the anterior longitudinal ligament near the S1 and 2 sacral vertebral bodies. Due to limitations of the model, there was no opportunity to simulate the vesicovaginal or rectovaginal dissection. Here, you can see that the mesh was trimmed to the proper length and placed into the surgical field. Several interrupted sutures are placed on the anterior vaginal wall. This model does not allow for placement of a vaginal manipulator and that portion of the procedure, therefore, cannot be simulated. With the assistance of the third arm, the vagina is deviated anteriorly to expose the posterior vaginal wall. Several interrupted sutures are placed on the posterior vaginal wall. The tension is then turned back to the sacrum and the mesh is fixed to the anterior longitudinal ligament at the level of S1, S2. Various suture or mesh types can be used in this simulation model and surgeons or trainees are not limited to the materials displayed here. After two sutures are placed in the anterior longitudinal ligament, the peritoneum is closed over the mesh to complete the procedure. Some strengths of this model are the ability for immediate feedback on surgical performance and reusability. Surgical skills such as knot integrity and knot placement can be evaluated to ensure that sutures are placed at the anterior longitudinal ligament at the level of S1, S2. For repeat use of the model, the knots are simply removed to release the mesh. The mesh remains intact and can be used repeatedly. The vaginal cuff is also able to sustain multiple uses. The quilt batting can be rotated to allow for multiple uses as well. The vessels and various organs are made with molds using smooth-on, The vessels and various organs are made with molds using smooth-on EcoFlex and can be recreated when necessary. A new peritoneum, also made with smooth-on EcoFlex, is required with each use and is secured in place with binder clips. In conclusion, we present a dry lab pelvic model to simulate robotic sacrocopalpexy. The HTA construction provides a method by which to assess the model's ability to replicate each step of the robotic sacrocopalpexy. The HTA results will be used in future construct validity testing of the model. Through ongoing validation studies, we hope to objectively show that this model is useful as a training tool. Thank you.

pelvic simulation model

robotic sacrocopalpexy

hierarchical task analysis

anatomy

training tool