Introduction: Due to the recognized failure rate of some native tissue repairs, the number of robotic-assisted abdominal sacrocolpopexy (rASC) procedures performed is increasing. However, the anatomy of this presacral space can be variable and closely surrounded by critical structures.
Methods: Our video presents fours cases, which highlight our experience with aberrant or challenging anatomy in the presacral space. In particular, we highlight how preoperative MRI with defecography (MRdef) assisted in identifying these anatomic challenges preoperatively.
Results: The first patient is a 70-year-old female with vault prolapse. Her pre-operative MRdef found a bulging disc at L5-S1 and a large amount of fat overlying the promontory. With the help of the suction tip and the tip of the scissors, the area of the promontory was finally identified and exposed, despite difficulty due to the thickness of the adjacent fatty meso-colon.
The second is a 74-year-old female with vault prolapse. Her MRdef illustrated a large amount of fat over the sacrum. During the rASC, we were unable to identify the precise location of the promontory due to excess fatty tissue. Due to these challenges, our dissection location was too medial. We encountered the left common iliac vein, which, fortunately, was not injured. However, this anatomic landmark did help us redirect our dissection.
The third is a 77-year-old female with vault eversion, her pre-operative MRdef study demonstrated a loop of colon in front of the promontory. During the rASC procedure, the colon was identified to be directly over the promontory, which we gently retracted and dissected to adequately expose the anterior longitudinal ligament underneath.
Finally, our last patient was a 69-year-old female with vault prolapse with a history of a back fusion. Unfortunately, no operative notes to confirm the location of her hardware were available. Discussion with our orthopedic colleagues reviewing her plain films concluded that the anterior longitudinal ligament would likely not be intact in this area. This impression was reinforced by the MRdef, which revealed artifact from the hardware directly over the promontory. In such a scenario, one could consider a lower presacral anchoring site or an alternative fixation technique such as the peritoneal colpopexy, as previously described [2].
Conclusions: Knowledge of the presacral anatomy, and the potential variants, is critical to safely perform a rASC. MRdef is an important tool in both defining the pelvic floor support defects prior to surgery, but also in highlighting difficult anatomy at the sacral promontory to assist with operative planning.
References.
Lee D, Zimmern PE. Abdominal mesh sacrocolpopexy without promontory fixation: initial results of the peritoneocolpopexy technique. J Urol. 2015 Jun;193(6):2089-93. doi: 10.1016/j.juro.2015.01.085
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