Hypogastric Nerve Dissection to Aid in Identification of the Sacral Promontory

Objectives: There are three main objectives of this video presentation. We review the relevant anatomy for presacral dissection during a sacral colpopexy procedure, describe the surgical technique for dissection of the right hypogastric nerve to aid in identification of the sacral promontory, and present a series of presacral dissection examples. In these cases of varying complexity, identification and dissection of the right hypogastric nerve may make a difficult presacral dissection more simple. While this technique can be adopted in all sacral colpopexy approaches, we show examples of robotic surgery.

Methods: Our surgical video was deemed IRB-exempt. We then queried previously recorded de-identified robotic sacral colpopexy surgeries from one Female Pelvic Medicine and Reconstructive Surgery surgeon. We then compiled and edited three case examples of identification and dissection of the right hypogastric nerve.

Clinical Relevance: Robotic sacral colpopexy is a highly effective treatment for pelvic organ prolapse.^1,2 Important anatomy prone to injury such as the right ureter, right common iliac artery, left common iliac vein, and right hypogastric nerve are in close proximity to the sacral promontory.³ To protect the nerve, few case studies describe a nerve-sparing approach during sacral colpopexy, ^4,5 as injury may cause sexual, voiding, and defecatory dysfunction. In contrast, we offer a novel approach for safe entry into the presacral space using the hypogastric nerve as a roadmap to the sacral promontory.