Robotic Sacrospinous Ligament Suspension

Video Objective To describe a robotic approach for performing a sacrospinous ligament suspension. Setting A 78 year-old woman presented with stage 3 uterine prolapse with the sole complaint of vaginal pressure. She had no urinary or bowel dysfunction. Her gynecologic surgical history included anterior and posterior vaginal wall mesh-augmented repairs. On examination, she had uterovaginal prolapse with underlying palpable uterus and calcified fibroid and the leading edge of he cervix at +6 cm from the hymen. Anterior, posterior and introital measurements on POP-Q were normal. This represented an isolated stage 3 Uterine Prolapse. Interventions A robotic hysterectomy with bilateral salpingo-oophorectomy was completed. Uterosacral ligaments were attenuated and could not be utilized for vaginal apical support. Alternatively, a robotic right sacrospinous ligament suspension was attempted successfully. Steps for this procedure include: developing the right pararectal space, identifying the levator ani muscles and sacrospinous ligament followed by suspension of the vaginal cuff to the sacrospinous ligament using resorbable suture. This surgical clip demonstrates the technique. Conclusion A robotic approach can be utilized for vaginal apical suspension to the sacrospinous ligament when uterosacral ligaments are attenuated. Pelvic floor and sidewall anatomic knowledge is required for successful completion of this procedure.