TITLE:
Robotic Assisted Laparoscopic Apical Suspension. Description of a 4 Points Technique (RALAS-4): First Case Reported
AUTHORS:
Hugo H Davila, Lindsey Bruce, Lindsey Goodman, Taryn Gallo
KEYWORDS:
Apical Prolapse, Vaginal Prolapse, Pelvic Anatomy, Robotic Surgery, Uterosacral Ligament, Cardinal Ligament
JOURNAL NAME:
Open Journal of Obstetrics and Gynecology,
Vol.7 No.9,
September
12,
2017
ABSTRACT: The uterosacral ligaments (UTSL), together with the cardinal
ligament (CL), hold the upper vagina and cervix over the levator plate.
These 2 ligaments provided 4 points support at the apex. Here we describe our
surgical technique of robotic assisted laparoscopic apical suspension (RALAS)
using non-absorbable sutures and describe a new 4 points technique (RALAS-4).
73-year-old Caucasian woman, gravida 5, para 4 had symptomatic pelvic organ
prolapse (POP) apical/anterior stage III. At pelvic ultrasound evaluation the
uterus was small and normal appearing of adnexa bilaterally. She failed pessaries
and was sexually active. The most relevant complaints were vaginal bulging,
pressure and urinary incontinence, mainly stress urinary incontinence; she is
using 5 - 7 pads/day. Robotic assisted laparoscopic hysterectomy, mid-urthral sling
and apical suspension was successfully performed in 125 min. Once we finished
with hysterectomy, we proceed with RALAS-4, we used V-Loc 3-0, CV-23 (Covidien)
sutures (absorbable) on the right and left uterosacral ligaments (2 points) and
theses were reinforced with Gore-Tex 2-0, CV-2 (non-absorbable, Gore Medical).
On the right/left anterior apical support we used Gore-Tex 2-0 and these
provided the 2 point suspension (UTLS = 2 and
anterior vagina = 2). The 2 anterior apical support sutures are taken from the vagina to
the transversalis fascia and the obliterated umbilical artery on the anterior
abdominal wall. The tension of these anterior sutures was maintained with
Hem-o-lock (TeleFlex) and LAPRA-TY (Ethicon). In our opinion RALAS-4 may
represents an alternative to robotic or laparoscopic sacrocolpopexy. This new
approach simulate the natural 4 points support given by uterosacral ligaments
and cardinal ligament, with the additional benefit of no mesh and no dissection
on the sacrum promontory. With this technique we are chasing the Trifecta: no
mesh, no complications and good anatomic support.