da Vinci® Sacrocolpopexy for
Vaginal Vault or Uterine Prolapse:
Lessons Learned
Oz Harmanli, MD
Chief, Urogynecology and Pelvic
Surgery
Baystate Medical Center
Professor of OB/GYN
Tufts University School of
Medicine
Massachusetts
Apical Prolapse
Vaginal apex is
the keystone
Any surgical correction
of the anterior and posterior
walls will fail if the apex is
not adequately supported
Procedures for Apical Support
 Sacral colpopexy
 Sacrospinous ligament fixation
 Utero-sacral ligament suspension
 Ilio-coccygeus suspension
 Vaginal mesh systems such as Prolift, Avaulta,
Perigee/Apogee and etc.
Apical Prolapse Surgery
 Cochrane Database Analysis for abdominal sacral colpopexy versus
vaginal sacrospinous colpopexy
 3 trials (Benson 1996; Lo 1998; Maher 2004)
 Abdominal sacral colpopexy was better than vaginal colpopexy in terms
of
 Lower rate of apical recurrence (3/84 vs 13/85; RR 0.23, 95% CI 0.07
to 0.77)
 Higher success rate (The number of women failing to improve to
Stage 2 or better) (3/52 vs 13/66; RR 0.29, 95% CI 0.09 to 0.97)
 Lower postoperative dyspareunia (7/45 vs 22/61; RR 0.39, 95% CI
0.18 to 0.86)
 No significant difference in reoperation rate for prolapse (6/84 vs 14/85,
RR 1.46, 95% CI 0.19 to 1.11)
 Sacrospinous colpopexy was
 Quicker
 Cheaper
 Faster return to normal activities
 The data were too few to assess other clinical outcomes and complications
Maher et al. Neurourology and Urodynamics 2008
Sacral Colpopexy
Abdominal Sacral Colpopexy
 Elevation of vaginal vault to Sacral 2 utilizing a
mesh bridge
 Abdominal, laparoscopic, or robotic approach
 May change the vaginal axis (if sacral promontory
is used)
 85-90% success rate
 May be done with cervical preservation as a
cervicopexy
 Mesh erosion around 3-5 %, higher with
concomitant hysterectomy
Nygaard, Obstet Gynecol 2004, Kohli , Obstet Gynecol 1998
da Vinci Robotic Surgery
Benefits

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All the benefits of standard
laparoscopy
Tremor filtration
Motion scaling
3D vision
EndoWrist® instruments with 7 degrees
of freedom
4th arm to perform traction and
retraction tasks
Net result: Improved technical
capabilities
5 cm
1 cm
Patient Benefits
Same as Standard Laparoscopy






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Less post-operative pain
Less blood loss
Fewer transfusions
Less risk of infection
Less scarring
Improved cosmesis
Shorter hospital stay
Faster recovery time
Equivalent
urogynecologic
outcomes
Surgeon Benefits







Improved access to the pelvis
Easier, more precise dissections
Improved handling of suture and
mesh
Easier, quicker and more precise
intracorporeal suturing
Control of camera and 3rd
instrument arm adds precision,
autonomy and efficiency
No short cuts just because it is
minimally invasive surgery
Easier to learn, perform and
teach
Surgeon Benefits
•
•
•
•
Precise dissection
Intracorporeal suturing
Mesh handling
Graft attachment
da Vinci Sacrocolpopexy:
Proven Results
 When compared with open techniques, robotic
abdominal sacrocolpopexy is associated with less
blood loss, shorter lengths of stay, and longer operative
times
 Geller Obstet Gynecol 2008
 McDermott Obstet Gynecol Clin North Am 2009
da Vinci Sacrocolpopexy:
Proven Results
E.J. Geller et al. Short-Term Outcomes of Robotic Sacrocolpopexy Compared With
Abdominal Sacrocolpopexy. Obstetrics & Gynecology. 2008;112:1201–6
Robotic
Sacrocolpopexy
N=73
Open (Abdominal)
Sacrocolpopexy
N=105
P Value
Pre-op POP-Q Exam: C point*
+3
+1
0.002
Concomitant Hysterectomy
47.9%
29.5%
0.02
Total Operative Time (min)
328
225
<0.001
Post-op POP-Q Exam: C point*
-9
-8
0.008
EBL (ml)
103
255
<0.001
Length of Stay (days)
1.3
2.7
<0.001
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


73 v 105 patients
Higher POPQ values and more concomitant hysterectomies in the robotic group
 Blood loss and length of stay in the robotic group
C point suspension superior to open cohort results
Obstet Gynecol 2014
 Costs of robotic sacrocolpopexy are higher than
laparoscopic
 Short-term outcomes and complications are similar
 Primary cost differences resulted from robot
maintenance and purchase costs.
Robotic vs Standard
Laparoscopic Sacrocolpopexy
Anger et al.
Systematic Review of Robotic
Sacrocolpopexy
Hudson et al FPMRS 2014
 13 studies were selected for the systematic review.
 Meta-analysis yielded a combined estimated success
rate of 98.6% (95%CI 97.0–100%)
 The combined estimated rate of mesh
exposure/erosion was 4.1% (95%CI 1.4–6.9%)
 The rate of reoperation for mesh revision was 1.7%
Systematic Review of Robotic
Sacrocolpopexy
Hudson et al FPMRS 2014
 The rates of reoperation for recurrent apical and non-
apical prolapse were 0.8% and 2.5%
 The most common surgical complication (excluding
mesh erosion) was cystotomy
 (2.8%), followed by wound infection (2.4%).
Baystate Medical Center
Tufts University School of Medicine
Massachusetts
Oz Harmanli, MD
Keisha Jones, MD
Beril Yuksel, MD
Faisal ElJehani, MD
University of Massachusetts
Isenberg School of Management
Massachusetts
Senay Solak, PhD
Armagan Bayram, PhD
• This research was funded by an unrestricted educational grant
from Intuitive Surgical Inc.
Optimizing Operating Room Efficiency in
Robotic Surgery
Objectives
 To assess the critical threshold to optimize operating
room time for each surgical team member in robotic
sacrocolpopexy.
1.
2.
Evaluate the peak and plateau of the performances for each
surgical team member
Determine the most optimal team configurations
Optimizing Operating Room Efficiency
in Robotic Surgery
Optimal Experience Level





Doctor
First Assistant
Anesthesia Provider
Scrub Technician
Circulating Nurse
44
13
46
66
56
Console Time for Surgeon by Experience
Descriptives
Davinci
N
Mean
Std.
Deviation
Std. Error
95% Confidence Interval for
Mean
Minimum Maximum
Lower Bound Upper Bound
1.00
2.00
3.00
Total
62
48
210
320
176.8226
141.0833
109.4190
127.2281
51.09442
44.75077
35.98811
48.56474
6.48900
6.45922
2.48342
2.71485
163.8470
128.0891
104.5233
121.8868
189.7981
154.0776
114.3148
132.5694
59.00
18.00
41.00
18.00
325.00
259.00
227.00
325.00
 The Console Time of an inexperienced surgeon
can be up to 1 hour longer
First Assistant’s Experience Level and
Console Time
Descriptives
Davinci
N
Mean
Std.
Deviation
Std. Error
95% Confidence Interval for
Mean
Minimum Maximum
Lower Bound Upper Bound
1.00
2.00
3.00
Total
13
14
293
320
149.6923
133.2857
125.9420
127.2281
74.59936 20.69014
59.49975 15.90198
46.52330 2.71792
48.56474 2.71485
104.6124
98.9316
120.5928
121.8868
194.7722
167.6398
131.2912
132.5694
66.00
59.00
18.00
18.00
325.00
240.00
295.00
325.00
 While some difference (up to around 25 minutes) in
average Console Times exists for FA with different
experience levels, these time differences are not
sufficient to claim a statistically significant distinction
Does the Time of the Robotic
Procedure Matter?
 Specifically, the impact of the shift change in the
afternoon
 Cases which start before 11am were significantly shorter
than those that start after 11am
 The average difference was 12 minutes
The Role of a Dedicated Anesthesia
Provider
 Effect of a highly experienced Anesthesia
Provider on OR time and specifically surgery
prep time was studied
 No significant difference in total OR times
(which may be due to the effects of other
factors)
 However, prep times was significantly different
The Most Optimal Team Configurations
Based on the Stochastic Model
 The optimization tool can be used at a hospital to
determine the `best’ surgical team assignments for any
set of available team members with known experience
levels
Practical Implications of
the Stochastic Model
 If a Surgeon has low experience, it is better to match him
with more experienced First Assistant
 If a Surgeon has high experience, it is fine to match him
with less experienced First Assistant and Scrub
Technician
 If both the Surgeon and First Assistant are not as
experienced it is better to match them with an
experienced Scrub Technician
Practical Implications of
the Stochastic Model
 A low-experienced Scrub Tech should be matched with
either a more-experienced Surgeon or First Assistant
 We do not recommend to team up a low-experienced
Surgeon, First Assistant, and Scrub Tech
 If the anesthesia provider has more experience, it is fine to
have a less experienced Circulating Nurse, however if
anesthesia provider has less experience, it is best to match
with a more experienced Circulating Nurse
 Low-experienced Circulating Nurse should be teamed with
an experienced Surgeon or vice versa