This course provides you the practical knowledge for an individual surgical procedure.
- a clear understanding of the steps to be taken to execute the procedure;
- seen an example of how the procedure is executed;
- a clear understanding of all anatomical structures encountered during the procedure;
- seen an example of how the anatomical structures look within the setting of the procedure.
Step by step
Abdominal cavity approach
Introduce five trocars to gain access to the abdominal cavity (in da Vinci Si type; In Xi type the trocar placement may differ slightly). First the camera port is inserted just below the umbilicus. Trocar 1 and 3 are located just medial to the anterior superior iliac spine. Assistant and trocar 2 are placed between the camera and the other two ports.
Insufflate gas into the abdominal cavity to produce a pneumoperitoneum.
Fixate the uterus to the anterior abdominal wall to give more exposure and ease the dissection of the rectovaginal septum later on.
Place a straight needle proximal to the pubis into the abdominal cavity. The straight needle is placed from dorsal to ventral through the uterus and is then stuck back through the abdominal wall again. The thread is knotted extracorporeal over a gauze, suspending the uterus to the abdominal wall.
Retract the sigmoid to the left lateral side to gain exposure of the peritoneum.
Identify the peritoneum and the underlying promontory, iliac vessels and ureter.
Incise the peritoneum over the promontory until the bone is visible without overlying structures.
The incision should not be medially as the hypogastric nerve lays there. The peritoneum should be opened slightly on the right lateral side and the nerves should be carefully moved away from the promontory bone where the mesh will be fixated.
Extend the incision in the peritoneum starting from the promontory downwards to the rectouterine (or rectovesical) pouch. Here a J-shaped incision of the peritoneum is made.
Rectovaginal/ rectoprostatic septum
Dissect the avascular rectovaginal or rectoprostatic septum between the dorsal side of respectively the vagina or prostate and the ventral side of the rectum to approximately 1.5 cm proximal of the anal verge.
Correct plane identification
If adhesions between the dorsal side of the vagina and the ventral side of the rectum are present (eg. after previous hysterectomy), the dissection plane can be unclear. An obturator might be helpful to identify the vaginal contours and guide the dissection.
Perform rectal examination to confirm whether the dissection of the rectovaginal or rectoprostatic septum is conducted to approximately 1.5 cm of the anal verge.
Position the mesh from the deepest point of the rectovaginal/rectoprostatic space (1.5 cm from the anal verge) towards the exposed promontory.
Fixate the mesh on the rectum at least 7 times with non-absorbable woven sutures. Then fixate to the promontory (eg. with 4-5 tacks or 3-5 non-absorbable woven sutures).
After placement of the sutures the traction force on the rectum should be divided equally over the tissue.
Close the incised peritoneum over the mesh with a running suture.
Incomplete peritoneal closure
If the peritoneum is closed incompletely and the mesh is not completely covered, the small intestine may attach itself to the mesh. This could complicate the postoperative course (postoperative ileus due to adhesions or rotation).
A self-anchoring barbed suture can be used, but alternatively an absorbable braided suture may be used, ensuring the whole mesh is covered with peritoneum.
Reposition the suspended uterus under laparoscopic vision (risk of bleeding).
Remove the trocars under laparoscopic vision.
Close only the fascia of the 12 mm camera port with absorbable braided sutures (see procedure “Trocar placement”).
Close the skin with absorbable monofilament sutures intracutaneously.