At this point and still prior to docking, it is also important to identify the ureters, the sacral promontory
, the midline with the sigmoid retracted, the middle sacral vessels, and the iliac vessels.
* Sacral attachment sutures should be placed in the anterior longitudinal ligament distal to the sacral promontory
to avoid the L5-S1 disc.
After this plication, attach the mesh somewhat loosely to the sacral promontory
without putting it under tension.
"The sacral promontory clearly is the strongest reattachment site," said Dr.
The investigators placed a single interrupted suture of #1 Prolene through the fascia of the sacral promontory, S1, S2, and S3 using eight alternating square knots.
Mean pull-out strengths were: 33.2 pounds for sutures secured at the sacral promontory; 23.4 pounds for S1; 16.7 pounds for S2, and 10,5 pounds for S3.
* Visualization and access to the sacral promontory may be compromised if the camera is inserted too low on the anterior abdominal wall
3 Dissect the sacral promontory and create a retroperitoneal tunnel
[TIP] When you attempt robotic sacrocolpopexy for the first time, it may help to identify the sacral promontory, using a standard laparoscopic instrument with haptic feedback, before you dock the robot.
Elevate the peritoneum overlying the sacral promontory and open it using monopolar cautery.
* In trying to find the sacral promontory, you risk entering the right common iliac vein if dissection is too far cephalad and lateral.
* In securing the mesh to the sacral promontory, you can puncture the left common iliac vein if you are not aware of the exit point of the needle and it traverses too far medially.