Robotic Assisted Laparoscopic Apical Suspension. Description of a 4 Points Technique (RALAS-4): First Case Reported

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 nonabsorbable 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