This video presents a series of MRI and intraoperative findings in four women to illustrate challenging anatomic variations around the sacral promontory.
The first patient is a 70-year-old female with symptomatic vault prolapse with associated cystocele and rectocele. Her pre-operative MRI with defecography found a bulging disc at L5-S1 and a large amount of fat overlying the promontory. During the procedure, the pre-sacral space was gradually entered. With the help of the suction tip and the tip of the robotic scissors, the area of the promontory was finally identified and exposed, despite bleeding and difficulty due to the thickness of the adjacent fatty meso-colon.
The second patient is a 74-year-old female with symptomatic recurrent vault prolapse post-hysterectomy, with an associated cystocele and rectocele. Her MRI prior to defecation illustrates a very large amount of fat between the sacrum and the bowel loops. During the robotic procedure, we were unable to identify the precise location of the promontory due to excess fatty tissue despite probing with the suction tip and the tip of the scissors. Due to these challenges, our dissection location was too medial. We encountered the left common iliac vein, which, fortunately, was not injured. However, this anatomic landmark did help us redirect our dissection more medially and caudally. Finally, after deeper dissection, we were able to identify the white shiny surface of the anterior longitudinal ligament.
In our third patient, a 77-year-old female with vault eversion, her pre-operative MRI defecography study demonstrated a loop of colon in front of the promontory. During the robotic procedure, the colon was identified to be directly over the promontory. In the video, we had to gently dissect and retract the colon with the Prograsp to adequately expose the anterior longitudinal ligament underneath.
Finally, our last patient was a 69-year-old female with very symptomatic vault prolapse and recurrent cystocele with a history notable for prior spinal hardware from a back fusion at L3 to L5. Unfortunately, no operative notes to confirm the exact location of her plates and screws were available. Pre-operative discussion with our orthopedic colleagues reviewing her plain films concluded that the anterior longitudinal ligament would likely not be intact in this area. This impression was reinforced by the MRI which revealed artifact from the hardware in the exact area of the dissection over the promontory. In such a scenario, one could consider a lower presacral anchoring site or an alternative fixation technique such as the peritoneal colpopexy using v-lock sutures, as previously described [2].