Retroperitoneal sacrocolpopexy with hysterectomy is a standard surgical procedure for pelvic organ prolapse treatment, yet existing approaches have limitations. Current gold-standard methods, including abdominal and laparoscopic or robotic-assisted techniques, typically involve abdominal incisions, necessitate peritoneal dissection, and pose a significant risk for bowel complications, as well as post-operative constipation and discomfort. We introduce a novel technique combining vaginal access with a purpose-built Da Vinci Single-Port (SP) robotic system (Intuitive Surgical Inc, Sunnyvale, CA), aiming to enhance patient outcomes and utilize natural orifice transluminal endoscopic surgery (NOTES).

Single female cadaver was placed in dorsal lithotomy position with Trendelenburg. Vaginal incision was made at the posterior fornix for retroperitoneal access, followed by transvaginal placement of a purposebuilt SP Access Kit. The SP robot was directed caudo-cranially utilizing a floating dock technique, and retroperitoneal dissection was achieved from the rectovaginal pouch to the sacral promontory. Total vaginal hysterectomy, bilateral salpingoophrectomy (TVH, BSO) was performed. Mesh fixation to the anterior longitudinal ligament and vaginal mucosa using a pulley system was done for prolapse reduction.

Initial findings indicate the feasibility and safety of our technique. Benefits include enhanced surgical precision, complete preservation of the peritoneum and intraperitoneal organs, improved visualization of the pre-sacral area, and favorable cosmetic outcomes. However, limitations of our technique include the confined space and restricted angles of access, making achieving adequate exposure in the retroperitoneal space more challenging. Additionally, suturing at the proximal end (sacral promontory) may be difficult when the distance from the vaginal skin exceeds 24 cm. Immediate post-procedure results demonstrate robust apical support and completely performed vaginal NOTES, via the SP system.

Extraperitoneal dissection for robotic sacrocolpopexy using a single-port robotic Da Vinci system is an advancement in pelvic reconstructive surgery. Benefits include enhanced surgical precision, complete preservation of the peritoneum and intraperitoneal organs, improved visualization of the pre-sacral area, and mitigation of the risk for intraperitoneal organ injury especially in hostile abdomens. The SP robot's narrow profile, flexible endoscope, and double-jointed instruments allow transvaginal retroperitoneal access to improve surgical outcomes. Limitations include the need for a learning curve working in a confined space and restricted angles of access. Further work on mesh placement is ongoing. Continued refinement and rigorous evaluation are imperative to optimize surgical outcomes.

In conclusion, our novel extraperitoneal transvaginal dissection technique for robotic sacrocolpopexy using the Da Vinci Single-Port system represents a significant advancement in pelvic reconstructive surgery, with the aim of enhancing patient outcomes and leveraging natural orifice transluminal endoscopic surgery (NOTES).