A Presacral Fixation Simulation Surgical Training Model for Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) Sacrocolpopexy

Objective

The number of sacrocolpopexies performed with transvaginal natural orifice transluminal endoscopic surgery (vNOTES) is increasing, and presacral fixation is the most dangerous step. Therefore, the training opportunities for trainees to become competent in performing vNOTES sacrocolpopexy are very important. Simulation-based training is ideal for filling this gap. The objective of this video article is to demonstrate a simulation surgical training model in vNOTES presacral fixation.

Setting

The Department of Gynecology at a university hospital.

Participants

A urogynecological surgeon.

Interventions

(1) Establish presacral model (Fig. 1) and pelvic model (Fig. 2). (2) Establish vNOTES single-port platform. (3) Steps of vNOTES presacral fixation: (a) Identify the sacral promontory and right hypogastric nerve (rHN), and incise the right pelvic peritoneum. (b) Expose and open the presacral fascia to expose the middle sacral vessels and anterior longitudinal ligament (ALL). (c) Complete mesh fixation. (d) Close the pelvic peritoneum. This study is exempt from IRB approval. Model materials and corresponding costs are given in Table 1.

Conclusion

We present a presacral fixation simulation model during vNOTES sacrocolpopexy. A piece of rubber tissue is attached to pelvic model to accurately simulate the vagina, thus achieving the establishment of the vNOTES single-port platform. The presacral model displays the anatomic hierarchy of presacral exposure: pelvic peritoneum, presacral fascia, presacral space, as well as the ALL, rHN, ureter, and presacral vessels, which are embedded in these layers. Presacral slope design enables realistic presacral suture and mesh fixation. In case of nerve, blood vessel, or ureteral injury during dissection, this model simulates the manifestation through the leakage of different colored liquids. This new model allows the next generation of urogynecological surgeons to acquire adequate training to make them more prepared to perform their initial vNOTES sacrocolpopexy on a patient, possibly increasing future safety and effectiveness.