Sacrocolpopexy (Laparoscopic / Robotic)
5742557280wRVU: 16.3 — Colpopexy, abdominal approach (open sacrocolpopexy)57282wRVU: 11.34 — Colpopexy, extraperitoneal (sacrospinous ligament fixation, vaginal approach)57283wRVU: 11.37 — Colpopexy, intraperitoneal (open abdominal colpopexy, intraperitoneal approach)57268wRVU: 7.38 — Repair of enterocele, vaginal approach (if enterocele sac repaired as separate procedure)
Vaginal vault prolapse [/ uterovaginal prolapse], [stage II/III/IV], symptomatic
Same
[Laparoscopic / Robotic-assisted laparoscopic] sacrocolpopexy with Y-mesh fixation
[Attending name], MD/DO
[Resident/Fellow/PA name]
General endotracheal
The patient is a [age]-year-old [female] with symptomatic vaginal vault prolapse [stage ___] [following total hysterectomy [X] years ago / with uterine descent]. She presents with [pelvic pressure / vaginal bulge / difficulty with defecation / incomplete bladder emptying]. [An enterocele was identified on examination.] Conservative management has been [failed / declined]. Laparoscopic sacrocolpopexy was recommended for durable apical support. The risks, benefits, and alternatives including sacrospinous ligament fixation were discussed and informed consent was obtained.
Laparoscopic exploration confirmed [stage ___] vaginal vault prolapse [/ uterovaginal prolapse]. [An enterocele sac was identified and [opened and ligated / excised] prior to fixation.] The sacral promontory was identified. Three key structures were identified before suture placement: the median sacral artery in the midline, the right common iliac artery laterally, and the right ureter sweeping medially beneath the peritoneum. The anterior longitudinal ligament at the promontory was [well-defined / accessible]. The rectovaginal space developed [without / with minimal] adhesions.
The patient was positioned in the dorsal lithotomy position with the legs in Allen stirrups. General endotracheal anesthesia was induced. A Foley catheter was placed. [A uterine manipulator was placed.] The patient was placed in steep Trendelenburg. Laparoscopic access was established via a [12-mm] umbilical port using [Veress needle / optical trocar / Hasson technique]. The abdomen was insufflated with CO₂ to [15 mmHg]. [Three / four] additional ports were placed under direct vision. [The robotic system was docked.]
The posterior peritoneum overlying the sacral promontory was incised. The median sacral artery, right common iliac artery, and right ureter were identified and confirmed before any suture placement. The anterior longitudinal ligament (ALL) at the S1 level was exposed by sweeping the periosteum and overlying fat.
[Enterocele repair: The enterocele sac was identified in the cul-de-sac, opened, and the peritoneal contents reduced. The sac was ligated with [0-Vicryl] suture at its base prior to mesh fixation.]
The cul-de-sac peritoneum was opened and the rectovaginal space was developed by blunt and sharp dissection between the posterior vaginal wall and the anterior rectum. Dissection was carried distally to the level of the perineal body. The vesicovaginal space was similarly developed anteriorly between the anterior vaginal wall and the bladder base.
A Y-shaped [10 × 4 cm] polypropylene mesh was introduced. The posterior arm was sutured to the posterior vaginal wall with [4-6] interrupted [2-0 PDS / 0-Ethibond] sutures placed through the full thickness of the vaginal muscularis without entering the lumen. The anterior arm was sutured to the anterior vaginal wall with [3-4] interrupted [2-0 PDS] sutures. Vaginal vault elevation was confirmed with each suture pass.
The proximal end of the mesh was fixed to the ALL at the sacral promontory with [2-3] interrupted [0-Ethibond / permanent] sutures, achieving good apical elevation without tension. The presacral space was [free of bleeding].
The peritoneum was closed completely over the mesh with a running [2-0 Vicryl] suture, burying the mesh from intra-abdominal contents to prevent bowel contact and reduce erosion risk.
Cystoscopy was performed confirming bilateral ureteral jets and bladder mucosal integrity. Port sites were closed with [0-Vicryl] fascial closure at the [12-mm] site.
None
[Enterocele sac peritoneum, if sent / None]
[X] mL
None
The patient was taken to the PACU in stable condition. The Foley catheter was removed [in the PACU / on postoperative day 1]. Diet was advanced as tolerated. Ambulation was initiated on postoperative day 1.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Vaginal vault prolapse, stage ***, symptomatic
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: [Laparoscopic / Robotic] sacrocolpopexy with Y-mesh fixation
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General
INDICATIONS: .PTAGE-year-old .PTSEX with stage *** vault prolapse after hysterectomy ***. Failed/declined conservative management. Consent obtained.
FINDINGS: Stage *** vault prolapse confirmed. [Enterocele sac present, ligated.] Promontory anatomy: median sacral artery midline, right common iliac lateral, right ureter medially beneath peritoneum — all confirmed before suture placement. ALL well-defined. Rectovaginal space developed without adhesions.
PROCEDURE:
Dorsal lithotomy, Allen stirrups. Foley placed. Steep Trendelenburg. *** port(s), CO2 to 15 mmHg. [Robot docked.] Posterior peritoneum incised over promontory; three key structures confirmed. ALL exposed at S1. [Enterocele: sac opened, reduced, ligated.] Cul-de-sac peritoneum opened; rectovaginal space developed to perineal body. Vesicovaginal space developed anteriorly. Y-mesh introduced: posterior arm — *** interrupted 2-0 PDS to posterior vagina; anterior arm — *** sutures to anterior vagina. Mesh fixed to ALL at promontory with *** permanent sutures. Peritoneum closed over mesh running 2-0 Vicryl. Cystoscopy: bilateral jets confirmed, bladder intact. Ports closed.
EBL: *** mL
SPECIMENS: ***
COMPLICATIONS: None
DRAINS: None
DISPOSITION: PACU. Foley out POD 1. Ambulate POD 1.
Signed: .ME, .MYDEGREE
.TODAYVariants
Sacrospinous Ligament Fixation (Vaginal Approach)
Sacrospinous ligament fixation (SSLF) was performed as an alternative to abdominal sacrocolpopexy for apical support [given patient preference for vaginal approach / medical comorbidities precluding general anesthesia / surgeon and patient discussion of options]. The patient was positioned in dorsal lithotomy. A posterior vaginal incision was made at the vaginal apex. The right pararectal space was developed bluntly through the right-sided rectal pillar to expose the right sacrospinous ligament, identified as a firm cordlike structure from the ischial spine to the sacrum. The ischial spine and pudendal neurovascular bundle (running medial to the spine) were identified. Two [#1 Prolene / 0-Ethibond] sutures were placed through the sacrospinous ligament [2-3 cm medial to the ischial spine] using [Miya hook / Capio device]. The sutures were passed through the full thickness of the vaginal apex and tied, suspending the vaginal vault to the right sacrospinous ligament. The vaginal incision was closed. Note: SSLF is associated with higher anterior compartment recurrence rates than sacrocolpopexy (due to posterior axis of suspension) and a characteristic buttock/posterior thigh pain from pudendal traction, which typically resolves within 6 weeks. Bill 57282 (11.34 wRVU).
Open Abdominal Sacrocolpopexy
Open sacrocolpopexy was performed via [Pfannenstiel / midline] incision [given prior abdominal surgery with dense adhesions precluding laparoscopic access / concurrent open procedure]. The technique follows the same steps as the laparoscopic approach: posterior peritoneum incised at the promontory, ALL identified, rectovaginal and vesicovaginal spaces developed, Y-mesh sutured to anterior and posterior vaginal walls and fixed to the ALL. The peritoneum was closed over the mesh. Open approach carries equivalent long-term efficacy to minimally invasive sacrocolpopexy with longer recovery. Bill 57280 (16.30 wRVU).
Charting Tips
- Document the three promontory structures identified before suture placement: median sacral artery, right common iliac artery, and right ureter. Presacral vein injury is the most feared intraoperative complication — veins retract into sacral foramina and cannot be clamped. Document 'presacral vessels were visualized and avoided' and have a plan (thumbtack, bone wax, packing) before placing any promontory suture.
- Document enterocele management. If an enterocele sac is not opened and ligated prior to mesh fixation, prolapse will recur through the sac regardless of how well the mesh is secured. Document identification, opening, reduction of contents, and ligation.
- Document cystoscopy with bilateral ureteral jet confirmation. Ureteral kinking during suture placement on the anterior vaginal wall is a recognized complication. Cystoscopy is mandatory at case end — document both jets and bladder mucosal integrity.
- Discitis (spondylodiscitis) after sacrocolpopexy is rare (<1 1,000) and anterior back bone but disc document implant in infectious into legs li ligament longitudinal mri not often or pain placed postoperative radiating removal required.< serious. space. sutures that the to urgent warrants were workup; —>
Billing Tips
- Bill 57425 for laparoscopic sacrocolpopexy (16.60 wRVU, 90-day global). This code applies to both laparoscopic and robotic-assisted approaches — document 'laparoscopic' or 'robotic-assisted laparoscopic' in the operative note; both use 57425. Bill 57280 (16.30 wRVU) for open abdominal sacrocolpopexy.
- Mesh is not separately billable for sacrocolpopexy — it is included in the procedure code. Document mesh type, configuration (Y-shaped vs. straight), dimensions, and fixation points. Abdominal sacrocolpopexy mesh was not subject to the 2019 FDA withdrawal order (which applied only to transvaginal mesh for POP); use is current standard.
- Concomitant procedures are separately billable with modifier -51: midurethral sling (57288) for concurrent SUI, hysterectomy if uterus present and removed (58570/58552), and enterocele repair (57268, 7.38 wRVU) if repaired as a distinct procedure. Document each procedure and indication.
- Sacrospinous ligament fixation (57282, 11.34 wRVU) is the vaginal alternative for apical support — same indication but distinct technique and code. Document approach (abdominal vs. vaginal) clearly.
- 90-day global period: stent removal, wound checks, and pelvic floor follow-up are bundled. Mesh erosion requiring OR excision within 90 days uses modifier -78.