A case of robot-assisted sacrocolpopexy for atypical internal iliac vein inflow: a case report

Introduction: In sacrocolpopexy, a mesh is fixed to the anterior longitudinal ligament of the sacrum, near the bifurcation of the iliac vessels, but variations in the iliac venous system may increase the risk of massive bleeding during dissection. We report a successful robot-assisted sacrocolpopexy (RASC) in a patient with a left internal iliac vein anomaly and present the findings and review the literature. Presentation of case: A 71-year-old, gravida 3, para 3 woman was scheduled for RASC due to bladder and uterine prolapse. Preoperative magnetic resonance imaging (MRI) revealed that the left internal iliac vein coursed anterior to the sacral promontory. The bifurcation of the common iliac vein could not be identified intraoperatively. Upon dissection of the inferior vena cava, the left external and internal iliac veins were found to drain directly into the inferior vena cava, with the left internal iliac vein coursing anteriorly to the sacral promontory. After confirming that the sacrum was caudal to the anomalous vessels, the mesh was fixed to the anterior longitudinal ligament without any complications. Discussion: Preoperative recognition of venous anomalies is crucial to avoid catastrophic bleeding during sacrocolpopexy. Preoperative imaging, such as MRI, plays an essential role in delineating the vascular anatomy, and meticulous intraoperative dissection is indispensable. Although RASC lacks tactile feedback, its superior visualization and precise instrument control facilitate safe management of complex vascular variations. Conclusion: RASC is extremely useful in venous anomalies, provided that thorough preoperative imaging evaluation and meticulous intraoperative dissection are ensured.