Women with symptomatic uterovaginal prolapse may be treated with a variety of surgical procedures. We present a case of a woman with stage 2 apical and anterior wall prolapse who desired uterine preservation and elected to have a non-synthetic mesh repair. The procedure begins with positive identification of the ureters to make sure there is enough distance between the ureters and the uterus sacral ligaments. The uterine manipulator is elevated and directed to the contralateral side to identify the left uterus sacral ligament and an initial purchase of the proximal ligament is taken with a CVO Gore-Tex suture. The two ends of the suture are then elevated and a second deeper purchase of the ligament is taken with care to avoid the ureter and the rectum. We then reef the peritoneum to prevent the development of defects in the repair which could result in internal intestinal hernias from bowel getting caught within these defects. Finally, a purchase is taken at the insertion of the ligament to the cervix. This suture is then held but not tied until the contralateral suture is placed so as not to limit access to the area. Again, an initial suture is placed after elevating the uterus with the uterine manipulator to the contralateral side. The sutures are elevated and a second deeper purchase of the proximal ligament is taken. The peritoneum is then reefed superficially, followed again by a deep bite at the insertion of the ligament to the cervix. We then tie down each side using an extracorporeal knot tying technique while the assistant elevates the uterus with the uterine manipulator. Attention is then turned to the paravaginal defect repair. The bladder has been backfilled with a solution of saline and blue dye so that the superior margin of the bladder can be identified. Usually, 200 to 300 cc's of saline is adequate for this purpose. Using monopolar cautery, an incision is made several centimeters above the superior margin of the bladder, staying between the obliterated umbilical arteries in order to avoid the deep inferior epigastric vessels. The space of retzius is entered and the loose areolar tissue is gently dissected, which reveals Cooper's ligaments. Once these structures are identified bilaterally, the bladder is drained, which permits dissection in the paravaginal space. Dissection with a laparoscopic peanut against the surgeon's finger in the lateral vagina is useful to expose the endopelvic fascia. Next, a series of sutures are placed between the detached lateral paravaginal fascia and the arcus tendineus fascia pelvis, or fascial white line, starting near the origin of the white line at the ischial spine and working distally to the bladder neck. The instrument being used here is a reusable, automatic suturing device that both drives and catches a proprietary curved needle with a trigger that the surgeon controls. This instrument requires a 12 millimeter port, which we have placed suprapubically. Each of the other three port sites are 5 millimeters. We are using an extracorporeal knot tying technique, although the knots may also be tied using an intracorporeal technique with the device. Another useful feature of this device shown here is that it may be articulated in order to get a more beneficial angle when taking a tissue purchase. Each of the sutures is placed with one of the surgeon's hands in the vagina, pushing up laterally in order to make sure that a full thickness bite has been taken without having permanent suture exposed in the vagina. Following the repair, the peritoneal incision is closed with a running barbed suture and the 12 millimeter suprapubic port site is closed. We have found this to be an effective surgical treatment for women with symptomatic mild to moderate uterovaginal prolapse with a confirmed paravaginal defect.

surgical procedure

uterovaginal prolapse

non-synthetic mesh repair

paravaginal defect repair

reusable suturing device