This is a 64-year-old female with multi-compartment post-hysterectomy vaginal vault prolapse. The support of the apex in these cases is highly important. This is a procedure that I am now doing to offer improved apical support of the anterior as well as posterior vaginal apex. In addition, an allograft is utilized to reinforce the apical aspect of the repair. We first begin by evaluating the prolapse. Here we are marking where the apex is and now showing where we want the apex to be once we're completed. We now utilize hydrodissection of the anterior wall and make an incision in the anterior wall, which is a full thickness cut. We now dissect off the underlying tissues, paying close attention to have a full thickness dissection. We're now dissecting back to the vaginal apex. Once we dissect to the vaginal apex, we then begin our dissection on the posterior wall. We again do hydrodissection. A diamond-shaped incision is made at the vaginal introitus, and a linear incision is made along the posterior vaginal wall, coming just short of the vaginal apex. Again, the underlying tissues are sharply dissected away from the vaginal epithelium, and we dissect back to the vaginal apex. We are now dissecting around the vaginal apex until we meet our dissection plane from above. We now begin the repair. We repair the anterior endopelvic fascia, and we're utilizing 2-O PDS suture. We're now dissecting out to the sacrospinous ligament. A lateral approach to the sacrospinous ligament is important to minimize bleeding. A proline suture is placed in the sacrospinous ligament approximately 2 cm from the ischial spine. This is done bilaterally. We're now evaluating the apex. We're going to place our proline sutures in the anterior aspect of the vaginal apex. This is done bilaterally. We do not tie the proline sutures. We're now placing our single incision sling for support of the urethra. We had left a small defect in the endopelvic fascia so that we could place the sling. The single incision sling is placed where it is flush but not tight up against the urethra. We now move to the posterior side of our repair, and we identify the uterus sacral ligaments, and we tie these together for support of the posterior vaginal apex. Two other PDS sutures are utilized on each side of that midline stitch. We're now repairing the posterior endopelvic fascia back to the posterior vaginal apex and uterus sacral ligaments. We now have the posterior aspect of the endopelvic fascia repaired as well as the anterior. We are now contouring the graft, and we will suture it in to the anterior endopelvic fascia, Our proline sutures that are in the sacral spinous ligament are now placed through the graft. We then wrap the graft around the vaginal apex and suture it in to the posterior repaired endopelvic fascia. This is all done with 2-0 PDS suture. We now have graft wrapping around the apex to further support and offer integrity to the vaginal apex. We're now removing posterior vaginal mucosa where it has stretched and lost its integrity. We're going to close the posterior vaginal mucosa. We will remove a small amount of redundant anterior vaginal mucosa, again, removing the area that is stretched and lost its integrity. We will now begin the closure of the anterior vaginal mucosa. And then we will now tie the proline sutures pulling the anterior vaginal apex and graft back to the sacral spinous ligament bilaterally. We will now finish our closure of the vaginal mucosa. To complete the procedure, a perineurophy is performed in the traditional manner. We will perform cystoscopy at the end of the procedure to ensure ureteral patency.

post-hysterectomy vaginal vault prolapse

surgical procedure

apical support

endopelvic fascia repair

sacrospinous ligament support