This video demonstrates our technique for post-hysterectomy laparoscopic utero-sacral ligament suspension. Utero-sacral ligament suspension is a common surgical procedure frequently performed at the time of a hysterectomy to address apical prolapse. Sacral copal pexi, or sacral spinous ligament suspension, are predominantly performed in patients with a past surgical history of a hysterectomy. Apical anatomical success rates for utero-sacral ligament suspension have been comparable to sacral copal pexi in the literature. Laparoscopic approach to utero-sacral ligament suspension demonstrates better visualization, decreased ureter obstruction, and an opportunity for bladder dissection to improve anterior compartment anatomical outcomes as compared to vaginal surgery. This video will demonstrate our surgical technique for laparoscopic utero-sacral ligament suspension as another option for patients with the need for post-hysterectomy apical suspension. Our patient is a 58-year-old, G4, P3, with symptomatic stage 3 pelvic organ prolapse. She had a history of a total abdominal hysterectomy 30 years ago and strongly desired no usage of mesh for her surgical procedure. Her POPQ is demonstrated here. We believe setting yourself up for surgical success begins with optimal port placement for laparoscopic suturing. The surgeon stands on the left side of the patient, a 10-mm umbilical port is placed, two left-sided ports are placed, one 10-mm port parallel to the umbilical port along with a 5-mm left lower quadrant port. A right-sided 5-mm assistant port is finally placed. The surgical procedure commences with a Foley catheter in place decompressing the bladder and a stent in the vagina identifying the vaginal apex. Opening of the peritoneum at the level of the bladder flap is created and dissected to the layer of the underlining endopelvic fascia. Careful dissection of the bladder along the anterior vaginal wall is performed using a combination of sharp and blunt dissection with endoshears and kitteners. Anterior dissection is performed ideally to the level of the trigone to include the anterior vaginal wall into the utero-sacral ligament suspension sutures to address anterior compartment prolapse at the time of apical repair. After anterior wall dissection, a second surveillance of the pelvic anatomy is performed with clear identification of the ureters prior to placement of sutures into the utero-sacral ligament. The distance between the ureters and the utero-sacral ligaments are closest at the most distal end of the ligament described in literature at approximately 1 cm. The middle portion is approximately 2.4 cm in distance between the two structures and the largest distance is noted at the most proximal portion of the ligament with a distance of approximately 4.1 cm away from the ureter. The utero-sacral ligament is grasped with the marrow lint and a clear peristalsis of the ureter is demonstrated here. The right utero-sacral ligament is grasped at the mid-portion and sutures pass completely through the ligament twice to placate the ligament midway and then down to the base of the ligament at the posterior insertion of the vaginal wall incorporating the posterior portion of the vaginal wall. The suture is then brought up to the anterior vaginal wall where two consecutive passes are performed to incorporate any anterior prolapse. We use 0 monofilament nylon on a GS21 needle passed through the left-sided 10 mm port on a Romeo needle driver. The marrow lint grasper through the left lower quadrant 5 mm port is used for manipulation of the tissue and to suture from the right to left of the pelvis. The suture is then passed within the left utero-sacral ligament in a mirrored fashion to the right incorporating the posterior vaginal wall with a second pass again at the mid-portion of the ligament to placate the ligament. The needle is carefully grasped and removed from the body. Extracorporeal knot tying is performed with a closed-loop knot pusher. A second suture is used in similar fashion to increase anterior wall and apical suspension. Cystoscopy is performed to confirm bladder integrity and urinal patency. Laparoscopic ports are then closed at the end of the procedure. A follow-up exam for our patient at 2 months demonstrated stage 1 support. In conclusion, post-hysterectomy laparoscopic utero-sacral ligament suspension provides a native tissue option for patients with apical prolapse. Thank you very much for the opportunity to demonstrate our surgical technique.

laparoscopic utero-sacral ligament suspension

post-hysterectomy

apical prolapse

surgical procedure

bladder dissection