Decay technique. An oval technique for laparoscopic apical suspension using barbed sutures. Hysterectomy is the most common gynecological procedure performed for common female pelvic disorders. There is a steady increase in the percentage of this procedure done laparoscopically. Vaginal vault prolapse is a recognized and fraught complication after hysterectomy. A recent study does highlight the importance of apical support at the time of hysterectomy, especially if prolapse is present. Failure to address apical support at the time of hysterectomy will increase the risk of this complication. The widely accepted levels of pelvic support were outlined by the work of Dr. De Lancey. His work did highlight the importance of the uterus sacral ligament in maintaining apical support. The ligament originates from the cervix and or the vagina and inserts into the sacrospinous ligament, coccygeus muscle, and the sacrum. Most of the surgical techniques developed to reconstruct the apical support utilize the uterus sacral ligament for anchoring of the vaginal vault. The procedure can be done vaginally and laparoscopically with the most common complication being a retro injury. The video we present does stress the importance of appropriate apical support at the time of hysterectomy, especially if prolapse was present at the time of surgery. It also does highlight the critical anatomical landmarks that are vital to reduce the risk of complications. The technique is a modification of an established concept with utilization of barb suture technology. In this patient, the ureter was easily visualized through the peritoneum. Using gentle inward and upward pressure using the uterine manipulator, the uterus sacral ligaments are easier to identify. Since the anatomy is more difficult to identify after the hysterectomy, the uterus sacral ligaments were tagged using surgical clips. We will highlight two steps during the hysterectomy that we do believe are critical to ensure adequate and more durable support. The first being the exposure of the anterior endopelvic fascia and dissection down to the level of the wide shiny tissue. For demonstrative purposes, the left pelvic peritoneum was incised in a way to expose the uterus sacral ligament and the ureter of course. At this point, the hysterectomy is continued as per the standard techniques, with the only exception being that the colpotomy incision should be done above the level of the uterus sacral ligaments. We do believe that it is critical to maintain the uterus sacral ligament cervical attachments to ensure more adequate and durable abdical support. After adequate hemostasis, the vaginal cup is closed using two barb sutures. The first layer of closure will incorporate the innermost layer of the vaginal mucosa with the underlying muscularis. Suturing will be done in a continuous fashion till the midline and the same will be done on the other side. The VLOC 180 sutures were used because of its comparable durability to the PDS sutures that are usually used for vaginal or laparoscopic uterus sacral ligament suspensions. After closure of the first layer, each suture is used to incorporate the endopelvic fascia with the uterus sacral ligament using the K technique. It is very important to maintain an adequate distance between the bladder and the edge of the endopelvic fascia. As demonstrated by the diagram, the first step would be the purchase of the endopelvic fascia, the anterior and posterior vaginal wall along with the mid-segment of the uterus sacral ligament, ensuring at all times safe distance between the uterus sacral ligament and the ureter. The second pass will also incorporate a more lateral part of the endopelvic fascia, anterior and posterior vaginal wall. And after that, a more lateral part of the uterus sacral ligament will be incorporated as well. Ensure at all times adequate visualization of the uterus sacral ligament cores as well as the ureter to avoid injury. The same technique is done on the other side. And then the mid-segment of the uterus sacral ligament is grasped for adequate purchase. You can see that at all times the ureter on the lateral side is shown to be at a safe distance from the uterus sacral ligament. You can see how the surgical clips that were placed at the most proximal and distal part of the uterus sacral ligaments did help delineate the anatomy for adequate support and placation after the hysterectomy. Now after the uterus sacral ligaments that come together in the midline, you can see how the uterus sacral ligaments and the vagina do make the letter K. To maximize benefit of using the barb sutures, maintain adequate tension on the tissue and ensure adequate approximation of the uterus sacral ligaments to the vaginal wall with each pass. Here you can see how important it is to keep the bladder at a safe distance so that the suture would not inadvertently pass through the bladder mucosa. After the third pass is passed through the most proximal part of the uterus sacral ligament, adequate tension is applied to ensure adequate lift. And using one of the sutures, a cold of plastic can be performed by purchasing the intervening peritoneum between the uterus sacral ligaments to decrease the risk of interseal formation. This patient had a uterine prolapse stage 2 for which permanent sutures were felt to provide additional support and decrease the risk of recurrence. It is very important to avoid the permanent suture entry into the vaginal epithelium to avoid erosion and granulation tissue formation. Barb sutures do have an excellent track record in providing an equivalent surgical outcome with less time and more ease. And that is why we believe that the K technique would help the generalist OBGYN who does the main bulk of these surgeries and would help decrease the burden of post-hysterectomy prolapse morbidity.

apical support

hysterectomy

vaginal vault prolapse

uterus sacral ligament

barbed sutures