Utero-sacral ligament suspension is a common vault suspension procedure performed for apical repairs. We will demonstrate an extraperitoneal approach to the utero-sacral ligament suspension. This technique is a viable alternative to intraperitoneal access as intraperitoneal entry may be difficult or challenging. The vaginal vault is marked at the apex to delineate the anterior and posterior compartments. Alice clamps are placed on the hymenal remnant to normalize the genital hiatus, the posterior forceps, and the posterior vaginal wall, creating a diamond shape. The tissue is infiltrated and the dissection is begun by incising the vaginal epithelium in between the clamps. A traditional posterior dissection is started and carried upwards to the vaginal apex as marked. The dissection of the fibromuscular layer is continued laterally to the vaginal sulcus on either side of the incision, similar to a posterior colporaphy. Blunt dissection is used in the pararectal space to isolate the utero-sacral ligament. The location of the ureters are confirmed by palpation. The utero-sacral ligaments are identified by placing Alice clamps deep on the vaginal cuff at the insertion of the utero-sacral ligament. Traction is applied medially and superiorly on the vaginal cuff, identifying the utero-sacral ligament. A zero-polypropylene suture is placed through the USL using a figure of 8. A second suture of zero-polydioxenone is placed through the USL in a similar fashion, slightly more caudal. The same procedure is repeated on the opposite side. A McCall's coldoplasty with zero-polypropylene is also began on the left USL and incorporates a portion of the muscularis on the vaginal cuff. The McCall suture is passed through the right USL to complete a modified McCall's coldoplasty. We then perform a rectal examination to confirm accurate placement and rectal integrity. If an anterior repair needs to be performed, it is usually done at this time. The zero-polypropylene suture is placed on the underside of the vaginal apex. Using a free mayo needle, zero-polydioxenone sutures are placed through the vaginal epithelium on the lateral aspect of the apex. After completing the same steps on the contralateral side, closure of the posterior wall is begun with a polyglycolic acid suture. In this image, you can see the four sutures used to perform the uterosacral ligament suspension and the polypropylene used to perform the modified McCall's. The sutures are tied down with elevation of the vaginal vault. The McCall suture is tied last. Next, cystoscopy is performed to confirm ureteral patency demonstrated by the fluorescein jet seen here. The posterior repair is completed by imbricating the fibromuscular layer in the midline. The bulbocavernosis and transverse perineal muscles are then re-approximated in the midline. The vaginal epithelium is trimmed and enclosed. This procedure has been performed on 36 patients with the mean age of 64 years old, median parity of 3, all patients were postmenopausal, mean BMI was 27, and 32 of the 36 patients had a prior hysterectomy. Preoperatively, the median C point was minus 4.5, BA was 0, and BP was minus 0.5. Of the 18 patients with follow-up between 19 and 33 weeks, the median C point was minus 7, BA was minus 2, and BP was minus 3. There was one congerator corrected after stent placement. The average time of procedure was 2 hours and 6 minutes. The average estimated blood loss was 99 mLs. In summary, a traditional posterior corporaphy dissection is performed. Utero-sacral ligaments are defined by placing an Alice clamp deep on the vaginal cuff and applying medial superior traction. Alice clamps are placed on the utero-sacral ligaments just proximal to the level of the ischial spines. A zero polypropylene suture is placed through the USL using a figure of eight. A second suture of zero polydioxinone is placed through the USL in a similar fashion, slightly more caudal. The same procedure is repeated on the opposite side. A modified Nicole's cotoplasty is performed with zero polypropylene suture. Sutures are tied down. An anterior repair may be performed prior to the utero-sacral ligament suspension and those with a significant anterior wall prolapse. Cystoscopy is performed to confirm ureteral patency. A traditional posterior repair is performed prior to completing the procedure.

extraperitoneal approach

utero-sacral ligament suspension

apical repairs

intraperitoneal access

vaginal vault marking