My name is Norena DeSoma, and I am a medical student from the University of Illinois College of Medicine at Peoria. In this video, footage of robotic utero-sacral ligament suspension will be presented. We present a step-by-step instructional video on how to utilize Xero V-lock suture to perform a vaginal apical suspension with utero-sacral ligaments, or USL, at the time of a robotic hysterectomy. These suspensions are integral in providing adequate support to the vagina and to reduce the incidence of post-hysterectomy vaginal bolt prolapse. At the conclusion of a robotic hysterectomy, the surgical specimen is delivered transvaginally. Once the vaginal cuff is deemed to be hemostatic, the posterior cul-de-sac is visualized and the anatomical landmarks for the suspension are identified. As seen in this overlay, Caudade traction of the posterior vaginal wall usually identifies the utero-sacral ligaments that track posteriorly around the rectal vault. The goal of proper apical suspension is to re-establish the pericervical ring of connective tissue after the hysterectomy. This includes the utero-sacral ligaments, the pubocervical fascia, and the rectovaginal connective tissue. Accordingly, it is imperative that these tissues are identified prior to the suspension. We start with the caudal development of the vesico-vaginal plane two centimeters distal to the anterior colpotomy. Subsequently, the right utero-sacral ligament is placed under traction. As shown in this overlay, it is important to identify the ureters and the rectum. Once identified, the suspension can then proceed with anchoring of the zero-V-lock suture into the mid-utero-sacral ligament. Rectal deviation away from the utero-sacral ligament minimizes the risk of rectal injury. The utero-sacral ligament is then plicated with the suture in a caudade fashion along the anterior colpotomy. The utero-sacral ligament is then plicated with the suture in a caudade fashion along its length, with subsequent suture throws into its distal aspect. The rectovaginal septum is then incorporated into the suspension. This is followed by suture passage into the pectoral cavity. The pectoral cavity is then closed with a closed-lip suture. The pectoral cavity is then closed with a closed-lip suture. This is followed by suture passage into the puboscervical fascia medial to the uterine artery at the vaginal cuff angle. The cinching down of the V-lock suspends the vaginal apex closer to the mid-utero-sacral ligament as seen here. The vaginal cuff is then re-approximated in a running fashion. We use large tissue bites with special emphasis on opposing the puboscervical fascia to the rectovaginal connective tissue. Simultaneously, the vaginal epithelium is inverted into the vaginal vault as seen here. Once the cuff is closed, the utero-sacral suspension on the opposite side is performed similarly with plication and cinching. This is followed by the extension of the ligament's distal aspect to its mid-segment with contralateral rectal deviation. Once the suspension is completed, the pericervical ring of connective tissue is re-established as seen in this overlay. This pericervical ring is a continuum of both utero-sacral ligaments, the anterior puboscervical connective tissue, and the rectovaginal septum. Apical vaginal suspension at the time of minimally invasive hysterectomy is a crucial step to minimize the risk of subsequent apical vaginal prolapse. Performing this additional step at the time of a vaginal, laparoscopic, or robotic-assisted hysterectomy is encouraged. This practice is of particular importance when uterine prolapse is present preoperatively. We suggest the following surgical pearls of wisdom for these suspensions. Identify and develop the vesicovaginal plane. Lateralize the ureters away from the utero-sacral ligament. Use caudad traction to identify the utero-sacral ligament. Deviate the rectum away from the suspension. Routinely perform sassopy. Thank you for your attention.

robotic utero-sacral ligament suspension

vaginal bolt prolapse

Xero V-lock suture

minimally invasive hysterectomies

apical vaginal prolapse