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34 inserts intothatstructure. ligament because asegmentoftheuterosacral ligamentcomplex(arrow) muscle-sacrospinous thecoccygeus through it ispossibletopasssutures suspension, When performinghighuterosacral OBG Management | MarchJune 20112010 | | Vol. 23 No. 6 Vol. 22 No. 3 obgmanagement.com Here aNd on tHe cover: Illustration By scOtt bodell fOr obg MaNaGeMeNt Surgical tecHniqueS Step by Step High uterosacral vaginal vault suspension to repair enterocele and apical prolapse you can provide good apical support without significantly distorting the vaginal axis, and passing sutures intraperitoneally can be cleaner, and simpler, than passage through retroperitoneal structures Mickey Karram, MD, and christine Vaccaro, DO he concept of utilizing the uterosac- suspend or support the vaginal apex at the ral ligaments to support the vaginal time of vaginal hysterectomy.1 t cuff and correct an enterocele is noth- Later, in the 1990s, Richardson promot- ing new: As early as 1957, Milton McCall de- In thIs ed the concept that, in patients who have Article scribed what became known as the McCall pelvic organ prolapse, the uterosacral liga- culdoplasty, in which sutures incorporated ments do not become attenuated, instead, Stepwise pictorial the uterosacral ligaments into the posterior they break at specific points. guide to surgery vaginal vault to obliterate the cul-de-sac and Shull and colleagues took this idea page 37 and described how utilizing uterosacral ligaments to support the vaginal cuff can be How this procedure Dr. Karram is director of the performed vaginally—by passing sutures bi- fellowship Program in female evolved in our hands Pelvic Medicine and reconstructive laterally through the uterosacral ligaments 2 page 38 Pelvic surgery, university of near the level of the ischial spine. cincinnati/the christ Hospital, cincinnati, Ohio; co-editor in chief Since Shull described this procedure, of the International academy of numerous published studies have demon- 5 surgical pearls Pelvic surgery (IaPs); and course strated outcomes similar to other vaginal for high uterosacral director of the Pelvic anatomy and Gynecologic surgery symposium (PaGs) and the female suspension procedures, such as sacrospi- vaginal vault urology and urogynecology symposium (FUUS), nous ligament suspension.3–5 suspension both co-sponsored by OBG ManageMent. Potential advantages of a high utero- page 42 Dr. Vaccaro is a urogynecology sacral vaginal vault suspension are that: fellow at Good samaritan • it provides good apical support without Hospital, cincinnati, Ohio. On the Web significantly distorting the vaginal axis, Hear Dr. Karram making it applicable to all types of vaginal discuss how to prolapse avoid surgical • intraperitoneal passage of sutures can be hazards during The authors report no financial relationships relevant to this article. a lot cleaner and simpler than passing su- suspension, at This article, with accompanying video footage, is tures, or anchors, through retroperitoneal obgmanagement.com presented with the support of the International Academy structures, such as the sacrospinous liga- of Pelvic Surgery. ment (FIGURE 1, page 36). continued on page 36 obgmanagement.com Vol.Vol. 22 23 No. No. 3 6 | |March June 20102011 | OBG Management 35 Surgical tecHniqueS / uterosacral Vaginal Vault SuSpenSiOn Figure 1 locating intraperitoneal sutures during uterosacral suspension ER H s I l the ureter can B u P become kinked e H t when sutures in f this procedure are ION O ATLAS OF PELVIC ANATOMY AND passed too far SS MI OM laterally ER FR , H P s t ION ) WI t P ER CA VI H t ELSE / , WI TED DERS N cross-section of the pelvic floor shows where sutures are placed as part of Mccall culdoplasty (1), IN r traditional uterosacral suspension (2), and modified high uterosacral suspension 3( ). Note: High uterosacral P SAU suspension may involve passing the suture through the sacrospinous ligament–coccygeus (SSL-c) muscle RE N. complex (dashed oval) because a segment of the uterosacral ligament inserts into that structure. a HOV ION, 2011; c t I e ED RD A disadvantage of the procedure is that our operation of choice for 11 years for pa- 1-5: JO (3 the uterosacral ligament may, at times, lie in tients who have pelvic organ prolapse in URES IG close proximity to the ureter. Studies have which the peritoneum is accessible (see f , shown that the ureter can become kinked “How this procedure evolved in our hands,” s when sutures in this procedure are passed page 38). In this article, we provide a step- ION too far laterally.2-5 by-step description of the procedure. Four LLUSTRAT GYNECOLOGIC SURGERY High uterosacral suspension has been accompanying videos that further illuminate I 36 OBG Management | June 2011 | Vol. 23 No. 6 obgmanagement.com Figure 2 Step by step: High uterosacral vaginal vault suspension a B e f anterior vaginal wall cystocele Peritoneum small intestine enterocele sac Posterior vaginal wall Vaginal wall Midline plication anterior vaginal wall trimmed closed anterior vaginal wall vaginal wall and vaginal cuff traction on uterosacral ligaments Peritoneum Posterior vaginal wall sigmoid colon G H c uterosacral ligament d a the most prominent portion of the prolapsed vaginal vault is e each end of the previously passed sutures is brought out grasped with two allis clamps. b the vaginal wall is opened up through the posterior peritoneum and the posterior vaginal and the enterocele sac is identified and entered.c the bowel wall. (a free needle is used to pass both ends of these delayed is packed high into the pelvis using large laparotomy sponges. absorbable sutures through the full thickness of the vaginal wall.) the retractor lifts the sponges out of the lower pelvis, thus F anterior colporrhaphy is begun by initiating dissection between completely exposing the cul-de-sac. When appropriate traction the prolapsed bladder and the anterior vaginal wall. g anterior is placed downward on the uterosacral ligaments with an allis colporrhaphy is complete. H the vagina has been appropriately clamp, the uterosacral ligaments are easily palpated bilaterally. trimmed and closed with interrupted or continuous delayed D delayed absorbable sutures have been passed through the absorbable sutures. delayed absorbable sutures that were uppermost portion of the uterosacral ligaments on each side, previously brought out through the full thickness of the posterior and have been individually tagged. vaginal wall are then tied; doing so elevates the prolapsed vaginal vault high up into the hollow of the sacrum. those steps can be viewed at www.obgman- anatomic structures (again, see ViDeO #1) agement.com; they are noted in the text here are not easily identifiable unless suspen- at appropriate places. (For example, ViDeO #1, sion is undertaken intraperitoneally. En- immediately below, sets the stage for the step- tering the peritoneum is, obviously, not a by-step discussion by reviewing pertinent concern if the patient is undergoing vagi- pelvic anatomy.) nal hysterectomy. If the patient has post- hysterectomy prolapse, however, you must be able to isolate an enterocele and enter Details of the procedure the peritoneum (follow FIGURE 2, begin- # ning here and through subsequent steps of 1 enter tHe peritOneuM the procedure). It’s our opinion that, even though extra- Once you have entered the peritone- peritoneal uterosacral suspension proce- um, the cul-de-sac must be relatively free dures have been described, the pertinent of adhesive disease if you are to be able to obgmanagement.com Vol. 23 No. 6 | June 2011 | OBG Management 37 Surgical tecHniqueS / uterosacral Vaginal Vault SuSpenSiOn How this procedure evolved in our hands • When we first performed high uterosacral vaginal vault suspension as described by shull and colleagues,1 we mobilized vaginal muscularis off the epithelium and suspended the epithelium and muscularis separately, making sure that sutures were passed through the anterior and posterior vaginal walls. Over time, we realized that this practice led to a shorter vagina—one that, in some cases, was less than ideal for the patient. We began, therefore, to pass sutures through the posterior vaginal wall only. (ViDeO #2 shows high uterosacral suspension in a patient who WATCH has post-hysterectomy vaginal vault prolapse.) tHe ViDeO With this change in technique, we have been able to create a longer vagina—and not at the expense of any increase in the incidence of cystocele or anterior rectocele. Our High uterosacral experience directly contradicts the notion that fascial continuity is necessary for prolapse suspension (post- repair to be successful over the long term. hysterectomy vaginal • Initially, we thought that a large cul-de-sac needed to be obliterated in the midline with vault prolapse) internal Mccall-type stitches that were separate and distinct from the uterosacral suspen- sion sutures. We no longer do this routinely because we believe that the numerous su- tures that are passed through the full thickness of the posterior vaginal wall, including the peritoneum, effectively obliterate the enterocele and keep down the incidence of recurrent enterocele and high rectocele. • We have come to realize that sutures placed medial and cephalad to the ischial spine are often passed through a portion of the coccygeus muscle-sacrospinous ligament complex. at times, a small window can be made in the peritoneum that provides direct access to this complex (FIGURE 1; FIGURE 3, page 39). 4 ways to reference watch this video: 1. Shull BL, Bachofen C. Coates KW, Kuehl TJ. A transvaginal approach to repair of apical and other associated sites of pelvic organ 1. go to the Video Library at prolapse with uterosacral ligaments. Am J Obstet Gynecol. 2000;183(6):1365–1374. obgmanagement.com 2. use the QR code to download the video to your smartphone* continue with this procedure. (See “5 surgi- # palpate tHe iScHial 3. text USS to 25827 cal pearls for high ureterosacral vaginal vault SpineS bilaterally 4. visit www.OBGmobile. 3 com/USS suspension,” page 42.) It’s important that you palpate the ischial spines.

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