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Video Description
Laparoscopic uterosacral suspension (L-USLS) is a native tissue technique used to address prolapse where the uterosacral ligaments are secured laparoscopically prior to initiation of vaginal hysterectomy and then affixed to the distal aspect at the vaginal cuff at the hysterectomy’s conclusion. This video describes the advantages of the laparoscopic approach and demonstrates the technique of L-USLS at the time of vaginal assisted hysterectomy.
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University of Toronto, University of British Columbia
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Summary:
- Laparoscopic Uterosacral Ligament Suspension (L-USLS) is a type of surgery that helps treat or prevent pelvic organ prolapse (POP). It involves stitching the top of the vaginal vault to the uterosacral ligaments in the pelvis for added support.
- POP can cause distressing symptoms like pressure, pain, bulging, and urinary or fecal incontinence. Up to 50% of all women will develop some degree of prolapse by age 50, especially if they’ve had multiple vaginal deliveries.
- “Laparoscopic” means the surgeon uses a thin, lighted tube to perform the procedure through small incisions in the abdomen. This approach reduces pain, complications, and recovery times.
- Most patients go home after a day or two, but you should expect to take 2-4 weeks off work to recover. Avoiding driving, heavy lifting, intense activity, and vaginal penetration for at least the first 6-8 weeks is the best way to let your body heal.
Laparoscopic Uterosacral Ligament Suspension at Time of Hysterectomy: A Stepwise Approach
If you’re having a hysterectomy, your surgeon may suggest having a laparoscopic uterosacral ligament suspension (L-USLS) at the same time. This procedure can help treat pelvic organ prolapse (POP) and/or lower your risk for developing it in the future.
Below, we’ll explain what L-USLS is, why doctors recommend it for patients who are having a hysterectomy, and how it can help.
First: What is Pelvic Organ Prolapse?
Pelvic organ prolapse (POP) happens when the muscles and tissues that support your pelvic organs (called the pelvic floor) become weak or stretched. This type of dysfunction sometimes allows parts of the bladder, uterus, rectum, or vagina to slip out of place.
Patients with POP often report symptoms like:
- A feeling of pressure or heaviness in the pelvis
- Cramping or pain in the lower abdomen or back
- Difficulty emptying the bladder or bowels
- Urine or fecal incontinence (leaking)
- A bulging sensation, or the feeling that something is “falling out.”
Once symptoms like these develop, they may worsen over time.
What Is a Laparoscopic Uterosacral Ligament Suspension?
L-USLS is a type of surgery that involves anchoring the top of the vagina (called the “cuff”) to the uterosacral ligaments. These ligaments act like natural support for the organs, helping to recreate some of the pelvic supports that may weaken over one’s life, or after surgery like a hysterectomy.
Surgeons typically use L-USLS to treat or prevent vaginal vault prolapse, a condition where the vagina itself sags downward. Since having a hysterectomy slightly raises your risk for POP, some surgeons recommend it for all patients undergoing a hysterectomy.
Who is Likely to Have a Prolapse?
Some studies suggest that up to 50% of women will experience some degree of POP by age 50. Your risk increases with each consecutive vaginal birth and with age, so you’re more likely to develop one if you’re over the age of 50 and have multiple children.
Giving birth by c-section carries less risk, but it isn’t risk-free. Anything that increases pressure in your abdomen—including carrying a child to term, constipation, or being overweight—can lead to prolapse.
Why Choose the Laparoscopic Approach?
Laparoscopy is a minimally-invasive surgical technique where a surgeon makes a series of small incisions in the abdomen (typically 1-5). They’ll complete the procedure by passing a series of thin, lighted tubes with special instruments into your body through these cuts.
This approach offers several advantages:
- Your surgeon can view important nearby structures, like the ureters (tubes that carry urine) and pelvic nerves, without fully opening you up.
- The risk of complications like excessive bleeding or infection is much lower.
- Patients often report less pain and go home within one to two days of the procedure.
If your doctor intends to use a surgical robot during your surgery, you may hear it referred to as a “robotic surgery.” This is another approach to minimally invasive surgery and has the same advantages as laparoscopic surgery.
What Are the Risks of L-USLS?
L-USLS is very safe when performed by an experienced surgeon, but like any surgical procedure, there are a few risks:
- Infection
- Excessive bleeding
- Injury to the ureter or bladder
- Urinary retention (difficulty passing urine)
- Injury to the rectum or pudendal nerve
Your prolapse may return in time if the stitches that hold the vaginal vault in place fail. This is more likely to happen if you have a condition like Marfan or Ehlers-Danlos Syndrome (EDS).
Before Your Procedure
Your care team will give you specific instructions to follow in the days leading up to your surgery. You may need to:
- Have bloodwork, urine tests, and/or imaging.
- Speak with the pharmacist to review your current medications.
- Stop eating or drinking around 8 hours before your surgery.
Your doctor may have other specific instructions to follow, and will inform you of these before surgery.
Pre-Surgical Checks
Someone from the hospital’s surgical team will call you to go over your procedure and answer any questions. During this call, they’ll ask about your medical history, including:
- If you’re allergic to any medications.
- If you’re currently taking any medications
- Whether you’ve had a bad reaction to anesthesia in the past.
- If you have any medical conditions like diabetes, sleep apnea, or heart disease.
They’ll also ask about lifestyle factors, like whether you smoke, drink alcohol, or use recreational drugs like marijuana. Asking questions like these can feel a little invasive, but your care team won’t judge—they just want to keep you safe during your surgery.
On the Day of Your Surgery
When you arrive at the hospital, a nurse or administrator will help you check in. They’ll take down your personal info, height, weight, and blood pressure, then place an IV in your arm.
You’ll be asked to remove your clothing and put on a surgical gown next. When it’s time for your surgery, someone will escort you to the operating room (OR). An anesthesiologist will speak to you shortly before the procedure starts.
Once you’re in the operating room, the anesthesiologist will give you medication to make you fall asleep. You’ll be asleep for the entire procedure.
During Your Surgery
The surgical steps of performing a L-USLS with hysterectomy may vary depending on surgeon preference and training. No single approach is better than another. One example of the steps of the procedure are:
- Step 1: A series of small incisions are made so your surgeon can pass thin, lighted tubes with special instruments into your pelvis. Once they locate the uterosacral ligaments on the sides of your pelvis, they place a few stitches in them.
- Step 2: The uterus is detached from the surrounding tissues, then removed through the vaginal canal. The top of the vagina (vaginal cuff) stays open at this point to allow your surgeon to connect it to the ligaments in the next step.
- Step 3: The stitches your surgeon placed in the uterosacral ligaments in step 1 are gently pulled through the vaginal cuff. This suspends the vagina in the correct position so the surgeon can anchor it in place during the next step.
- Step 4: While closing the top of your vaginal cuff, the surgeon ties off the support stitches to permanently anchor it to your uterosacral ligaments. After inspecting all nearby tissues, they’ll withdraw the tubes and “close up.”
You’ll be taken to the recovery room next, where a nurse will closely monitor your vitals and help you manage any pain once you’re awake until you’re ready to go to a room.
The Recovery Process
Most patients go home within one to two days of surgery. Your healthcare team will go over any post-surgical care instructions with you before you leave.
You’ll need a support person to drive you home and stay with you for at least the first 24 hours once you go home. Here’s what you can expect:
- Mild to moderate pain and swelling. This usually subsides over the first week. Take ibuprofen, Tylenol, or any prescribed pain medication according to the directions on the bottle. Waiting until the pain is severe makes it harder to treat.
- Discharge or bleeding from the vagina. It’s normal to have light discharge or bleeding for a few days after surgery. If bleeding starts suddenly or you bleed through a pad in a few hours, call your doctor right away.
- Fatigue. It’s very normal to be tired or become exhausted by light activity during the first few weeks after your surgery. Your body is putting a lot of energy into healing, so indulge it by getting plenty of rest and avoiding heavy activities.
- Feeling “off.” Some patients feel generally “under the weather,” depressed, or anxious in the first few weeks after surgery. Rest, hydration, and time usually help, but let your care team know if these symptoms become severe.
L-USLS can also raise your risk for problems voiding urine and urinary tract infections during the recovery period. Let your doctor know right away if you lose the ability to urinate or develop symptoms like a high fever, tea-colored urine, pain while urinating, or confusion.
Activity Restrictions & Follow-Up Care
Gentle activity is acceptable and can even help you heal faster, but overdoing it too soon can raise your risk for complications or even cause your surgery to fail. For best results, follow these guidelines for at least the first six to eight weeks:
- Avoid lifting anything heavier than a grocery bag (about 10 pounds).
- Don’t drive for at least the first couple of weeks after your surgery.
- Don’t engage in any exercise that involves pushing, straining, or jumping.
- Don’t return to high-impact or intense exercise until your surgeon clears you.
- Avoid putting anything into the vagina, including tampons, toys, and sex.
You’ll have follow-up visits with your surgeon to check healing and pelvic support. They may recommend pelvic floor therapy to further improve your results.
L-USLS Can Help Prevent or Treat Prolapse
Laparoscopic Uterosacral Ligament Suspension (L-USLS) is a safe and effective procedure for treating or preventing POP during or after hysterectomy. If your surgeon recommends this procedure, it’s because they feel the benefits outweigh the risks.
CanSAGE is dedicated to helping patients and their providers make informed decisions about gynecological health. For more information about gynecologic procedures like L-USLS and laparoscopic surgeries, browse our patient-friendly videos and educational guides.
Video Transcript: Laparoscopic Uterosacral Ligament Suspension at Time of Hysterectomy: A Stepwise Approach
Laparoscopic Uterosacral Ligament Suspension at the Time of Hysterectomy, a Stepwise Approach. The objectives of this video are to describe the indication and advantages of the laparoscopic approach to uterosacral ligament suspension and demonstrate the technique of laparoscopic uterosacral ligament suspension at the time of hysterectomy.
Uterosacral ligament suspension is primarily indicated to address apical prolapse. Advantages of the laparoscopic approach can include a magnified view of the operative field, which can enable easier dissection and enhance the identification of pelvic floor supporting defects. Improved visualization of vital structures, specifically the ureter and hypogastric nerve, may minimize injury. The laparoscopic view allows for more precise suture placement and the option of securing the uterosacral ligament more than the vaginal approach, or in its proximal aspect, and higher rates of concomitant adnexal surgery completion.
Compared the two techniques of laparoscopic versus vaginal uterosacral ligament suspension in 206 patients in a retrospective review. Those that underwent the vaginal procedure had the Maher McCall culdaplasty or Shull technique, whereas those in the laparoscopic group underwent the Brennan technique.
In those that underwent the vaginal uterosacral ligament suspension, there were higher rates of ureteric obstruction demonstrated by intraoperative ureter kinking found at cystoscopy, and there were higher rates of postoperative urinary retention. The vaginal approach also had lower rates of adnexal surgery completion. Finally, there were higher rates of patient-reported symptomatic recurrence of prolapse using the pelvic organ prolapse distress inventory.
The laparoscopic group had no ureteric obstruction and lower rates of postoperative urinary retention. Additionally, there was over a 98% completion of adnexal surgery, and overall there was decreased recurrence of prolapse, as compared to the vaginal group. There was no difference in case time, length of stay or infection.
The steps to the procedure begin with the laparoscopic component, where the proximal uterosacral ligament is sutured and tied extracorporeally. The vaginal component begins with the transvaginal colpotomy, where the distal uterosacral ligaments are clamped, cut, tied and then held.
The suture that was tied laparoscopically to the proximal uterosacral ligament is then swept through the vagina and passed through the remnant of the ipsilateral distal uterosacral ligament. After the closure of the vaginal vault, the proximal uterosacral ligament sutures are then tied down on their ipsilateral sides. We will now demonstrate the procedure.
The laparoscopic portion of the hysterectomy, including any adnexal surgery, is completed to the level of the ligation of the uterine arteries. The important anatomical landmarks, including the cervix, rectum, and course of the ureters, are identified in relation to the proximal uterosacral ligaments. At this point, ureterolysis can be performed if necessary. A figure-of-8 suture using O Prolene on a MO-6 needle is then placed in the proximal aspect of the uterosacral ligament. Assurance is made of adequate tissue capture. The suture can then be tied through the left ipsilateral ports using the assistance of a knot pusher.
The two free ends are then held and tagged outside the abdomen until the vaginal portion of the procedure. The procedure is then repeated on the left side. The procedure then continues through the vaginal approach, whereafter the transvaginal colpotomy is performed, and the distal uterosacral ligaments are clamped, ligated and tagged. The Prolene suture attached to the proximal uterosacral ligament that had been tagged outside the abdomen is released, and a finger is placed into the vagina and swept along to bring out the proximal uterosacral ligament tag.
The sutures are then organized to clearly identify the distal uterosacral ligaments that have been tagged and the proximal uterosacral ligament that’s been tagged. The suture attached to the proximal uterosacral ligament is then loaded onto a free Mayo needle and then passed through the distal remnant of the uterosacral ligament. It is then passed through a second time. We can now see the proximal uterosacral ligament suture pass twice through the distal uterosacral ligament remnant. The steps are then repeated in the exact same fashion on the contralateral side. And note the sutures remain held and are not tied down as of yet.
The vaginal vault is then closed, and any anterior repair can be performed. The last step of the procedure involves tying down the proximal uterosacral ligament sutures. The vaginal vault is then elevated using a Babcock instrument. This allows for the Prolene uterosacral suspension sutures to be tied down without tension. The Prolene suture is then tied down on each ipsilateral side. The original suture placed vaginally to the distal uterosacral ligament is then trimmed. Before trimming the Prolene sutures, a cystoscopy is done to evaluate ureteral patency. At the conclusion of the procedure, the abdomen can be re-insufflated to evaluate the uterosacral suspension laparoscopically.
In conclusion, we have demonstrated a stepwise approach to the laparoscopic uterosacral ligament suspension at the time of hysterectomy. Thank you for taking the time to watch this video.