Laparoscopic Uterosacral Ligament Suspension at Time of Hysterectomy: A Stepwise Approach

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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.

Presented By

Dr. Angela Deane
Dr. Sara Houlihan
Dr. Abheha Satkunaratnam
Dr. Cici Zhu

Affiliations

University of Toronto, University of British Columbia

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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.