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Laparoscopic And Minimally Invasive Procedures continued
Laparoscopic Uterosacral Ligament Suspension
The laparoscopic uterosacral ligament suspension involves suturing the uterosacral ligament to the apex of the vagina. This procedure is normally performed by placing two sutures through each uterosacral ligament and then through the cuff or apex of the vagina. The suture is tied to support the cuff or apex to the uterosacral ligaments (Figure 3). Drs. Miklos and Moore perform this surgery with no modifications to either the vaginal or abdominal approach. Their only adjustment is utilizing the laparoscope, which provides better visualization resulting in decreased incidence of bladder, ureter, and bowel injury in their hands.
Laparoscopy Figure: 0.1 |
Vaginal vault support
- the vaginal vault prolapse is corrected by suturing the apex of the vagina to its original supporting ligaments known as the uterosacral ligament. |
Advantages
Drs. Miklos and Moore have performed over 1000 laparoscopic uterosacral ligament suspension procedures with an 85% success rate. They believe the laparoscopic visualization of the uterosacral ligaments is superior to the vaginal visualization. One of the major concerns is injuring the ureter during this procedure. Researchers at Duke University Hospital confirmed that the uterosacral ligament suspension is one of the procedures most likely to have a ureter injury.
PubMed Site
Techniques
By performing the uterosacral ligament suspension laparoscopically, our physicians are able to reposition the vagina to its anatomic position in a minimally invasive manner. Most surgeons perform this procedure through a large incision or through the vagina . A large abdominal incision (laparotomy) will contribute to a longer recovery time. If performed vaginally there is often difficult identifying the uterosacral ligaments appropriately. The laparoscopic approach allows us to define the ligaments readily and also identify the ureter making the laparoscopic approach safer in our hands.
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Laparoscopy Figure: 1 |
Laparoscopy Figure: 2 |
Laparoscopy Figure: 3 |
Upon entry into the abdomen the bowel is mobilized or swept out of the cul de sac allowing for a better view and easier access to the uterosacral ligaments (Figure 4)
Laparoscopy Figure: 4 |
Figure 4 – Laparoscopic View of Vaginal Apex (ie Vault) |
This patient (figure 4a) had her uterus removed (therefore the top of the vagina is opened) and a posterior repair with a graft placed (link to post. repair) and therefore one can see the vaginal probe placed in the vagina to elevate it and the top or apex of the dermal graft that has been used to augment the posterior repair. This portion of the dermal graft will be sutured to the top of the vagina (apex) which will then be attached to the uterosacral ligaments.
Laparoscopy Figure: 4.1 |
Figure 4.1 - The first suture for the laparoscopic uterosacral ligament suspension is taken through the right uterosacral ligament then up through the apex of the vagina. |
By suturing the uterosacral ligament to the apex of the vagina, this restores the vaginal apex back to its normal anatomic position. (Figure 5)
Laparoscopy Figure: 5 |
Figure 5 - Uterosacral ligament are sutured to the apex of the vagina (ie vault) Note: the surgical instrument is on the vaginal apex. |
In this patient, the vaginal vault is closed (after hysterectomy) and the apex of the vagina is elevated and a suture is placed through the base of the uterosacral ligament as seen below.The suture is then placed through the apex of the vagina (top of rectovaginal fascia, dermal graft(if placed) and pubocervical fascia) and tied down. Two sutures are placed through the ligament and then through apex on each side for a total of 4 sutures to elevate the vagina.
Laparoscopy Figure: 6 |
Figure 6 - The first suture for the suspension is taken through the right uterosacral ligament then up through the apex of the vagina. |
The final view shows the patient with two sutures through each uterosacral ligament, a total of 4 sutures, then through the apex of the vagina. ( Figure 6a) This surgical procedure is the most anatomic surgical procedures for restoring the vaginal apex back to its original position. At one time the uterosacral ligaments held the uterus in place but once the uterus is removed the surgeon should then attach the ligaments to the apex of the vagina.
Laparoscopy Figure: 6.1 |
Figure 6.1 – Completed Laparoscopic uterosacral ligament suspension |
Results/Complications
Drs. Miklos and Moore have approximately a 2% complication rate in comparison to 9.5% during the same procedure at Duke University. The only difference being that Atlanta Urogynecology utilizes a laparoscopic technique vs. Duke’s vaginal technique.
The value of intraoperative cystoscopy
Laparoscopy Figure: 7
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By performing the uterosacral ligament suspension laparoscopically, Drs. Miklos and Moore can also offer other reconstructive supportive procedures simultaneously such as:
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Paravaginal Repair |
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Enterocele Repair |
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Posterior Repair |
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Fistula Repair |
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Burch Urethropexy |
Other risks of the procedure include: failure of the procedure secondary to the ligaments being weak , nerve injury or pain (<1%) secondary to tension or injury to the lower sacral nerve roots, pelvic floor muscle spasms (typically short-lived and treated with muscle relaxants), pain with intercourse at apex of vagina (1%) from scar tissue, shortening of the vagina (<2%). Dr Moore and Miklos again feel the laparoscopic approach helps minimize these risks secondary to having better visualization of the ligaments and the anatomy surrounding the ligaments.
Atlanta Urogynecology Associates Experience
Drs. Miklos and Moore have performed the laparoscopic uterosacral ligament procedure over the past 10 years with approximately 80-85% success rate in selected patients. We believe that this minimally invasive approach is a safe and effective way to suspend the vagina. Patients usually go home the next day and experience minimal pain and discomfort. It is their experience that most patients are pain free within 2 weeks. Some patients do suffer from some pelvic muscle spasms and discomfort from this called levator myalgia, secondary to muscles reacting to the procedure. Patients are treated with muscle relaxants and this discomfort typically resolves in a week or two. Dr Moore and Miklos believe that with patients that have moderate vault prolapse, that this is a very good approach to utilize. Although the laparoscopic sacralcolpopexy with mesh (link) has a higher cure rate, the uterosacral vault suspension utilizes the patients own tissues therefore decreases the risk of adding mesh to the procedure. It is a very anatomic repair that offers excellent cure rates in this group of patients. However, in patients that have more severe vault prolapse it has been shown that the sacralcolpopexy with mesh has a much higher long term cure rate and therefore in those patients they will recommend adding mesh to the repair with this procedure. It only makes sense that in more severe prolapse, the ligaments are stretched out and not very strong, therefore the addition of mesh is necessary. In these patients, Dr Miklos and Moore feel the benefits of the mesh outweigh the risks. Each individual patient is counseled however in the risks/benefits of both approaches and ultimately it is the patient’s decision on which procedure they feel comfortable with.
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