Two Methods for Vaginal Vault Suspension at Total Laparoscopic Hysterectomy

This video outlines two approaches to the suspension of the vaginal vault following total laparoscopic hysterectomy to prevent post-hysterectomy vault prolapse, a recognized complication. The methods include the laparoscopic modified McCall’s culdoplasty and the laparoscopic uterosacral ligament suspension. Both techniques involve using sutures to suspend the vaginal cuff to the uterosacral ligaments while ensuring the ureter is not damaged. These procedures aim to provide minimally invasive surgeons with effective techniques to prevent vault prolapse after hysterectomy.

Two Methods for Vaginal Vault Suspension Summary:

• Objective: Prevent vault prolapse with vaginal vault suspension during total laparoscopic hysterectomy

Laparoscopic Modified McCall’s Culdoplasty:

1. Complete hysterectomy and vault closure
2. Grasp uterosacral ligament, identify ureter lateral to it
3. Use long-acting dissolvable monofilament suture, take bite in uterosacral ligament
4. Run suture along vaginal cuff, take superficial bites including cuff tissue and peritoneum
5. Reach contralateral side, grasp uterosacral ligament, identify ureter
6. Take bite of left uterosacral ligament, tie knot using intracorporeal technique
7. Maintain tension across knot

Laparoscopic Uterosacral Ligament Suspension:

1. Grasp uterosacral ligament before hysterectomy, identify ureter
2. Demarcate uterosacral ligament with monopolar electrosurgery for later identification
3. Repeat for contralateral side
4. Use six sutures to close vaginal cuff and suspend it to uterosacral ligaments
5. Complete hysterectomy, grasp uterosacral ligament
6. Take bites in uterosacral ligament, posterior and anterior vaginal mucosa, and bladder peritoneum
7. Tie extracorporeal knots
8. Place three sutures on contralateral side
9. Close and suspend vaginal cuff to uterosacral ligaments, obliterate enterocele, lay bladder peritoneum over cuff

• Conclusion: Demonstrated techniques can help prevent post-hysterectomy vault prolapse

Presented By

Affiliations

University of Toronto, Mount Sinai Hospital & Women’s College Hospital

See Also

• All our gynecology education videos and articles.
• Hysterectomy videos

Watch on YouTube

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What is Vaginal Vault Suspension?

• Vaginal vault suspension is a surgical procedure aimed at supporting the upper part of the vagina after a hysterectomy.
• The procedure aims to prevent or treat post-hysterectomy vault prolapse, a condition where the vaginal vault descends or collapses.
• This collapse occurs due to the loss of support from the uterus.
• The technique involves suspending the vaginal cuff to nearby supportive structures, such as the uterosacral ligaments.
• The suspension helps maintain the proper anatomical position of the vagina and prevents prolapse.

What are the Risks of Vaginal Vault Suspension?

• Potential complications arising from vaginal vault surgery include:
  • Injuries to the ureter and lower urinary tract
  • Fistula development
  • Pelvic infections
  • Bowel damage
  • Graft exposure
• In the case of sacrospinous ligament fixation:
  • Added risk of hemorrhage and nerve damage involving the pudendal neurovascular bundle
  • Recurrence of vault prolapse

Video Transcript: Two Methods for Vaginal Vault Suspension at Total Laparoscopic Hysterectomy

This video will demonstrate two methods for vaginal vault suspension at the time of total laparoscopic hysterectomy. Post-hysterectomy vault prolapse is a recognized complication following hysterectomy. This can occur after abdominal, vaginal or laparoscopic surgery. Risk factors for vault prolapse would include age, increased parity, lifestyle factors, and the initial indication for hysterectomy, especially if it was for prolapse.

This video will demonstrate two methods for preventing vault prolapse by suspending the vaginal vault at the time of TLH. The first is the laparoscopic modified McCall’s culdoplasty, and the second is the laparoscopic uterosacral ligament suspension. In this procedure, the hysterectomy and vault closure has been completed according to the surgeon’s preference. The uterosacral ligament is grasped and pulled away from the pelvic sidewall medially.

For safety purposes, the ureter is identified lateral to the uterosacral ligament. Using a long-acting dissolvable monofilament suture, a bite is taken in the uterosacral ligament lateral to the vaginal cuff angle. The suture is pulled through, leaving a short tail which will later be used to tie the knot. The suture is run along the length of the vaginal cuff, being careful to take small superficial bites that include the cuff tissue as well as the peritoneum.

It is important to avoid any suture material from the previously closed vaginal cuff. Once the suture has reached the contralateral side, the uterosacral ligament is grasped once again, identifying the ureter and the pelvic sidewall. A bite is taken of the left uterosacral ligament. Bringing the two uterosacral ligaments medial, a knot is tied using an intracorporeal technique. Since there is significant tension across this knot, the first row is grasped in order to maintain tension while the second row is laid down.

Here, the final product is demonstrated with the vaginal cuffs suspended to the uterosacral ligaments. The uterosacral ligament suspension. The uterosacral ligament is grasped prior to beginning the hysterectomy. Once again, the ureter is identified in the pelvic sidewall lateral to the uterosacral ligament. The uterosacral ligament is then demarcated using monopolar electrosurgery. This is important because it allows the surgeon to safely identify the uterosacral ligaments after the uterus has been removed.

The same technique is done on the contralateral side. A single technique using six sutures will be employed to simultaneously close the vaginal cuff and suspend it to the uterosacral ligaments. Following the completion of the hysterectomy, the uterosacral ligament is grasped. Notice the area of desiccation. Once again, using a monofilament dissolving suture, a bite is taken to the uterosacral ligament lateral to the vaginal cuff. The suture is then placed through the posterior peritoneum and vagina, being sure to include vaginal mucosa in the bite.

Finally, a bite is taken through the anterior vagina at the angle. A knot is then tied extracorporeally. The second bite is taken through the uterosacral ligament 1 to 2 cm proximal to the previous bite in a cephalad direction. A bite of the cul-de-sac peritoneum is then taken in order to obliterate any potential enterocele. Then, a bite is taken through the posterior peritoneum and posterior vaginal mucosa, followed once again by the anterior vaginal mucosa.

The bladder peritoneum is then included in this bite. Once again, a knot is tied extracorporeally. For the third and final bite, the uterosacral ligament is again taken proximal to the previous bite. The posterior peritoneum, vaginal mucosa, anterior vaginal mucosa, and bladder peritoneum are all included in this bite as well. A knot is tied extracorporeally. The same three sutures are placed on the contralateral side. Here, the final product is demonstrated.

The vaginal cuff is closed and suspended to the uterosacral ligaments. The enterocele is obliterated, and the bladder peritoneum is laid over the vaginal cuff. To conclude, this video demonstrates two techniques that can be used by MIS surgeons to suspend the vault at the time of TLH and prevent post-hysterectomy vault prolapse. These are the laparoscopic modified McCall’s procedure and the laparoscopic uterosacral ligament suspension. Thank you for watching.

vaginal vault suspension, total laparoscopic hysterectomy, vault prolapse, abdominal surgery, vaginal surgery, risk factors, modified McCall’s culdoplasty, uterosacral ligament suspension, surgeon’s preference, pelvic sidewall, ureter, dissolvable monofilament suture, vaginal cuff angle, peritoneum, contralateral side, intracorporeal technique, tension, monopolar electrosurgery, uterus removal, six sutures, vaginal cuff closure, desiccation, vaginal mucosa, extracorporeal knot, cul-de-sac peritoneum, enterocele, bladder peritoneum, MIS surgeons, post-hysterectomy prevention, laparoscopic techniques