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Minimally Invasive Slings — 387
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Figure 14.2.20. Transobturator passage of TOT avoiding space of Retzius. (Permission granted by Caldera.)
severe as those with the TVT. Similar to the TVT, the TOT was
embraced rapidly by the medical community, with little or no
long-term data with regard to safety or success. Despite these
limitations, the technique appears to be as good as the original
TVT, with fewer injuries.
Technique
Preoperative preparation and anesthesia are the same as those
for the TVT. The patient is positioned at the end of the table
in the dorsal lithotomy position. A weighted speculum is placed
on the posterior vaginal wall. A marking pen is used to make a
transverse line at theleveloftheurethraontothe vulva. “X” marks
are made 2 cm superior to this line on both sides of the midline
just at the medial aspect of the obturator foramen. This spot is
usually easily palpable, even in obese patients. Anesthetic with
epinephrine is injected at these two spots. Using a small-blade
scalpel, stab incisions are made at the injection spots.
Figure 14.2.22. Injection of anesthetic with epinephrine. (Permission
granted by Gynecare.)
The same anesthetic is injected under the urethra and lateral
toward the obturator foramen (aiming at a 45
◦
angle). A #14
blade scalpel is used to make a 3-cm vertical incision under the
urethra. The incision is safely made without entering the urethra
if the vaginal epithelium blanches white from the injection. This
will also decrease significant blood loss (Figure 14.2.22).
Using either the tenotomy or plastic surgical Metzenbaum
scissors, flaps are developed toward the obturator foramen on
both sides. Oncetheflapisstarted,thespaceshouldaccommodate
the diameter of an index finger. Gentle digital dissection to the
obturator foramen will make the operation safer because this
will limit the distance that the TOT needle will be out of sight or
palpation (Figure 14.2.23).
Figure 14.2.21. “Outside in” TOTneedle passage. (Permission granted
by Caldera.)
Figure 14.2.23. Palpation of landmarks during TOT procedure. (Permission granted by Caldera.)
388 — Alan D. Garely and Cedric K. Olivera
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The needle glides overthe guide, through the obturator foramen,
and then out through the vulvar incisions.
There are two basic designs for the transobturator needles.
One has a corkscrew appearance, and the other looks like a hook.
One company (Caldera) offers both types of needles as reusable,
and they can be used with different types of sling material (permanent ordelayedabsorbable mesh).Other systems are designed
to clamp onto a proprietary coupling device.
READJUSTABLE SLINGS
Figure 14.2.24. Minimally invasive sling needles. (Permission granted
by Caldera.)
The TOT needle is introduced into the vulvar incision on
either side and gently rotated or pushed into the flap on that side.
The needle will traversetheobturatorforamen and then puncture
through the pubocervical fascia into the flap under the guidance
of the surgeon’s contralateral index finger. There are differently
shaped TOT needles made by different companies, but they all
accomplish the same goal (Figure 14.2.24).
Once the needle is in the flap, the preferred mesh/sheath system isfastened onto the needle, which is then backed out, pulling
the mesh/sheath with it. The sheath can be clamped onto the
drape to keep it out of the way while the same technique is done
on the other side, with the other end of the sheath.
Once both sides have been done, the Foley is removed and
cystourethroscopyis performed. If there areno injuries, the bladder is emptied and the sling is adjusted using the same tensioning
technique as for the retropubic TVT (Figure 14.2.25).
Variations
The tension-free vaginal tape-obturator (TVT-O) is an “insideout” TOT that pushes the mesh from inside the vagina and then
out through thevulvar incisions. TheTVT-O uses awinged guide
that acts like a shoe horn for the TVT-O needle. The guide is
pierced into the obturator foramen through the vaginal flaps.
The first Food and Drug Administration (FDA)-approved readjustable sling was developed in Spain and approved for use in
the United States in 2004.[39–41] This sling uses minimally invasive techniques with the advantage of allowing the surgeon to
adjust the tension at the time of placement, and at any time in
the future. Because of the permanent presence of the tensioning device above the fascia, this sling is best reserved for patients
with previous incontinence surgery failures.Before the adjustable
sling, bulking agentssuchasContigen (C. R. Bard, Inc.) were used
to increase coaptation of the urethral walls. If the bulking did not
help, the only other option was to redo the entire sling.
The kit consists of a small piece of polypropylene mesh, two
tensioning sutures (Prolene), a tensioning device, and a screwdriver set (Figure 14.2.26).
As with a TVT-type MIS, the mesh isplacedunderthebladder
neck or mid-urethra through a vaginal incision. The lateral sides
of themesharestitchedwiththeProlene tensioningsutures.These
sutures are pulled up through the retropubic space as with the
SPARC approach. A small suprapubicincision allows the tensioning device to be fastened to the two proline sutures. Cystoscopy
must be performed to confirm urinary tract integrity. The device
is tightened with the screwdriver until it rests directly on top of
the rectus fascia. The screwdriver is left exposed through the skin
incision. After leaving the operating room, the patient’s bladder
is filled with water, and in the standing position, the patient performs cough and Valsalva maneuvers. The screwdriver is used
to make incremental changes in the suture tension. When the
patient achieves continence, she is asked to void, and a postvoid
residual is obtained. Assuming the patient can empty well and is
Figure 14.2.25. TOT sling tensioning. (Permission granted by AMS.)
Figure 14.2.26. Remeex kit. (Permission granted by Neomedic/TriAnim.)
Figure 14.2.27. Tensioning of the Remeex device. (Permission granted
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by Neomedic/Tri-Anim.)
dry, the screwdriver is detached from the tensioning device and
the incision is closed (Figures 14.2.27, 14.2.28).
Because of thepresenceofa prosthesis, antibiotic coverage for
7 to 10 days is recommended to avoid infection, although at least
one study suggests that routine antibiotic use in an uncomplicated patient may not beofsignificant value.[42–44] If the patient
develops recurrent incontinence, readjustment ofthe sling is possible by opening the incision just enough to allow entry of the
screwdriver. The same test protocol is used again. Because there
is adequate support under the urethra secondary to the Prolene
mesh, leak point pressure can be increased by tightening the lateral sutures.
Although long-term data on the adjustable sling are lacking,
preliminary studiesindicate cure ratesin the range of 95.5%.[38–
40] For patients with continued leakage, improvement is also
significant. Given the unique nature of the readjustable sling, it
warrants further investigation.
Minimally Invasive Slings — 389
COMPLICATIONS
Among all types of MIS, complications are common. Early studies show that the retropubic approach probably has more overall injuries than do the transobturator slings. Most retropubic
sling injuries are minor and resolve spontaneously. This is probably related more to the anatomic placement of the sling than to
the absolute skill of the surgeon. There have been severe injuries
reported, some resulting in death. Attentiontodetailisimperative
to ensure a positive outcome. Skill alone will help, but complications will never be eliminated.
Bladder Perforations
In retropubicMIS, bladder perforations occur in up to 5% ofcases
[17–19], although thefrequencydecreasesprecipitouslywith surgical experience. As long as the perforation site is not bleeding,
nothing more needs to be done. If bleeding is seen, the bladder
may be filled with sterile water for a few minutes. This is usually
enough tostop the bleeding bytamponade. When active bleeding
is seen, it is best to leave aFoley in place until the urine is clear for
at least 24 hours. This is typically enough time for the cystotomy
to heal itself. If multiple cystotomies are seen, or if the hole is
larger than the diameter of the needle, longer bladder drainage
may be indicated.
The TOT slings are inserted lateral to the urethra and are a
few centimeters away from the bladder. Although bladder perforations do occur with TOT slings, the rate of these injuries is
significantly lower (≤2%)than those ofTVTs.[45–47] It has been
suggested by some of the companies producing TOT slings that
cystoscopy is not indicated. Some surgeons consider this to be
a marketing gimmick to sell more slings to physicians who do
not have cystoscopy privileges. Although bladder and urethral
injuries are uncommon, they do occur. Most experienced surgeons would consider cystoscopy an essential part of any incontinence procedure.
Patients receiving the readjustable sling have had numerous
anti-incontinence procedures in thepast. Complication rateswill
probably be increased in this population. Cystoscopy with the
use of indigo carmine dye to visualize ureteral patency is advised
during the case.
Figure 14.2.28. Closure of the skin with Remeex screwdriver in place.
(Permission granted by Neomedic/Tri-Anim.)
Vascular Injury
Retropubic slings such as the TVT are associated with a very
low incidence of vascular injury. Because the needles are placed
blindly, relying on anatomic landmarks, the needles may sometimes wander. A small change in the angle of placement can
mean the difference between being safely lateral to the bladder
and perforating the external iliac or obturator vessels. These vessels are only 4 to 6 cm away from where the needle should be
passed.[47,48]
If a major blood vessel is injured, the patient typically will
show symptoms. She may experience a drop in blood pressure,
swelling or ecchymosis in the lower abdomen or vulva. She may
also have visible blood pouring out of the vaginal or abdominal
incisions. If there is bleeding only at the suburethral incision, the
blood most likely is fromthe superficial plexus of veins.Firm pressure held in the vagina for 5 or 10 minutes can stop or slow blood
loss, allowing the procedure to be completed. Packing can be left
in thevagina andremoved in therecovery room afew hours later.
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Bleeding that does not slow down or that starts coming
through the abdominal incision is more worrisome. This may
indicate a major vessel injury and requires immediate decision
making. Ifthe blood is oozing out of theincisions only, firm pressure held over the lower abdomen and from the vagina for 5 or
10 minutes should be attempted first. Extra tamponade can be
provided by retrograde filling of the bladder with water through
the Foley catheter.
If the bleeding does not significantly slow down after 10 minutes, anabdominal incision may be warranted. Superficial vessels
can be ligated or coagulated. Larger vessels may need repair, and
a vascular surgery consult may be indicated. Overall transfusion
rates are much less than 1% in experienced hands.[18, 50, 57]
Postoperative hematomas are common and usually asymptomatic. If the size of the hematoma appears stable and the
patient is without complaint, observation only is indicated. If
the hematoma appears to be enlarging or if the patient is becoming symptomatic, sonographic imaging is helpful to determine
its size. In some cases, the hematoma can be drained undersonographic guidance. Infected hematomas are rare, but antibiotic
augmentation may be considered.
Bowel Injury
Bowel injuries are always considered life threatening and require
immediate intervention once they are recognized. Unfortunately,
most bowel injuries go unnoticed until the patient has signs of
an acute abdomen or sepsis. It seems difficult to picture how
the bowel could be perforated with an MIS needle until one
does cadaveric dissections and sees how close the intraperitoneal contents are to the retropubic space. Bowel injuries
have been reported in the literature during suprapubic catheter
placement.[52–54] Patients who have had previoussurgery inthe
retropubic space are at an increased risk of injury, as the bowel
may have slid into the space. This is why the peritoneum must
be closed during any concurrent abdominal procedure (open or
laparoscopic) to prevent herniation of the small bowel into the
space anterior to the bladder.
Patients undergoing the readjustable sling need to be treated
a little differently. Many candidates for this procedure have had
multiple prior surgeries. Patients with a history of prior abdominal approach pelvic surgery are at increased risk of bowel injury.
Overnight observation may be warranted. Any clinical signs of
peritonitis require an extensive and immediate work-up.
Patients with a bowel injury may present with an acute
abdomen, nausea, vomiting, and diarrhea. Fever and elevated
white blood count are frequently seen. These patients look sick.
When a patient complains of any lower abdominal pain postoperatively, she must be taken seriously.
Evaluation for bowel injury may include a flat plate and
upright radiograph to look for free air, bowel obstruction, or
ileus. A computed tomography (CT) scan can show changesconsistent with bowel injury, including free air. A sonogram may
also be helpful. Bowel injuries require aggressive management
with resection, drainage, and possible colostomy if indicated.
Wound Infections
Surgical site infections are very rare secondary to prophylactic
antibiotics. It is has been suggested that the outer sheath reduces
the bacteria load after they are removed. Some surgeons soak the
MIS inan antibiotic solution before starting the case.One animal
study using a polymer mesh soaked for 15 minutes in rifampicin,
vancomycin, and gentamicin showed decreased infection rates
when the mesh was reimplanted into rabbit tissue.[33,55–57]
POSTOPERATIVE MANAGEMENT
Incomplete Bladder Emptying
If the patient has failed thevoiding trial, eitheran indwellingFoley
catheter is left in place or the patient begins intermittent selfcatheterization. Most commonly, the patient is sent home with
the catheter,a leg bag, and a night bag. The Foley will stay in place
for 2 to4 days, after which anothervoidingtrial will be attempted.
Repeated failure of the voiding trial results in approximately 3%
to 5% of patients with less than 1% needing a sling revision.[58–
60] Earlyintervention in the first 2weeks will allow the slingto be
loosened by opening up the vaginal incision and gently pulling
down on thelateralsidesof the exposed sling.This allows the sling
to remain flat under the urethra, without disrupting its integrity.
After 2 weeks, the sling will have started to have tissue ingrowth,
and it is best to wait for 4 to 6 weeks after surgery to cut the
sling in the midline. In cases in which the patient has no urine
output, resection ofthemid-portion of thesling may be indicated
if the sling cannot be loosened. Continued continence with good
bladder emptying occurs in over 85% of patients undergoing
revision. Patients with borderlinehigh residuals will oftenrequire
occasional self-catheterization. In this smallsubgroupofpatients,
many will prefer to continue self-catheterizing rather than risk
becoming incontinent again.
As a rule, tight slings can be loosened by cutting them under
the urethra. Loose slings need to be redone or improved with
bulking agents. Experienced surgeons will often make the sling
“tighter” rather than “looser.”
Antibiotic therapy with nitrofurantoin 50 mg/day is helpful in
preventing urinary tract infections in patients with an indwelling
catheter. Antibiotics are not indicated in patients who use the
intermittent self-catheterization technique.
Vaginal and Urethral Erosions
It is difficult to determine whether a sling has eroded into the
vagina or was inadvertently placed there at the time of surgery.
This difficulty applies to slings found in the urethra as well. The
time from surgery thattheerosionisfound probably gives the best
indication of the cause.Ifthesling is found withinthefirst month,
it is probably the result of surgical error. This is not always the
case, however, as suture lines can break down and some patients
have decreased tissuevascularity secondary to prior medical conditions.
Mesh in the vagina often presents with persistent vaginal discharge or odor, or the patient’s partner may complain of pain
during sexual relations, which may be accompanied by the finding of small lacerations on the partner’s penis (which does not
require examination). Thisproblem is bestdealt with in the operating room, with the patient under anesthesia. The visible mesh
should either be resected or be completely covered over with
healthy vaginal epithelium. In most cases, resection will be the
easiest approach, and the entry and exit sites should be closed
Minimally Invasive Slings — 391
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with absorbable suture. Cases in which only a small amount of
mesh is palpable but not seen, may respond to 8 to 12 weeks of
topical estrogen cream.
Urethral erosions require removal of the material. This
can be attempted transurethrally but usually requires a vaginal
approach. Developing a few layers of inverted u-flaps under the
urethra helps to identify the sling and also preserves the urethral
sphincter.By taking down the tissue inthin layers, minimal damage is done to the urethra itself, allowing a repair that decreases
the risk of urethra–vaginal fistula. If the erosion into the urethra
requires extensive repair,it is best to leave a transurethral catheter
in place for 5 days to prevent stricture of the healing urethra. In
these cases, a suprapubic catheter is also placed for up to 10 days
to divert urine flow and allow adequate healing.
Pain
Pain control is rarely a problem. A few days of nonsteroidal antiinflammatory drug (NSAID) therapy is usually enough. Patients
who demand or require stronger medication warrant immediate evaluation because of the unusual nature of the complaint.
Continued pain may be caused by a range of conditions, with
most being self-limited. A urinary tract infection should always
be looked for first. A digital exam of the vagina will rapidly rule
out the presence of mesh in the vagina. Rarely, patients are sent
home without removal of the vaginal packing. Retained packing
presents as “pressure” that quickly resolves once it is taken out.
Complaints of protracted pain may occur along the path of
the sling placement. This is not dependent on improper technique, as the patient may be completely continent, with good
bladder emptying. There is no “one cause” for this occurrence,
but most symptoms abate after 4 to 8 weeks of NSAIDs. If pain is
present after 12 weeks, excision or release of the sling is advised.
It is not easy to excise the sling in its entirety because of tissue
ingrowth.[61–65] It is usuallypossibletoremovemostofthe sling
to the obturator foramen bilaterally or near the pubocervical fascia.
Failures
mayrequireyearlyrepeatinjections.These injections can be easily
applied and performed in the office if necessary.
New in-office modalities using radiofrequency therapy are
now FDA approved but still lack long-term data. Clinical trials
are under way and show improvement in up to 80% of patients
treated. It is unclear how this therapy will affect the urethra in
cases in which a sling will be placed at a later time. If this therapy
demonstrates encouraging results, it may be considered a firstline treatment in patients who either do not want surgery or are
poor surgical risks.
Patients who develop hypermobility of the anterior vaginal
wall after a sling has been placed are at increased risk not only of
recurrent stress incontinence but also of urinary retention.[66–
69] Retention occurs when the sling, acting as a fulcrum, causes
kinking of the urethra and bladder neck as the anterior vaginal wall descends. These patients will have stress incontinence
secondary to overflow from incomplete bladder empting. Resupport ofvaginal mobility willusually correct the problem without having to redothe sling. Placing a pessary into thevagina will
sometimes cure the problem by relieving the kink. Although not
always an accurate predictor of success, the pessary can give a
good indication of how corrective surgery will work.
SLINGS WITH CONCOMITANT SURGERY
The sling should bethelastprocedureperformedwhen combined
with other surgery. This is because it is important to have the
anterior vaginal wall and urethra resting at the point where the
sling is placed. If the vaginal wall and urethra are moved in any
direction (i.e., posterior repair or apical suspension), this may
increase or decrease the tension placed on the sling. This can
increase the risk of retention or continued incontinence.
For surgeons who are doing laparoscopy, the Burch or MMK
procedure may be their primary incontinence procedure. By
avoidingthe retropubic space, decreased morbidity andincreased
success rates may be achieved by switching to a MIS. Overall, the
MIS is applicable to a wider range of patientsthan is any retropubic bladder neck suspension. It may also decrease operative time.
Patients with continued incontinence require reassessment. In
most cases, the anterior vaginal wall is still well supported but the
sling is justtoo loose. Retesting with urodynamicsis the best place
to start. Confirmation that the patient has stress incontinence
and not de novo urge incontinence is helpful from a practical
and legal perspective. Some patients may think they have stress
incontinence, but the leakage is really caused by a contraction
of the detrusor muscle of the bladder. Reoperating on patients
without true stress incontinence will only make their symptoms
worse. These patients will respond to anticholinergic medical
therapy. Patients who continue to have stress incontinence have
a few treatment options.
When the incontinence is severe, repeating the initial MIS is
probably the best place to start. Patients who have already had
more than one anti-incontinence procedure will probablybenefit
from the readjustable sling. For patients whohave improved with
the MIS, urethral bulking shouldbeconsidered.Differentbulking
agents are available, and improvement in the condition can be
expected,butthismayrequiremorethanonesessionofinjections.
Long-term cure has not been seen with these products, and they
CONCLUSION
The MISis now considered the“goldstandard” for stress incontinence therapy. Long-term safety data confirm low morbidity and
mortality rates.[70–73] Cases can be done in the ambulatory setting and do not require extensive recovery periods. Familiarity of
pelvic anatomy and a thorough understanding of the pathophysiology of bladder dysfunction are essential. This will ensure the
proper choice of both the procedure and the technique. Despite
any marketing ploy to the contrary, cystourethroscopy should
still be considered essential during these procedures.
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36. Andonian S, Chen T, St-Denis B, Corcos J. Randomized clinical trial comparing suprapubic arch sling (SPARC) and tensionfree vaginal tape (TVT): one year results. Eur Urol. 2005;47:537–
541.
37. Tseng LH, Wang AC, Lin YH, Li SJ, Ko YJ. Randomized comparison of the suprapubic arc sling procedure vs tension-free vaginal
taping for stress incontinent women. Int Urogynecol J Pelvic Floor
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38. Gandhi S, Abramov Y, Kwon C, et al. TVT versus SPARC: comparison of outcomes for two midurethral tape procedures. Int Urogy-
necol J Pelvic Floor Dysfunct. 2005;17:125–130.
39. Sousa-Escandon A, Lema Grille J, Rodriguez Gomez JI, Rios
Tallon L, Uribarri Gonzalez C, Marques-Queimadelos A. Externally readjustable device to regulate sling tension in stress urinary incontinence: preliminary results. J Endourol. 2003;17:515–
521.
40. Sousa-Escandon A, Rodriguez Gomez JI, Uribarri Gonzalez C,
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42. Gomelsky A, Dmochowski RR. Antibiotic prophylaxis in urologic
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43. Abouassaly R, Steinberg JR, Lemieux M, et al. Complications of
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44. Garcia Florez D, Perez Sanz P, Briones Mardones G, et al. Surgical
management and complications of urinary stress incontinence:
our experience in 385 patients operated on during thelast 25years
[in Spanish]. Actas Urol Esp. 2003;27:92–96.
45. Roumeguere T, QuackelsT, Bollens R, et al. Trans-obturator vaginal tape (TOT) for female stress incontinence: one year follow-up
in 120 patients. Eur Urol . 2005;48:805–809.
46. Smith PP, Appell RA. Transobturator tape, bladder perforation,
and paravaginal defect: a case report. Int Urogynecol J Pelvic Floor
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55. Goeau-Brissonniere O,LeflonV, LetortM,NicolasMH. Resistance
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Section 14.3. Laparoscopic Uterine Suspension, Sacrocolpopexy,
https://t.me/med1917
Vault Suspension
James E. Carter and Senzan Hsu
PART 1: LAPAROSCOPIC UTERINE
SUSPENSION
LAPAROSCOPIC UTERINE SUSPENSION FOR
PAIN AND UTERINE RETROVERSION
Uterineretroversionisabackwarddisplacementofthe uterus into
the pouch of Douglas from its normal anteverted position.[1]
Uterine retroversion may be congenital or may result from adhesions and fibrosis. The condition occurs in20%to30%ofwomen.
Commonly reported symptoms include dysmenorrhea, dyspareunia, and backache. Laparoscopic ventral suspension has been
performed to successfullytreatsymptomatic retroversionandsignificantly reduce symptoms.[1–17] Long-term follow-up of 5 to
20 yearshas demonstrated continued relief of chronic pelvic pain
and deep dyspareunia by uterine suspension.[14] Several techniques have been described to treat uterine retroversion. These
include suspension of round ligament at midpoint, modified
Olshausen uterine suspension, and the Uterine Positioning by
Ligament Investment, Fixation, and Truncation (UPLIFT) technique.
Ventral Suspension of the Round Ligaments
at the Midpoint
This procedure involves the placement of two 5-mm suprapubic trocars and the introduction of grasping forceps into the
pelvis throughthem. Alternatively, longKellyclamps are inserted
through suprapubic stab incisions. Both round ligaments are
grasped near their midpoints, and partial escape of pneumoperitoneum is allowed. The knuckle of the round ligament is pulled
gently and firmly through the fascial incision (Figure 14.3.1.1).
The round ligaments are sutured to the rectus fascia with 2-0Ethibond nonabsorbable sutures (Ethicon, Somerville, NJ). Uterine
position is confirmed with the laparoscope, and one must avoid
kinking the fallopian tubes.[18,19]
Potential complications with this procedure include avulsion
of the round ligaments secondary to inadequate fascial incision
and undue tension or positioning of the round ligaments with
full pneumoperitoneum. The inferior epigastric arteries may be
lacerated during placement of the suprapubic trocars. Although
transilluminating the abdomen often helps prevent this complication, it is difficult in obese patients. For most patients, incisional pain and discomfort are managed with mild analgesics
and a heating pad. Occasionally, patients who experience more
significant postoperativepain from secondary spasms of the recti
muscles are relieved with heat, muscle relaxants, and analgesics.
Patients are advised to avoid strenuous exercise for 4 to 6 weeks
postoperatively.
Modified Olshausen Uterine Suspension
A delayed absorbableor permanent sutureis passed transabdominally at the suprapubic trocar site, using a swaged-on needle.
While the round ligament is placed on stretch, several areas are
taken where the round ligament enters the inguinal canal moving toward the uterus. Approximately 2 cm from the uterus, the
direction of the needle is reversed and a similar maneuver is performed along the length of the round ligament to the inguinal
canal. The needle is passed transabdominally. After both sides
have been completed, pneumoperitoneum is decreased, and the
suture is tied above the fascia (Figure 14.3.1.2). The result is a
plication of the round ligaments.
The UPLIFT Procedure
The UPLIFT laparoscopic uterine suspension is performed with
a Carter-Thomason 2-mm needlepoint suture passer. A tiny skin
incision is made near the exit point of the round ligament into
the inguinal canal (Figure 14.3.1.3). Size 0 (3.5 metric) monofilament polybutester suture is used to make two passes subcutaneously and transfascially into the extraperitoneal space and
within and along the round ligament (Figure 14.3.1.4A–F). The
first pass’s exit point of the suture is 0.5 to 1.0 cm from the uterus
in the fibrous portion of the ligament. The second pass starts 1 to
2 cm cephalad or caudad from the previous puncture site. The
exit point of the suture from the ligament is approximately 1 to
2 cm proximal to the exit point of the previously placed suture.
The suture is retrieved and withdrawn to outside of the skin and
tied. This technique creates a pledget of round ligament and a
bridge of fascial tissue. The ligament imbricates within itself as it
is pulled up by the suture. This moderately anteverts the uterine
position by ligamentinvestment, fixation, andtruncation (Figure
14.3.1.5).
Useofthis techniquehas resulted in an average operating time
of less than 15 minutes for this portion of the patient’s surgery.
In one series of 75 patients [20], the average time to discharge
was 4 hours. Mild incisional and abdominal wall discomfort,
which occurred in most patients for the first 24 hours, was readily relieved with mild oral analgesics. There were no intraoperative complications. After theUPLIFT and associated laparoscopic
procedures,immediateandsustainedreliefof pelvicpainhasbeen
reported in majority of patients.[20,21]
394
Laparoscopic Uterine Suspension, Sacrocolpopexy, Vault Suspension — 395
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Figure 14.3.1.1. The round ligaments at midpoint are pulled through
the suprapubic incision and tied to the rectus fascia.
Multiple procedures for uterine suspension have been
described in the literature that involve folding, plicating, bending, and fixingtheround ligament to theanteriorabdominal wall,
and these procedures have been reported as being successful. The
UPLIFT procedure avoids potential problems with bowel herniation into the anterior cul-de-sac, which may occur with some
of the other procedures. It also results in an anatomically correct
anteversion, with the suspension at the lateral extension of the
round ligaments.
LAPAROSCOPIC UTERINE SUSPENSION
FOR DESCENSUS
Maher and colleagues [22] described laparoscopic suture hysteropexy for uterine prolapse in women wishing uterine preservation. As Maherpointedout, “Vaginal hysterectomy remains the
acceptedsurgicaltreatment for womenwith uterine prolapse. The
Manchester repair is favored in women wishing uterine preservation. Vaginal hysterectomy alone fails to address the pathological cause of the uterine prolapse. The Manchester repair has a
Extracorporeal knotApplying sutures
Figure 14.3.1.2. Modified Olshausen technique.
Anterior
superior
iliac spine
Ilioinquinal
nerve
Figure 14.3.1.3. Position ofthe skinnicksrelativeto theexitingpointof
the round ligament through the inguinal canal. The retroverted uterus
is pictured before uterine suspension. (Courtesy of Inlet Medical, Inc.)
Skin
nick
Genitofemoral
nerve
Iliac
artery
Iliohypogastric
nerve
high failure rate and may causedifficulty sampling the cervix and
uterus in the future. The laparoscopic suture hysteropexy offers
physiologic repair of uterine prolapse.”
Maher performed surgery as follows: Surgery was performed
in a low lithotomy position. The bladder was drained with a
Foley catheter, and a Pelosi uterine manipulator (Apple Medical,
Bolton, MN) was used to obtain exaggerated anteversion of the
uterus. A steep Trendelenburg position facilitated mobilization
of the bowel from the pouch of Douglas. Following placement of
two 5-mm ports for performance of the surgery, the bowel was
removedfrom the pouch ofDouglas, and thecourseof the ureters
was followed from the pelvic rim along the lateral sidewall.As the
cul-de-sac at this stage is an expansive hernia-like area between
the bowel posteriorly and the cervix and posterior vaginal wall
anteriorly, the uterosacral ligaments are frequently deficient. A
Moschcowitz culdoplasty was performed using a size 0 polydioxanone purse-string suture. The uterosacral ligaments were independently plicated using two size 1 Gore-Tex sutures (CV-2, Gore,
Flagstaff, AZ).The uterosacral ligamentplication started midway
along the uterosacral ligament between the sacrum and thecervix.
The ligamentswere reattached to theirpoint ofphysiologic insertion on the posterior aspect of the cervix. At the completion of
surgery, a 3- to 4-cm gap was left between the sacrum and the
plicated uterosacral ligamentstoensure normal largebowelfunction. The course of the ureterswas checked.Ifkinkingwaspresent,
a peritoneal releasing incision was performed between the ureter
and uterosacral ligaments
In the 43 women who underwent this procedure for symptomatic uterine prolapse to or beyond the introitus with straining,
Maher reported that the mean operating time for the laparoscopic suture hysteropexy was 42 ± 15 minutes and the mean
blood loss was 50 mL or less. Intraoperatively, one woman had
broad ligament hematoma resulting from laceration of the left
uterine artery. Peritoneal releasing incisions were performed in
two women in whom the ureter was kinked medially, close to the
plicated uterosacral ligament. No postoperative complications
were reported. With a mean length of follow-up of 12 months
(range 5–19 months), majority of women had no symptoms
of or no objective evidence of prolapse (81% and 79%, respectively). Seven women (16%) underwent additional surgeries for
symptomatic uterine prolapse such as abdominal and sacral
colpopexy, vaginal hysterectomy, and sacrospinous vault suspension and sacrospinous hysteropexy. Two women subsequently
396 — James E. Carter and Senzan Hsu
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Skin
TM
suture
TM
MetraGrasp
ligament
grasper
Round ligament
TM
MetraPass
suture passer
Fat
Fascia
Peritoneum
A
MetraPass
passer inserted within
the round ligament
B
Creating the Fascial Bridge
C
Figure 14.3.1.4. The UPLIFT procedure creates thickened, shortened, and strengthened round ligaments. (A)
The polybutester suture is grasped and passed subcutaneously. (B) The suture exits the round ligament 0.5 to
1.0 cm from the uterus in the fibrous portion of the ligament. (C) The empty suture passer is passed 1 to 2 cm
cephalad to caudad from the first pass. (continued )
completed term pregnancies, delivered by cesarean section, and
were without prolapse at follow-up.
Yen et al.[23], believing that uterine retrodisplacement itself
was associated with dyspareunia, chronic pelvic pain and uterine
prolapseintheabsenceoforganicdisease,describedtheefficacyof
amodifiedtechniquetotreata symptomaticretrodisplaced uterus
with a combination of laparoscopic shortening and plication of
the uterosacral ligaments and modified Gilliam round ligament
suspension.
The surgery began by noting the anatomic relationship of
rectum, ureters, and uterosacral ligaments to avoid injury. Four
size 0 propylene sutures were placed (two on the left uterosacral
ligament and two on the right) to make a circle. Beginning with
the left uterosacral ligament, the first suture was placed at the
lower level near the pelvic wall beside the junction with the rectal margin. A deep bite of the ligament was included while care
was taken to avoid the rectum and ureter. The second suture was
placed at the upper part of the left uterosacral ligament at the
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