V10-08: VIDEO DEMONSTRATION OF LAPAROSCOPIC SUTURE HYSTEROPEXY FOR UTERINE PROLAPSE USING A BI-DIRECTIONAL BARBED SUTURE
Surgical treatment for uterine pelvic organ prolapse (POP) aims to restore the apical support of the cardinal/uterosacral ligament (USL) complex. A variety of techniques for uterosacral ligament suspension (USLS) have been described. Vaginal procedures have favourable outcomes and cost-benefit profiles. Ureteric injury occurs in approximately 5.9% of women undergoing vaginal USLS. Sacral mesh hysteropexy has a high success rate, however after the US FDA warning, there has been a growing fear of mesh complications. Our aim was to demonstrate, by video, a mesh-free laparoscopic technique that suspends the uterus from the USL, allows careful identification of the ureters, and produces excellent support of the uterus.
A 39-year-old woman presented with stage II POP and had failed conservative measures (pelvic floor muscle training, pessary). She requested surgical treatment, uterine preservation and a mesh-free procedure. She was consented to laparoscopic suture hysteropexy (LSuH) with an anterior and posterior colporrhaphy and video recording of the LSuH. The technical steps of the LSuH include: 1 Uterine elevation with a uterine manipulator; 2 Identification of ureters; 3 Incision of the peritoneum above each USL; 4 Uterus suspended from each USL using a bi-directional barbed suture; 5 Careful inspection of the bowel and ureter. Paramount to this technique is appropriate tension on the bi-directional suture in order to achieve appropriate support of the uterus.
We utilised this minimally invasive technique for apical support in a patient with significant POP, and a desire to avoid mesh. Postoperatively, she was discharged home after a 2-night stay without any complications. Her postoperative convalescence was uneventful and at 6 weeks, examination revealed excellent support of all three components of the vagina.
This video demonstrates a safe and effective mesh-free technique to suspend the uterus from the uterosacral ligaments. In patients with symptomatic uterine prolapse, laparoscopic re-suspension of the uterus from the cardinal/uterosacral ligament complex is an anatomic approach for women wishing to retain their uterus and avoid mesh. Laparoscopy affords an excellent view (not achieved at vaginal surgery) of important pelvic structures such as the uterosacral ligaments, ureters, bowel, blood vessels and hypogastric nerve. Compared to vaginal surgery, the laparoscopic approach is likely to cause less ureteric injury. Further studies are required to establish the role of Laparoscopic Suture Hysteropexy.