A Breisky-Navrital retractor is utilized to retract the sigmoid colon in the opposite direction of the ligament in which the sutures are being passed. At times, attaching a light to a suction device or a retractor is also helpful to visualize this area.
Use an Allis clamp to elevate and apply traction on the distal uterosacral ligament; this facilitates palpation and visualization of the appropriate site for placement of the sutures. The exact area of suture passage is best identified by palpation.
(Note: In early descriptions of this procedure, permanent sutures were utilized; again, we use delayed absorbable sutures because all sutures are brought out through the full thickness of the posterior vaginal wall. Permanent suture in our approach would be unacceptable because the sutures are tied in the lumen of the vagina. In some other modifications of this procedure, sutures are passed through the muscular layer of the vagina to exclude epithelium; under those circumstances, permanent sutures can be utilized.)
Once the sutures are brought through the full thickness of the posterior vaginal wall—including the peritoneum, if possible—tag them individually. If the anterior segment is well-supported, close the vaginal incision with a continuous delayed absorbable suture.
Tie the suspension sutures, elevating the apex into the hollow of the sacrum.
If anterior colporrhaphy is needed, perform that repair. Close the anterior vaginal wall as well as the vaginal cuff before tying off the suspension sutures.
5. Ensure that the ureters are patent
After the sutures are tied, instruct the anesthesiologist to administer 5 cc of indigo carmine dye intravenously. Assuming no renal compromise, you should see dye in the bladder 5 to 10 minutes later. If the patient is elderly or if you want to expedite this step, furosemide, 5 to 10 mg, can be given by IV push.
Next, perform cystoscopy to ensure ureteral patency. You should observe a spill of dye-colored urine out of both ureteral orifices. If dye does not spill from either orifice after a reasonable wait (usually, 20 minutes), assume that the ureter on that side is obstructed.
FIGURE 4 Providing support for the posterior vaginal wall
A View of a posterior vaginal wall defect secondary to an enterocele and rectocele. B After entry into the enterocele sac, intraperitoneal suspension sutures are brought out through the full thickness of the vaginal wall at the level of the apex. C Tying these sutures after the vaginal incision is closed at the apex not only results in greater vaginal length but also contributes to overall support of the entire posterior vaginal wall.
6. Completely reconstruct the vagina
The remainder of steps required to complete the procedure usually involve posterior colporrhaphy and perineoplasty. We also reserve placement of a synthetic midurethral sling (if one is needed) until after the vault procedure is complete.
Refer to FIGURE 2 for a step-by step guide to how best to perform high uterosacral vaginal vault suspension.
Questions often asked about this procedure
What do I do if I can’t isolate an enterocele sac and enter it?
Perform a unilateral or bilateral sacrospinous ligament colpopexy.
Is it always possible to identify a usable uterosacral ligament in patients who have advanced prolapse?
We’ve found it extremely rare not to be able identify a usable and durable structure.
The trick to identifying the ligament is to pass an Allis clamp so that one end is positioned intraperitoneally, as high up as possible, and the other end is on the vaginal mucosa side. Elevating the clamp puts the ligament on tension. These clamps are usually placed between 4 and 5 o’clock on the left side and between 7 and 8 o’clock on the right side.
With appropriate traction, the ligament can usually be easily palpated.
If I don’t see indigo carmine dye spilling from one side during cystoscopy, what sequence of events should I undertake?
If the only sutures placed on that side were the uterosacral ligament sutures, cut them individually. If the ureter spills dye after a suture is cut, decide whether you think it is appropriate to replace that suture. Sometimes, unilateral suspension or a suspension with one remaining suture on the side where you cut a suture or two is sufficient.
If you do want to replace a cut suture, ureteral patency must be confirmed again after it is replaced.
No further management of the ureter is required—that is, it isn’t necessary to catheterize the ureter or perform postoperative imaging studies. If anterior colporrhaphy has also been performed, however, apply your highest index of suspicion to determine the source of the offending suture: the uterosacral suspension or the anterior repair.*