Multiple sutures may increase the incidence of tissue devascularization and necrosis, thus resulting in failure of the suspension. One case series of bilateral single suture uterosacral suspensions demonstrated a 15% stage I and no stage II recurrence among 71 women with a mean follow-up of 21.3 months (72). Exposure can be accomplished through the vaginal cuff after hysterectomy, a transverse incision at the vaginal cuff in cases of vaginal vault prolapse or descent, and, rarely, through a posterior colpotomy when uterine or cervical conservation is desired. When the apical vaginal wall is attenuated, it is excised. The pelvic sidewall, lateral to the sigmoid colon, is exposed using Breisky-Navratil retractors and a pack to hold the small bowel cephalad and to place the sigmoid colon and sidewall peritoneum on stretch (Fig. 27.12A). After palpation of the ischial spine, single permanent sutures of 0 or 1 polypropylene are placed through the peritoneum and adjacent ligament approximately 1 cm cephalad to and at the same posterior level as the ischial spines. Traction on the sutures and palpation of the site should reveal that the sutures are firmly attached to the ligamentous structures. The sutures are tagged for use after repair of defects of the anterior compartment. The peritoneum is dissected off the vaginal fibromuscular wall posterior to the vaginal cuff. The suspension sutures are then secured with large bites into the posterior vaginal fibromuscular tissue and anterior fibromuscular tissue, then locked in place to approximate anterior to posterior connective tissue and to fix the suture to the vaginal apex so that it may be moved up to the ligament (Fig. 27.12B). If a rectovaginal enterocele is present, it is dissected, reduced, and closed, approximating the prerectal fascia or anterior rectal wall to the posterior fibromuscular vaginal tissue just caudad to the suspension sutures. Absorbable cuff closure sutures are placed at each cuff angle and one to two bites are taken to approximate anterior to posterior vaginal cuff over the suspension suture sites. When indicated, plication of the central cuff anterior to the posterior fibromuscular tissue with a box stitch is also performed. These sutures are secured after the suspension (pulley) sutures are tied, then cuff closure is completed from each side with the absorbable sutures in a running fashion. Cystoscopy is performed to document ureteral patency. Ureteral compromise has been noted in only 2 of 150 cases performed. The procedure provides adequate support of POP-Q point C and D in all 58 subjects evaluated more than 1 year postoperatively (72).
Figure 27.12 Diagrams illustrating open vaginal apical area with (A) exposure of site for suture placement or lateral pelvic side wall and (B) suture placement through ligament then through the posterior and anterior paravaginal tissue where they are locked to enable pulley action to the ligaments when tied. (Redrawn from an image by J. Taylor.)
Figure 27.12 (continued )
The Anterior Compartment