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Vaginal Hysterectomy, Uterosacral Ligament Suspension, Anterior Repair, and Perineorrhaphy

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CHAPTER 1

So this is a 75-year-old multiparous woman who has Stage 3 uterovaginal prolapse. She had tried a pessary in the past, but was - She came to my office because she was desiring definitive therapy. So we talked about the options and she decided that she would like to have a vaginal procedure done.

So the plan today is to perform a total vaginal hysterectomy, a uterosacral ligament suspension, and likely anterior and posterior repair and perineorrhaphy. So vaginal procedure is a minimally-invasive procedure. We don't do a lot of abdominal procedures now, we try to do everything as minimally invasive as we can, so the other option would have been a laparoscopic procedure. And if we did a laparoscopic procedure, we would have done what's called a sacrocolpopexy at the same time. I did discuss with the patient both options of a sacrocolpopexy, which involves a Y-shaped piece of mesh, as well as a vaginal procedure, and she decided that she wanted to proceed with the vaginal procedure.

So the plan for the procedure is to start with doing the vaginal hysterectomy. So, with doing that, we remove the uterus and the cervix because you're starting from below and working your way up. If we can reach the adnexus of the ovaries and the Fallopian tubes, we will also remove them at the same time. Once that specimen is passed off the field, then we isolate and find the uterosacral ligaments and those are then tagged with suture.

We then perform a cystoscopy, because one of the risks of a uterosacral ligament suspension, there's about a 3% risk of kinking of the ureter. So we perform a cystoscopy and apply tension to the sutures to make sure that we don't see that. If we did, we would remove the sutures. Then, those sutures are brought through the vaginal cuff, and then tied, and then additional repairs are done, such as an anterior and posterior repair.

CHAPTER 2

This is a self-retaining retractor that we're using here, it's called a Lonestar. It helps for visualization during surgery, especially when you don't have assistants.

So this is - we're grabbing the cervix here with tenaculums, and then we're going to inject circumferentially with local anesthetic and make a circumferential incision around the cervix.

So this is a dilute, or straight-up marcaine with epi. So this helps with hydrodissection, as well as hemostasis, when we make this incision.

Good.

CHAPTER 3

So it won't - you know, the bladder is anterior, so what we're doing is we're protecting the bladder anteriorly, we're protecting the side walls.

I don't hear it.

Oh. Can we turn up the - ? Never mind. So we're going to make a - incision now, circumferentially around the cervix.

Yeah. And so we like to go down in a V in the back because we're going to be entering the peritoneum posteriorly. So by doing this, we get away from the cervix and bleeding and vascularity. She's going to continue like this around the cervix until we see a nice plane.

So the patient has an indwelling Foley catheter. She's in the dorsal lithotomy position. I'm using Allen stirrups, some people use candy cane stirrups. Her legs are up pretty high, which allows for access and visualization.

Little lower. Yep. Yeah, that's good there.

Are you happy up here?

Below.

So now what we're doing is we're - going to try to get into the peritoneum posteriorly. We're going to use Mayo scissors, these are heavy Mayo scissors. We're going to take a large bite here.

I think it might be a little lower.

It looks like that. Yeah. Feel, and then, when you're happy, open. Do a spread. Feel like you're in?

Is this in your way?

One more. Yep. Right there. I see the peritoneum.

Yep. That looks good. Mhm. Big bite. Good. And then once we confirm entry into the peritoneum, we're going to take a heavy-weighted speculum. We're going to feel around. She's feeling to make sure there's no adhesions.

So the rectum is below us. Above us is the uterus, the cervix. Feels free. So now, what this is doing is, this is protecting the rectum. So we are in the peritoneal cavity now. So now we're going to get in anteriorly. So now what we think about is the bladder.

So you're going to have to do some more dissection.

So I'm going to go through that supravaginal -

Mhm.

We’re a little - Yep. And drop it back more, yeah. See, that's nice. And go around lateral.

Out here.

Mhm.

I think you're digging in a little bit. A little higher. Yep.

Sometimes it's difficult to get in anteriorly, so what we start doing is we take bites with a Heaney hysterectomy clamp. That will allow for access, it gives you a little bit more traction. The uterus drops down further and allows us to actually get into that anteriorly.

So we're going to clamp. We're going to take a 0 Vicryl. So we're going to hold this suture for our uterosacral suspension that we're going to do. This patient has prolapse. So this is going to help us find the uterosacral ligament once we have removed the uterus. This is a Heaney stitch. So a stitch is first placed at the tip of the - clamp, and then at the heel. So she's going to tie down and then I'm going to release the clamp as the knot comes down. It's going to cinch. And we're going to hold it. We'll do the same thing on the patient's right side.

Next is another 0 Vicryl.

Alright. We're going to take another SNaP.

So traditionally you use clamps, like we just did with the hysterectomy clamp, the curved Heaney, but you can also use electrocautery like we have here, which does decrease blood loss. So we're going to do a combination of the two. So now we're going to take bites with the electrocautery, marching up so that we can enter anteriorly.

Can I have that? So just feel. Let me just get this here.

Come a little closer - I just don't want you to get the suture. It does have a lot of spread.

It does, yeah. It usually does with the suture.

So the LigaSure does get quite hot, so you have to be careful about what's around you. So right now we worry about the vaginal sidewall. As we get higher up, you have to always make sure that the bowel or the omentum is not near this device because it can cause thermal injury.

Little bit more Tberg.

Just make sure you've got that peritoneum - that's good.

No, small.

Now you're going to get your - come a little closer. There goes your stitch.

Yeah, so she's hugging the cervix. We want to stay within our pedicle, so these are - the tags will tell us where our pedicles are. If you get out laterally, you worry about things like the ureter which are coming down. So she's taking bites that are always close to the cervix. And again we have not gotten it in anteriorly, so we do still have to worry about the bladder. But we do know where the reflection is. If we just hug that cervix, we'll be okay.

So now what we're going to do is we're going to get in anteriorly. So we've used 2 pickups, we're grabbing the peritoneum and we're going to make a snip into the peritoneum. The bladder is protected with the - Breisky.

There you go. Yeah. So now we have this nice, glistening - peritoneum. So now we confirm with our finger, we're feeling the fundus of the uterus or we're feeling the uterus below us, and anteriorly is the bladder. So we're going to use the right angle retractor to protect the bladder as we continue to march up, taking bites for our hysterectomy.

Okay, let's just get this out of the way. There we go.

CHAPTER 4

So as we march up the broad ligament, we're going to get the uterine vessels - actually, there's a really nice visualization of our uterine artery and vein coming down along the uterus here.

So again, we always want to make sure we're mediate, we're taking bites medial so the LigaSure is staying within our pedicles. So we're going to be taking bites along this side here.

So we always want to protect - feel posteriorly, make sure there's no bowel that can slip down here. We know that the bladder is protected anteriorly, and again we're always staying medial to our pedicles. What I'm doing with my Breisky retractor here is I'm also protecting the sidewalls, making sure that no thermal injury occurs.

Can I just feel here for second?

Are you going to take the utero-ovarians with a stitch or with a LigaSure?

I take the utero-ovarian with a LigaSure. Yeah.

You have a little ways to go. Just continue to stay in. So hopefully - let me know if you start seeing the utero-ovarians. I don't see the utero-ovarians. She's got a long cervix.

Which is very normal with prolapse.

Mhm.

We're getting there. So we continue to march up. What I'm feeling for right now is I actually can get my finger around the utero-ovarian ligament. I think it's freer on this side.

It's definitely freer on this side.

So do the side that's freer - yeah.

So currently our finger is inside. We're feeling the tip because you can't see the tip of the LigaSure. Again, we're protecting bowel that can slide down, making sure the bowel does not slide down while we're taking our bites with the LigaSure device.

So the bowel is sneaking down into our field, so what we're going to do is we're going to place a small pack to push the bowel away. If you do it posteriorly, it should push it all up.

Right, that's what I was thinking.

So we're placing a pack to help the bowel get out of our field as we march up. Just to show you some anatomy here, so at the - this is the fundus, so that's the top of the uterus, so we're almost there. You can see coming down here on the patient's left side, this is going to be her utero-ovarian ligament.

So what we're going to do next is come across that on both sides. Behind that, what we're protecting anteriorly with the Sims retractor, we're protecting the bladder, and we have packed the bowel away so it does not sneak down when we take those last final bites that are quite high up in the pelvis.

Alright. So for these higher bites, we really do have to be worried about the pelvic - think about the pelvic sidewall laterally, as well as the bowel. So what we're really doing is we're hugging the fundus of the uterus, we're putting our fingers in and we're feeling to see where that tip comes out. Making sure no bowel slides down. So she's going to keep her finger here as she cauterizes. Now this is freeing the ovary and the Fallopian tube from the uterus.

So now we have freed, as you can see here, we have freed the ovary and the Fallopian tube from the patient's left side. We're going do the same now on the patient's right side.

So you do need to take care - once you've gotten the - one of the utero-ovarian ligaments, it's a very small pedicle that you have left, you can always - you can evulse it if you pull too high - too hard, excuse me, on the uterus. So we are not applying too much traction. Which can be counterintuitive because you are so high up in the pelvis.

Get the fundus down. Just make sure that there's no bowel.

So right now we are around the utero-ovarian ligament on the right side. Protecting the bladder anteriorly, the pelvic sidewall laterally. A finger is in to make sure the bowel is well away from the field. With this, the uterus and the cervix will be free.

Nice. Alright.

So she has a very small fibroid here, as well as on the back side. So we're going to look at her pedicles and make sure that they are hemostatic, which they are.

CHAPTER 5

So now we've done the vaginal hysterectomy. This patient has prolapse. In order to correct her prolapse we have to do a suspension. The suspension that we're doing is called a uterosacral ligament suspension.

So now we're packing the bowel. We're going to visualize the uterosacral ligaments as they come down the pelvis. I'm protecting the pedicles with the Breiskys on both sides. We're packing the bowel away. So currently what we have - we have Allises on the uterosacral ligament on the vaginal side of the cuff. We are feeling with our finger for the uterosacral ligament.

Now will you just - is your Allis on it now? We can palpate the ischial spine. We have a long Allis - the bowel is packed, and we have a long Allis that is on the uterosacral ligament.

You can use either permanent suture or delayed absorbable suture to go through the uterosacral ligament. You can place 2 or 3 sutures. We are going to use a delayed absorbable suture and we're going to place 2 sutures going through the uterosacral ligament. We are performing a high uterosacral ligament suspension, which is 2 cm above the ischial spine, which we can palpate.

When we use delayed absorbable suture, we are driving the needle from lateral to medial. You have most control over the needle as it comes in, so we need to - again, we're always worried about the ureter, so that ureter is along the pelvic sidewall. My retractor is also protecting it, but we're going to go in that way to avoid injury to the ureter. Placing the Allis on the uterosacral ligament also helps for identification, and - What you worry about with this procedure, the recorded incidence of ureteral kinking is about 3%. So by placing an Allis on that uterosacral ligament, it does decrease the risk of that kinking. Things that can help with placement is placing a long Allis along the uterosacral ligament, tagging the uterosacral on the vaginal cuff.

So we like to place 2 different SNaPs so we know what suture is higher and which one is lower.

I'll take that straight, um -

Long needle driver.

Is this going to be high or low?

This is going to be high.

Okay. We'll take a straight SNaP.

Can we get our cysto set up?

Got it?

A curved SNaP? Got it.

Alright, so 2 sutures were placed on the patient's right side. So if we pull on our Allis on the vaginal side, you can see the uterosacral as it fans out along the pelvic sidewall. We're grabbing it with a long Allis. We have long Breisky retractors retracting the bowel and the rectum.

I'll take that stitch.

Again, the needle is traveling lateral to medial. You have the most control going that way, away from the pelvic sidewall where there's vasculature and the ureter.

So now we are going to take the pack out and do a cystoscopy.

CHAPTER 6

So now we're performing what's called a cystoscopy because there is that 3% risk of ureteral kinking with the uretosacral ligament suspension. So what we're going to do is we're going to look into the bladder and we're going to apply traction to the uterosacral sutures to confirm that we see ureteral jets.

So you can see the patient's urine looks very orange. It's because we gave her pyridium preoperatively and that allows us to see the ureteral jets. Other people - you can use indigo carmine or fluorescein, which can also be used to help visualize the ureteral jets.

So currently I'm supporting the anterior wall of the vagina because she has a large anterior wall prolapse and this is allowing us to see the ureteral orifice. That's tension. I had tension, yeah. Alright, let's look at the other side, then. Nice! That's what we want to see. Perfect. That's tension, yeah. That's beautiful.

CHAPTER 7

So once ureteral patency is confirmed on cystoscopy, now we're going to do - if additional repairs are needed. She needs an anterior repair so we're going to do that now.

Take a little Tberg, bed up.

So we feel for the bladder neck, which is - we do that by pulling back on the Foley catheter. We want to avoid the bladder neck when we do our anterior repair. This patient does not have urinary incontinence or stress urinary incontinence, so she's not having a mid-uretheral sling. If she was, we would place it at the mid-urethra, which is right about here.

For the anterior wall, we place 2 Allises along the anterior wall, and we're going to dis - we will inject - with marcaine - 0.25% marcaine with epinephrine. This aids in both hemostasis, but as well as - it helps us with hydrodissection. So you can see the blanching of the tissue. As well as the blebs that we're creating. That, again, helps with our hydrodissection, it prevents the - it keeps the bladder well out of our field.

You're okay right now. Yeah, you're good. Right now.

A Raytec.

So vaginal surgery is all about traction and countertraction. So I'm providing countertraction with these Brown forceps here. We have a finger placed behind the vaginal epithelium and that also allows with traction and countertraction.

So we keep this dissection nice and thin because we want to allow the stronger fibromuscularis tissue to allow for our plication. Prolapse is just like a hernia and so what we're doing is we're reducing the hernia by using plication stitches, which you'll see in a little bit.

Once you get into a nice plane, you can do some blunt dissection with a moist Raytec like we're doing here.

So we take our anterior repair down to the incision that we made during the vaginal hysterectomy. And this will be closed together.

There's just one little vessel I think right here.

Happy?

Yep. So let's replace the stays on that side and then come to the other side.

So we do the same dissection on the other side. Again, this allows for the bulge of the cystocele to be right in the midline and then we'll plicate over it.

Can I get another Raytec?

Alright, so what we've isolated here is the cystocele or anterior vaginal wall prolapse, which you'll see here. Now we're going to take this stronger tissue that's off lateral and bring it from side to side to reduce this bulge. We use a delayed absorbable suture for this.

Do you want to use your 2-0 PDS?

Yeah. Let’s take a 2-0 PDS.

So underneath this is the bladder, so we do not want to go deep into the tissue, but we also don't want to go too thin because we want to have strength.

Where are the suture scissors?

This is a running suture, so it's a continuous closure or imbricating stitch. It's going from side to side. Yep. Just don't get the ureter. Don't go too lateral, because you saw where the ureter was, right? So just do like a Christmas tree.

Up top. Yeah.

So you can kind of see this is a stronger tissue we have here compared to the midline, where it's - really there's not a lot of tissue that we can bring across. The tissue's retracted to the midline and a suture is placed horizontally.

So now you can see, as we travel our way down, the bulge is now reduced.

Alright. Good. Right to the cuff. Good.

I'm going to do one more layer.

So we're just going to do a second layer. This is now with a - this is with a Vicryl suture. This just helps with scarring because this is a native tissue repair, meaning that we're not using - we're not augmenting with either a graft or a mesh. We're using the patient's own tissue.

So now what you can see here is the vaginal bulge has been reduced so the cystocele that was here is now reduced. This is all redundant vaginal epithelium or mucosa because of the - the prolapse has stretched this tissue out. So we're going to - we'll excise some of this excess vaginal tissue.

Go in and - yeah.

This is trash.

Yeah. Just cut this one and then take a little more.

You're twisted.

Thank you.

Next is going to be a full-length 2-0. Full-length 2-0. Vicryl. Vicryl.

CHAPTER 8

Full-length. This is going to be a full closure. So you're going to take it to the end of the -

Can we take that off? I just want to make sure I get the apex.

You're going to travel down to the cuff and then you're going to place your uterosacral ligament sutures through it. Yeah. Just like you do if it's vertical. And then continue the closure.

So now we're going to incorporate the anterior repair closure in with our vaginal hysterectomy closure. So we're going to take this suture all the way down to the vaginal cuff and then we're going to place those uterosacral ligament suspension sutures through the cuff. We are using a non-permanent suture, so we're able to go through and through the cuff. If you were using a permanent suture, you would not want to do that because that's on the vaginal side.

Good. I'll just blot this after that. You're getting close to the cuff.

Oh, yeah. Yeah.

Yeah. Exactly. Then we can cut that.

Oh, okay. You want to do the transverse?

No no, then we can cut the uterosacral, um - this guy.

Yeah, one more there. And then we'll do the uterosacral - yeah, we'll grab it. Good. Pull that up.

I think so. Let me just look at it. Yeah, that's nice.

So we've closed the anterior repair now, as you can see here. Now we're going to take time to place the uterosacral ligament stitches through the vaginal cuff. Again, this is a non-permanent suture, so we're able to go through and through the cuff.

So when we place these Allises, we're making sure that we're including the - in the closure, I always want to make sure you include the peritoneum because it can bleed if you do not.

So this one's further back.

Yep.

And then the other ones will be - more distal, or - ?

Yeah. So that PDS is brought through the vaginal cuff one side, the other side does not have a needle so we use what's called a Mayo or free needle. Looks like this. And then we thread the end of the suture through it. SNaP the other end.

You do that?

I did.

So now both ends of the suture will be through the vaginal cuff. Good. SNaP those two. And do the next one.

That's the ligament. This one's the ligament, right? You want to take it out on that side of the SNaP.

Yeah, you can travel back. Yep. Alright. You can SNaP those two. Go to the other side.

Just don't get the bladder. Obviously. I mean, you're not going to get the bladder, but - Yeah. You're fine.

You can do it right in the corner. It seems like - it's funny, this side's, like - tethered.

Well, her peritoneum's right there.

Peritoneum should be included, I think I got it. There's the peritoneum. Yeah, just don't get that. Yep.

So what you can see here now is we've done our anterior repair. This is our stitch from our anterior repair. We're going to use that to finish closure of our colpotomy from our hysterectomy. We have brought the uterosacral ligament sutures now through the cuff on both sides, so we've done 2 delayed absorbable sutures on both sides. We will continue with the closure and then we're going to tie down these apical suspension sutures and what you'll see once we tie them down is that we'll elevate both the anterior wall as well as the apex of the vagina. So this is a vertical closure, which helps preserve vaginal length, prevent her vagina from getting too short.

When you get low, just don't forget to get the - make sure you get the peritoneum. Posterior wall.

The counts are correct. All of the sponges are correct. We've closed the peritoneum.

So the vaginal cuff has been closed. And now what we're doing is we're going to tie down the apical suspension sutures to elevate the vaginal cuff and the anterior vaginal wall.

So we've made sure that all tension is off of the vaginal wall to allow for tying it down completely. So you want to free up any sutures, anything that could hold up.

Can we have the bed down a little bit? And a little touch of Tberg.

That's good. And a little Tberg? Good. Thanks.

So we cinch down these knots to make sure there's no air knots. Since this is a delayed absorbable suture, we tie 6 knots. We will continue to hold these sutures, we'll do one last cystoscopy before cutting them.

Thank you.

It does look good. Might measure her vaginal length too, it looks nice and long.

And with that vertical closure.

Yeah, that's nice.

So now you can see that the anterior wall and the apex of the vagina are well supported, they're way up here. So we'll need to do a repeat cystoscopy and then we need to make the opening of her vagina a little bit smaller, which is called a perineorrhaphy. It's gotten dilated because of her prolapse. Take the syringe for the Foley.

CHAPTER 9

Can you see it? Do you see it? Oh, there it is. Is that it? Yeah. Alright. Let's go to the other side.

Is it going right now? Oh, there it goes. Perfect. It worked. Let's do a survey, yeah.

So we repeat cystoscopy, make sure that both ureteral jets - make sure we have both brisk ureteral jets. Now we're looking to make sure there's no sutures in the bladder from the anterior repair. Now it's going. And that side.

Happy?

Yep. We'll take the room lights on.

CHAPTER 10

So now that we've confirmed ureteral patency, we're going to cut our uterosacral ligament stitches.

CHAPTER 11

So right now what we're doing is a posterior repair and perineorrhaphy. Allises are placed along the hymen. We want to allow at least 3 finger breadths', 2-3 finger breadths' entry to prevent dyspareunia. So we make sure that that's correct before we place our Allises.

… and a SNaP, please.

So I just put a finger in the rectum. This shows me where the defect is. She has a little pocket here, so we want to by - bypass that pocket and close that dead space. We're injecting again. This is - 0.25% with - same thing.

You're just doing a perineorrhaphy, you don't really want a little posterior repair?

I think we need to. Up in there. I think you just do that diamond.

You're good. Bring it together.

So we're making a diamond-shaped incision. We're going to excise the epithelium and then rebuild the perineal body. Just excising the epithelium here. You're just going to do like a U and bring that together. You know what I mean by that? In here, out here, in here, out here?

Yep. I was going to get it started in the vaginal -

Oh yeah, you can start it - yeah. Tag the apex.

Sorry?

We're going to tag the apex.

That's what I was going to do, is just put it up there so I can reach it later.

So the apex is tagged with a 2-0 Vicryl suture.

Alright. Good. No, you're fine. I'll take the 0.

That's what you want, there?

Yeah. Maybe a little bit higher.

Well, I'll do the vertical, too.

Yep. Good. That's perfect. That's good. Same thing on the other side. You might do another one after that.

Higher up. Build it up a little higher. Good.

Can I get another left glove?

Alright, we're just about done. We have like 2 minutes.

We're just going to run to the end and then stop, because there's nothing really to come back up. Because we didn't go that low.

Just kind of build back up that perineal body.

It's pretty, huh?

It does look good.

CHAPTER 12

So now - We need to feel up high for the - make sure the uterosacrals aren't - hitting the rectum. So we always want to do a rectal exam at the end of our procedure. We're feeling for the uterosacrals, make sure that there's no stitches in the rectum, which there are not.

We have restored normal anatomy. She no longer has prolapse. And the procedure is complete.

CHAPTER 13

So today's case went as planned. We were able to do everything we thought we were going to do other than we weren't able to see, actually, her left adnexus. So we did not remove that ovary and Fallopian tube on that side. But she did end up having a vaginal hysterectomy and we did the uterosacral ligament suspension and the anterior and posterior repair and perineorrhaphy, bringing the vagina to make it a little bit smaller so the prolapse does not come back.

The great thing about vaginal surgery is that the patients actually do really, really well. They have very little pain and their recovery is pretty quick. I would say, for my patients, the majority of what their complaints are, if they have any after surgery, is just feeling tired. The procedure takes about 3 hours or so. It's, you know, intricate with a lot of steps and you're operating in a very small space. So I do think that patients often are quite tired after surgery. They also often have constipation, which kind of goes along with what we see in this patient population, so that's also a big thing we talk about in the preoperative counseling. But they do very well and have very little pain.

In the patient population that I have to deal with, they have prolapse, so in one sense that makes the vaginal hysterectomy easier because the cervix and the uterus are dropped, right, so you're not operating really high up in that very small space. But, with that, you do also have - the ureters are dropped down too, so you always have to look out for any - any of the organs around where you're operating. So what we think about with a vaginal hysterectomy is, anteriorly, think about the bladder, posteriorly, you think about the rectum. At the apex, you're also thinking about the small bowel coming down, and then the ureters as well.

If you're operating on someone who is younger, they may have a large, like a fibroid uterus. That makes it much harder because the uterus is often very high in the abdominal cavity.