1. Inject Local Anesthetic

a. Incision

b. Dissection and Identification of Uterosacral Ligaments

2. Gain Peritoneal Access Posteriorly

3. Tag Uterosacral Ligaments

b. Dissection

4. Gain Peritoneal Access Anteriorly

5. Finish Hysterectomy

6. Tag Uterosacral Ligaments

a. Excise Redundant Tissue

b. Suture

7. Posterior Wall Repair

8. Anterior Wall Repair

9. Suspension Sutures

10. Vaginal Cuff Closure

11. Post-op Remarks

Uterine prolapse refers to the uterus descending into the vaginal canal because of weakened pelvic floor muscles and overstretched ligaments. It can occur at any age but most often affects postmenopausal women. Common causes of uterine prolapse include childbirth, surgery, menopause, aging, extreme physical activity, and heavy lifting. There is also a genetic component. Uterine prolapse can be categorized as incomplete or complete. Incomplete uterine prolapse refers to partial displacement of the uterus into the vagina without protrusion to the exterior. Complete prolapse refers to the uterus protruding from the vaginal opening. The severity of uterine prolapse is graded by how far the uterus descends: Grade I refers to the uterus descending to the upper vagina; Grade II refers to the uterus descending to the introits; Grade III refers to the cervix descending outside of the introitus. In Grade IV, the cervix and uterus have both descended outside the introitus. Symptoms depend on the severity of the prolapse; however, most women have a feeling of fullness or heaviness in the pelvic area that often worsens when coughing, standing, or lifting. Other symptoms include lower back pain, urinary incontinence or retention, bulging in the vagina, and problems with sexual intercourse. Uterine prolapse is generally diagnosed during a pelvic examination. Treatment depends on the severity of the prolapse. Self-care measures include Kegel exercises, avoidance of heavy lifting, managing chronic cough, and treatment of constipation. These can reduce the risk of uterine prolapse and prevent it from worsening. Nevertheless, in severe cases, a vaginal pessary, reduction of the uterus to its normal position, or hysterectomy may be needed. Here, we present a patient with a severe case of uterine prolapse. A vaginal hysterectomy with uterosacral ligament suspension and excision of redundant vaginal tissue was performed.


<h4>CHAPTER 1</h4>

<p>The purpose of this is to try to keep it as dry as we possibly can, because it's a vascular region. Okay, save that, we might need some more. Okay, let's just… This is the cervix, by the way. It's the cervix? Okay Lester, if you just kind of hold that up like that, please. Okay, I'll take a knife. And have a Metzenbaum ready please.</p>

<h4>CHAPTER 2</h4>

<p>Okay, watch this blade, and I'll take Metzenbaum and pickups.</p>

<p>I'm just trying to dissect this tissue we're on. What I want to do is try to identify the uterosacral ligaments where they come on in, try to get in safely, within the cul-de-sac do a colpotomy, and kind of work backwards. Because it's hard to, you can feel it, it's hard to really feel any, any anatomy, but the uterosacrals come in like that. Feel that peritoneum there it's... Yeah. Okay, I'll tell you what, let's, let's go ahead and get me a- give me a Heaney. You can feel the uterus there, Lester. Okay. So what I'm going to do is… This is- I'm- this is the uterosacral ligament. at least it's some of it. And okay, here's easy, now take a suture.</p>

<h4>CHAPTER 3</h4>

<p>And I do what's called Heaney sutures, I- it's inter- interlocking suture. So you can take, and you hold it- hold this one up there. You hold that up. Yes. No, yes. You hold that up, I'll hold the clamp. I'll take the clamp, thanks. Okay, I got it Lester, thanks. Hey, this is 0, isn't it? Yes. Okay, off. And then we're going to tag this. We're gonna tag this with a- Mosquito. Okay, tag this one, down here. Okay. Okay. Okay, I'll tell you what, give me a… Boy, there- she has such redundant uterosacrals, you can't even feel them, so it's, not much here, give me a- if you want to put your finger up in there and see if you can feel them. Thank you. Yes, that's good. Scissors? Do you have a Mayo scissors on there? Yes, that's good. Metzenbaums are a little bit weak. Oh, that's pretty short, isn't it- I'll make it work. Pickups? Thank you. No, no, I'm tagging it. Okay.</p>

<h4>CHAPTER 4</h4>

<p>See if I can come across- see, it's blanched where we injected. Yes. Lester, see that, it's really tough scar tissue in there. Okay, watch the blade.</p>

<p>Just- not taking big bites, just kind of, so I can- scissors- I can control, you know? Suture. Pickups? You can hold that, just like that. Pickups. Here, you got it. Okay, I have this now. I'm going to give it back to you right now. Okay, let's- you take that, and I get this. Okay, off. Take this, I'll use this- no, no, I'm going to just incorporate it into this one. That way we don't have too many instruments here, it gets confusing. Okay, why don't we go to the other side. If you'd hold that up for us..., and give me the... Heaney. Heaney. You guys are doing good, I appreciate it. I'll tell you, maybe I ought to just use one, these things are pretty short, aren't they? Okay, now take that around this way. Okay, you cut that one off. Watch this needle. Okay, that's fine. Actually, those little ones work pretty good. Yes, let me just see this, Lester. What is it on? It's working, okay, it's good. What we want to avoid is getting the bladder here. Scissors? Suture, good, thank you. I'm going to come behind you here. These are Heaney sutures, it's just interlocking, that's all. Okay, off. Scissors. It should be coming up to the peritoneal fold here, pretty soon. Peritoneum there, see? Okay. Heaney. Okay guys, we're moving along okay. Well that's what you're giving me, isn't it? This is 0 Vicryl. Huh? Oh, is this 2-0? I thought it was… Asking for more. Okay. I'm taking small bites intentionally. Yes, taper. Scissors. You don't have any curved Mayos, huh? Pretty short, isn't it? Okay, I'm a- yes, come behind, you take that. Okay, off. Let's see, uterine artery there. Okay. Metzenbaum? Metz? You see, the bladder. Let me see, here. The bladder's right up there, but that's just occurred to me. Okay, you hold that, just like that. Heaney? Much better. Smaller needles. It's okay though, we'll make it work. No, it's okay. Okay, maybe give this to… Okay, you hold that. Okay, give me a Heaney. It's really tough tissue, isn't it? Oh boy, that's short. Go behind, under. Wow! Okay, off. We won't- when they're that short, no, we won't use them again. Okay, watch the needle. This is the round ligament here, okay, give me a Heaney. Army-Navy?</p>

<h4>CHAPTER 5</h4>

<p>I think I'll take it in 2- I think I'll take it in 2 bites. One more Heaney. No- I'll get it with the next one. Okay. Suture ready. We'll tag this one. Suture. We removed the vagina already, we're going to cut it out? No. Yes, no, once I get this side, we'll take it out. I'll take that, and you take this one. Okay, off. Scissors? Okay, Heaney? What causes the prolapse? What causes it? Yes. Oh, it's- there's probably a genetic element to it, but you know, stress, mostly- she's only a gravida 2, but… Yes, you hold that up there like that, that's good. Okay, off. Scissors, please? I'll tell you what, just cut this one. Let's tag this. Okay, get me a sponge.</p>

<h4>CHAPTER 6</h4>

<p>So we're going to suspend the uterus back up. Yes- well I'm going to see if I can get one of the ligaments where I could get sutures in it that just- to give it some support, and then we'll do- try to do like an anterior repair on it, and posterior repair. And then we can reduce the skin here? Yes, we will cut some off, but- but if you've cut too much off, she won't have any vagina. This is her whole vagina. Yes. So, she won't have a vagina. Okay, give me a suture. You can feel- put your finger here, and you can feel it, that's the ligament. Okay. That's it. Yes. Uterosacral ligaments. And you go high up? Yes, I'm going to go as high as I can. Okay, I'm going to leave this needle on, and- tag? Okay, another one? Okay, you hold that. Okay, yes.  Can you hold this, please? Suture? Yes, just hold that. Okay, tag? And you can take that off, you can take that off. Okay. Okay, now let's see if I can- get a- anything else besides that, because they're not that- they're not that prominent. There's nothing really prominent, except a lot of redundant vaginal tissue. If we take it, you know, a lot off, she's not going to have any vagina. Yes. Uh. Okay, let's just take this out.</p>

<h4>CHAPTER 7</h4>

<p>Take and do a repair here. Get rid of a lot of that in the posterior repair, get a lot of- get rid of a lot of this. I think that's the best I can do is just try to eliminate as much of the redundancy as I can, and then close it, because there's not that much… What I'm going to do is do that and then take all this out. Okay. You know, bring these ligaments together and bring the tissue together in layers. And do the same up here. You know, the thing to maybe do is just do not- not too much tissue destruction, and then at a later date, somebody can even- you put a scope in, do a laparoscopy, and go above, and- and pull everything up, and attach it to her upper sacrum. Well, Well I can't do that vaginally, I mean that's too far up. One more? Are you gonna use Vicryl 0 for this one? Huh? Are you going to use Vicryl 0 for this one? Vicryl, yeah, is that what you're asking? Vicryl ready. You got 2 more- 2 more long clamps. Okay. Suture. Give me a 0-Vicryl.</p>

<p>Tag this. Mosquito? Okay, let's see here. Pretty short, isn't it? I'll tell you, you can take that off. Suture? Watch that needle. Watch your finger there. Scissors? You got this? Yes. Pickups? Okay.</p>

<h4>CHAPTER 8</h4>

<p>I'll tell you, I think the better part of valor is to just kind of do a smaller of the same on the anterior wall. Okay. And hitch that to the- to the round ligaments that I have marked here, and hitch the posterior one to the uterosacral, and just close it up. It's going to- it's going to give her support, but she's got so much redundancy, I just- I just hate to cut a lot because I think eventually somebody might be able to do an abdominal procedure and attach it to her sacrum. Okay, 2 straight- long clamps again. Okay, scissors?</p>

<p>Okay, you can cut this. Okay. Okay, I have this. See, if I had a bigger needle, I could just do one swipe. They're puny needles for this, it's a tough tissue. We have CT-1, we got you a bigger one. Yes, CT-1 would be much better. Take that one off. You can relax on that here, that, Allis. Okay, I got it. Okay, and cut. Okay, watch this needle.</p>

<h4>CHAPTER 9</h4>

<p>Okay, this is my round ligament on the left. So what I'm going to do is take this… Needle holder? Okay, let me see this. Okay, you can cut that. Okay, that's round ligament on the right. Cut this needle off. Scissors? What I'm going to do is put a bite, then I'll tie it to this. We'll make it work. Okay, you can cut that. I can use this suture again. You can cut this. Sponge? Okay, you can that out, take this out. You can take that off- I'm just going to- that's all I'm going to do.</p>

<h4>CHAPTER 10</h4>

<p>She'll have a lot of natural retraction from here too, but... Okay. But still, I think probably eventually, someone is going to have to secure this up high, up in the sacrum. Where do they normally anchor- anchor the- in the sacral area, what part in the sacrum? Oh, you know, I'd go as high as I could. Okay. I mean, it depends on how much tissue, you know you want to- you don't want to stretch it too much, but I'd go as high as I could. Usually, when they use it- a sacrospinous, or a sacroiliac, they- they usually go up around the- almost up to the- well, right up as high as you can go. You got to stay out of this vessels and all that. See, there's nothing- there was nothing I can hitch it to down there. It's gotta be way high. Okay. And then the only way to do that is through the abdomen- through a scope, you could do it through a scope. You wouldn't have to open her abdomen up. Well, thanks everyone.</p>

<h4>CHAPTER 11</h4>

<p>We did a- trans-vaginal hysterectomy, and a reduction of vaginal tissue, both anterior and posterior, and we did a high uterosacral suspension, and a- a round ligament suspension to the distal vaginal cuff. But the redundancy of the vagina was just so great that we couldn't get high enough. She eventually might need a laparoscopic sacrospinous fixation of the vaginal cuff.</p>

Watch this full-length, narrated surgical video of a vaginal hysterectomy, uterosacral ligament suspension, and excision of redundant vaginal tissue

Romblon Provincial Hospital