Mesh-Free Laparoscopic High Uterosacral Ligament Suspension during Total Laparoscopic Hysterectomy for Uterine Prolapse

Abstract

Study objective: To demonstrate a mesh-free approach for uterine prolapse during a hysterectomy.

Design: Technical video (Canadian Task Force classification III).

Setting: Benign gynecology department at a university hospital.

Patient: A 50-year-old woman.

Intervention: Laparoscopic high uterosacral ligament suspension technique.

Measurements and main results: A 50-year-old woman presented with irregular vaginal bleeding and grade 3 uterine prolapse. The patient was concerned regarding the use of mesh and erosion. After counseling the patient agreed to a mesh-free single procedure. The use of mesh for the treatment of pelvic organ prolapse has become the subject of controversy and litigation. Complications of mesh erosion have resulted in the US Food and Drug Administration reclassifying transvaginal meshes as high-risk devices in 2016 [1]. Mesh erosion risk is up to 23% with hysterectomy and concomitant laparoscopic sacrocolpopexy [2] and 3% with sacrohysteropexy [3]. We present an alternative laparoscopic approach of treating uterine prolapse with high uterosacral suspension during laparoscopic hysterectomy. Our method avoids the use of mesh, sacrocervicopexy and morcellation, or an interval sacrocolpopexy. Although high uterosacral ligament suspension can be performed vaginally, it carries up to an 11% risk of ureteric injury [4].

Conclusion: In this video a bilateral ureterolysis is performed, before hysterectomy, isolating the uterosacral ligaments. These are then suspended to the vaginal vault in a purse-string fashion using Vicryl 0 (polyglactin 910) and intracorporeal knot-tying. Postprocedure the vault is well supported with a vaginal length of 12 cm.

Keywords: Laparoscopic vaginal vault suspension; Mesh free; Pelvic organ prolapse.