Transverse incision uterosacral ligament (USL) plication.
The cervix is grasped with a tenaculum.
Forceps are placed 5cm apart 3-4 cm below cervix or hysterectomy scar
(fig5) at apex of enterocele, stretched towards the surgeon, and a 5cm
transverse incision is made. Inserting a Sims speculum helps open out
the incision. With major prolapse, USLs are often laterally located.
Stretching vagina facilitates identification, generally at 2 and 10
o’clock.
.
The enterocele is gently dissected off the vagina but not entered. The
USLs are grasped with strong forceps, penetrated and approximated using
a No2 polyester suture, fig5to close the enterocele without opening it.
Attachment of rectovaginal fascia to USLs is made with a purse-string
suture 1cm from the cut vaginal edge (VIDEO) then tied deep into the
already approximated USLs. Vagina is closed with 00 vicryl.
If the ligaments cannot be accurately located , take two sutures
laterally beyond the vaginal incisions and approximate. The tissues
taken up are invariably attached to the
ligaments and the sutures will approximate them.