Transverse incision cardinal ligament (CL) plication.
All steps in the surgery are performed with the vagina stretched and
under tension. The cervix is grasped with a tenaculum and pulled towards
the surgeon. Under tension, a transverse incision is made 1 cm above the
cervix or hysterectomy scar. The bladder is dissected off the cervix or
vagina (with previous hysterectomy), initially with dissection scissors,
then with finger dissection to expose the anterior cervix and push
ureters away from the field of surgery. With previous surgery, the scar
may be very adherent to bladder. Grasp bladder wall with forceps to
create counter tension to vagina to facilitate entry to the right
dissection plane.
The CL ligaments are located at 9 and 3 o’clock. Tensioning the lateral
ends of the vaginal incision helps locate CLs. A strong band at 3 and 9
o’clock identifies CLs which are approximated to the midline with two
polyester *sutures (fig 3).
*No2 polyester creates a collagen reaction which will help reinforce the
ligament. The collagen1created has a breaking strain of 18,000lbs/sq
inch and may be sufficient to create a longer-term result. Clearly it is
not as collagenopoietic as a 7-10 mm polypropylene tape which can no
longer be used in many countries.
If CLs cannot be accurately located, take a No2 polyester suture 1-1.5cm
inferolaterally on each side, “S”, fig 3, and approximate. The tissues
taken up are invariably attached to CLs
Re-attachment of musculofascial layer of vagina to the approximated
cardinal ligaments is best done with a purse-string suture 1cm from the
cut edge with 00 vicryl (see VIDEO).
Push the vagina down to the CL suture and tie the purse string deep into
the vagina onto CL Close vaginal skin with 00 Vicryl.