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.