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.
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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.