A rectal pack soaked with betadine is inserted to allow recognition of the rectum throughout the procedure [6]. Then, with the patient in Trendelenburg position, a Scott retractor to expose the vagina and a urethral catheter to drain the bladder are placed. Two sutures are placed at each vaginal vault fornix to confirm location of the vaginal apex for later repositioning (Fig. 11.1b). The dimensions of the reduced vagina are measured. A midline incision is made overlying the bulging prolapse, extending anteriorly and/or posteriorly as far distally as needed based on associated compartment prolapses when present. Vaginal flaps are raised on each side of the original incision. After opening the enterocele sac, a pack is placed to reduce the bowels. The pack in the rectum can now be palpated, as well as the medial edge of the levator muscle bordering the rectum on each side. For a right handed surgeon, a No. 1 absorbable suture is then placed into the levator musculature on the right side, and passed over the rectum and secured to the medial edge of the levator muscle on the other side. The suture is left on a stay clamp. A second suture is then placed in a similar fashion 1 cm proximal to the last suture. After this is done, the closure of the enterocele sac is accomplished. A No. 1 polypropylene purse-string suture is pre-placed circumferentially to close the peritoneal cavity and eliminate the enterocele sac. After the peritoneal packs are removed and the purse-string suture cinched down, a dye (e.g. fluorescein) is administered intravenously and cystoscopy is carried out to confirm ureteral patency.

The two preplaced levator sutures are tied sequentially across the midline. These two levator sutures (proximal and distal) are then tagged with a hemostat. The end of each suture is threaded on a No. 6 curved Mayo needle and then transfixed at the new restored site of the vaginal apex from inside out, approximately 1 cm apart from each other. The proximal and distal ends of each levator sutures are then tied to each other bringing the vaginal vault down over the rebuilt levator plate just underneath the mucosa with direct tissue apposition.

If an anterior repair or anti-incontinence procedure is required, it can now be carried out (Fig. 11.1c), followed by a rectocele repair with perineorraphy when indicated (Fig. 11.1d).

Figure 11.2a illustrates the location of the uterosacral ligaments (USLs) when used to fix the vaginal vault during a hysterectomy. Several years after hysterectomy, these ligaments are no longer present. Since they represent the medial edge of the levator muscle, and a pack has been placed rectally to identify the rectum, it is easy to secure the medial edge of the levator muscle (former USLs) with two sets of absorbable sutures as shown on Fig. 11.2b. Once the enterocele defect has been closed, these high levator myorraphy sutures can be tied together in front of the packed rectum without risking a reduction in rectal lumen caliber and then they can be transfixed from inside out at the location of each apex identified by the marking sutures placed at the start of the procedure (Figs. 11.2c and 11.3a, b). Then once tied down, these sutures return the vaginal apex over the rebuilt levator plate underneath with direct tissue apposition (Figs. 11.2d and 11.3b, c). While HMLM started out as an intraperitoneal procedure, it can also be performed as an extraperitoneal procedure, thus decreasing the potential for ureteral injury.