The support of the cervix, and in its absence, the apex of the vagina is provided by vertical and transverse fibres that have a broad origin at the sacrum and lateral pelvic wall (the utero-sacral and cardinal ligaments), described by de Lancey as Level I supports. When these fail, uterine or vaginal vault prolapse occurs. Loss of apical support is associated with concomitant defects of the anterior or posterior wall in 67–100 % of cases [3]. This is commonly caused by failure of adequate reattachment of the pericervical ring to the cuff at hysterectomy.

Patient is placed in a Lloyd Davies modified lithtotomy position with port placement to suit the Surgeon’s preference. The vagina is manipulated with a probe to define the vault and vaginal walls and to allow peritoneal dissection. Anteriorly dissection of the parietal peritoneum exposes the apex of the pubovesical fascia; posteriorly, the apex of the rectovaginal septum.

Separation of the pubovesical and rectovaginal fascia exposes a coexisting cystocoele or enterocoele. On occasion, with a small enterocoele, the sac can be plicated with permanent sutures to the vaginal apex or the lax anterior wall may need plication with the pubovesical fascia being attached to it. Larger enterocoeles should be resected, with removal of excessive vaginal epithelium and a permanent Y-mesh applied to provide the necessary support. In women with diverticulosis, it is helpful to suture the appendices epiploicae to the anterior abdominal wall to help with retraction.

The next crucial step is identification of the sacral promontory and its relationship to the right ureter and the right common iliac vein. Deeper to the proposed peritoneal dissection lie the middle sacral vessels. A longitudinal incision of the peritoneum over the sacral promontory is carried out, extending to the cul-de-sac. The pneumoperitoneum helps expose underlying tissues – blunt dissection is then used to expose the anterior longitudinal ligament over the sacral promontory.

A Y shaped monofilament polypropylene mesh is then sutured in a tension-free manner to the vaginal vault using non absorbable sutures, with the vagina being placed in an anterior and cephalad direction. The free end of the Y- shaped mesh is then fixed to the anterior longitudinal ligament with non absorbable sutures, titanium tacks or staples. Complete peritoneal reapproximation helps cover the mesh internally.