McCall described culdoplasty in 1957, where purse-string sutures were used to plicate the uterosacral ligaments along with the peritoneum to support the post-hysterectomy vaginal cuff [6]. The technique has been in regular use since then with modifications.

Culdoplasty technique usually involves placement of internal and external sutures on the uterosacral ligament after hysterectomy and plicating them in the midline. About one to three internal sutures are placed from the uterosacral ligament of one side to the opposite side, incorporating the peritoneum in between. This obliterates the cul-de-sac and reduces the risk of postoperative enterocele. The external or distal sutures on the uterosacral ligament anchor the ligament to the vaginal vault. The close proximity of the ureter at the cervical end of the uterosacral ligament should be borne in mind during McCall’s culdoplasty.

The shortening and plication of the distal uterosacral ligaments in midline appears to be effective in apical support. The success rate has been quoted as high as 90 % at the end of a year to about 85 % in a 4–9-year follow-up study [7]. In a study comparing the sacrospinous ligament fixation with McCall’s culdoplasty, recurrence in the anterior compartment was less frequent with the culdoplasty [8].

The technique of HUSL suspension was first described by Miller in 1927 [9]. The suspension procedure can be employed for vault support either at the end of the hysterectomy or for vaginal vault prolapse. In HUSL, the uterosacral ligament portion, proximal to the ischial spine, is used to suspend the vaginal apex along with incorporation of the anterior and posterior vaginal walls to create a pericervical ring.

The technique has been described in detail and popularized by Shull et al. in the last decade [10]. The uterosacral ligaments are identified posteromedial to the ischial spines at the 4 o’clock and 8 o’clock positions. The transverse portions of the pubocervical and rectovaginal fascia are identified, and bowels are packed away. Traction is applied on the uterosacral ligaments, and the strong suspensory ligament tissue towards the sacrum is traced. In the original technique, three double-armed, nonabsorbable sutures were placed through the ligament on the sacral side of ischial spine. The first suture is closer to the ischial spine and the other two sutures are then placed posterior and medial to the initial suture. This is repeated on the opposite uterosacral ligament. Once the sutures are placed on either side, pack is removed and the double-armed sutures are used to secure the transverse portions of the pubocervical and rectovaginal fascia. Before the sutures are tied, 5 ml Indigo carmine is given intravenously. The sutures are then tied in sequence bringing the pubocervical and rectovaginal fascia together at the apex. Cystoscopy is performed to check ureteral patency, and the suspensory sutures are trimmed. The risk of ureteral kinking makes it mandatory to perform cystoscopy during this procedure. This technique appears to provide good support using the native tissue in the vaginal approach (Fig. 15.1).

In the case series by Shull et al., the anatomical success rate using Baden-Walker scoring system was 87 % for all sites with follow-up over 3.5 years [10]. A meta-analysis of the HUSL suspension has shown successful outcome for apical compartment to be 98 %, for anterior compartment 81 %, and 87 % for posterior compartment [11]. With a low overall recurrence of 4–18 % and a reoperation rate of less than 7 %, it is an effective procedure addressing the apical prolapse. In addition, the procedure also maintains the normal vaginal axis and appropriate vaginal length.

The intraoperative complications reported in an analysis of 195 cases by David-Montefiore includes, vascular injury in 0.5 %, rectal injury in 0.4 %, and the need for blood transfusion in 5.2 % [29]. Buttock pain is a problem with SSLS, reported in about 3 % of patients and usually resolves in 6 weeks time. In pain persisting beyond 6 weeks, there appears to be a 50 % risk of significant long-term pain, and release of suture may have to be considered in these patients [30].

Pudendal and sacral neurovascular injuries are the serious complications of SSLF. The efficacy of the SSLS as a vaginal procedure for apical prolapse is well recognized and studies assessing the route of repair have largely compared SSLS with abdominal sacrocolpopexy.

In abdominal sacrocolpopexy, the vault is secured to the anterior surface of sacrum at the level of S1–S2 by a graft material. The procedure was originally described by Lane [36]. Conventionally done as an open technique, ASC can also be performed using laparoscopic and robotic approaches.

In the open technique, the vaginal vault is lifted from below using an end-to-end anastomosis sizer (EEA) or a similar instrument (Fig. 15.3). The peritoneum over the vault is incised, and the vesicovaginal and rectovaginal spaces are entered along the proximal portion of the anterior and posterior vaginal wall. This area is used for securing the graft to the vaginal walls. Polypropylene mesh is commonly used as a graft material. Addison et al. promoted the use of two separate graft strips for the anterior and posterior vaginal wall, so that the tension on both is varied and spread out [37]. Two straps of meshes are secured, each to the anterior and posterior vaginal walls using multiple delayed absorbable or permanent sutures. In the recent past, commercially designed Y-shaped meshes have become available for use in ASC (Fig. 15.4). The depth of the graft extent distally is determined by the extent of anterior and posterior wall prolapse. In cases of perineal descent associated with vault prolapse, extending the posterior graft up to the perineal body, termed as colpoperineopexy, has been described [38].

The anterior longitudinal ligament overlying the sacrum is exposed, taking care to identify the sacral vessels in this area and avoiding them. The close proximity of common iliac vein, middle sacral artery, ureter, sigmoid mesocolon, and sacral vessels in this area demands meticulous dissection. Apart from the median sacral artery, other accessory vessels have been shown to traverse the presacral space, and dissection in this area should take into account these anatomical aberrations.

The proximal free ends of both the anterior and posterior graft materials are secured to the anterior longitudinal ligament at the level of S1–S2, using a nonabsorbable suture or bone anchors. It is important to anchor the graft without tension. Anchoring the graft to sacral promontory will place the vagina under tension and alter the vaginal axis. If graft fixation is attempted below the level of S3, risk of hemorrhage in the presacral space is increased. The graft material once secured is placed along the sacral curvature and re-peritonealized. It is recommended that the peritoneum is closed over the graft material to reduce the risk of bowel obstruction.