The vaginal epithelium is hydrodissected away from the underlying enterocele, pubocervical and rectovaginal fascia at the vaginal apex. Following an apical incision, using sharp and blunt circumferential dissection a plane is created immediately deep to the vaginal epithelium (Fig. 9.2). It is the author’s preference to make a midline apical incision for post-hysterectomy vault prolapse, given the ease of a more natural angle of dissection left and right. In the case of concurrent hysterectomy, an oval defect in the apical vault will be available for the repair, typically with a nice thick cervical ring and underlying pubocervical and rectovaginal fascia for attaching apical suspension sutures. Once the entire apical enterocele sac is dissected free, the peritoneum of the enterocele is then lifted away from the underlying bowel and incised sharply (Fig. 9.3). If the peritoneum cannot be safely entered, alternatively a retroperitoneal approach (sacrospinous ligament or iliococcygeus suspension) may be performed. These alternative apical suspension techniques should be discussed preoperatively with the patient when consenting for native tissue transvaginal apical prolapse repair.

Upon opening the peritoneum, it may then be mobilized and retracted circumferentially, thus allowing the bowel to be packed into the abdomen cephalad using counted laparotomy pads. Meanwhile a long weighted speculum or a Deaver retractor is placed through the peritoneal opening (Fig. 9.4a). The position of the left and right uterosacral ligaments is then identified. The previously placed silk sutures are tensioned, allowing the uterosacral ligament to be palpated (the uterosacral ligament is about the width of the pinky digit on a small hand and should be running in alignment with the silk towards the sacrum at the 5 and 7 o’clock position adjacent to the introitus). The mid to distal uterosacral ligament is grasped using a long Allis clamp. The uterosacral ligaments should be strong and their tented surface when grasped should direct tension towards the level of the sacrum. If concomitant total vaginal hysterectomy is being performed, the uterosacral ligaments should be tagged where they insert into the cervix to aid in identification. It is then the author’s preference to place a total of three sutures into each uterosacral ligament, with the highest and most proximal one made of permanent monofilament or braided suture, and the distal of absorbable braided or delayed absorbable monofilament (Fig. 9.5a, b).

The needles for these sutures should be strong to prevent bending and fracture (consider UR-6, CT-2 or equivalent). The ureter may be palpated running lateral to the uterosacral ligament, and along with underlying neurovascular structures are protected by gently tenting the uterosacral ligament away from the retroperitoneal fat using the Allis clamp. The anatomy of the uterosacral ligament can be appreciated in Fig. 9.4b. Neurologic structures within the uterosacral and cardinal ligaments include autonomic branches from the inferior hypogastric plexus innervating the bladder as well as the plexus itself [5]. Deep to the uterosacral ligament, the sacral nerve roots may be inadvertently encircled during suture placement, as noted in 7 out of 10 unembalmed female cadavers subjected to bilateral uterosacral ligament suspension by Siddiqui et al [6]. These authors found that a more dorsal and medial needle arc was associated with sacral nerve root injury, and that by ventrally tenting the uterosacral ligament nerve injury was minimized. It is also advocated that in order to avoid ureter injury, needle passage should be directed toward the floor (clockwise needle passage on the patient’s left side, and counter-clockwise on the patient’s right side), rolling away from the ureter, about one-third to one-half the lateral depth of the tented ureterosacral ligament to prevent compromise of the underlying hypogastric plexus and sacral nerve roots Fig. 9.5a [6]. The needle itself should be used to lift lateral soft tissues off the ligament as the suture is placed in order to further prevent ureteric compromise. The needles are then kept on the sutures and secured to the Scott retractor or drape preserving their orientation for later identification.

At this point, it is mandatory that cystoscopy be performed to visualize efflux of urine from the bilateral ureteric orifices. Traction is placed on the six preplaced uterosacral suspension sutures to simulate the tension that will be in place at the completion of the procedure. If the integrity of the ureter is in question or if there is suspicion of ureter injury, a retrograde pyelogram may be performed or alternatively a guidewire with open ended ureteral catheter may be passed up to the collecting system. If the vaginal apex dissection or the identification of the uterosacral ligaments is anticipated to be difficult, then ureteral stents may be placed preoperatively to assist with ureter identification (one of the authors does this for every patient and uses the stent to palpate the ureter while the uterosacral ligament is tented away from underlying structures with an Allis clamp). If a stent was preplaced it can be manipulated to feel for resistance. Of note, ureteral stents are not without risk, as they prolong the procedure duration and can lead to hematuria or edema of the ureter.