Laparoscopic Uterine Suspension

Introduction

Uterine retroversion is a backward displacement of the uterus into the pouch of Douglas from its normal anteverted position. This uterine retroversion can be either congenital or the result of adhesions and fibrosis. Commonly reported symptoms include severe dysmenorrhea, dyspareunia, and backache. Laparoscopic ventral suspension has successfully treated symptomatic retroversion and significantly reduces symptoms.

Objective

The procedure described herein involves the investment of the round ligament with sutures in a percutaneous-extraperitoneal approach, resulting in truncated, thickened, and strengthened ligaments supporting the uterus in mild anteversion (UPLIFT procedure).

Description of UPLIFT Procedure

The laparoscopic uterine suspension is performed using a Carter-Thomason 2- mm needle point suture passer. A tiny skin incision is made near the exit point of the round ligament into the into the inguinal canal. Either 1-0 or 2-0 monofilament polybutester suture is passed subcutaneously and transfascially into the extraperitoneal space and then within and next to the round ligament. The suture is exited from the ligament near the uterus. The instrument is withdrawn, and second pass of the instrument under the skin is angled so that it pierces the fascia but not the peritoneum, 1 to 2 cm cephalad or caudad from the previous puncture site, creating a fascial bridge near the natural exiting point of the round ligament. The suture is exited from the ligament approximately 1 to 2 cm proximal to the exit point of the previously placed suture. The suture is retrieved and withdrawn so that both ends are outside of the skin. This technique creates a pledget of round ligament and a bridge of fascial tissue. The suture is tied down to shorten, thicken, and strengthen the round ligament. The ligament imbricates within itself as it is pulled up by the suture. This moderately anteverts the uterine position by ligament investment, fixation, and truncation. Performing the uterine suspension procedure in this manner creates thickened, shortened, and strengthened ligaments that suspend the uterine fundus securely at the level of the exit point of the round ligaments through the inguinal canal.

Results

The operating time for performing a laparoscopic uterine suspension for 75 patients by using uterine positioning by the UPLIFT procedure averaged less than 15 minutes for than portion of their surgery. All surgeries were performed in an outpatient center, with patients discharged on the same day. The average time to discharge was 4 hours. Mild incisional and abdominal wall discomfort, which occurred in most patients for the first 24 hours, was readily relieved with mild oral analgesics. There were no intraoperative complications. Delayed postoperative pain at the suspension site significant to require injection with local anesthesia occurred in five patients (7%). Four of these had their pain resolved with one 5-ml injection of 0.5% bupivicaine. One patient required three local injections of 5 ml or 0.5% bupivicaine during a 1-month period to resolve the discomfort.

For all 75 patients with up to a 2-year follow-up, reports of pain with menstrual periods decreased from an initial 8.4 to 1.7, with 0 being no pain and 10 being the worst pain the patient had experienced. (P <0.01, Wilcoxon's signed rank test). Pain with intercourse decreased from 8.1 to 1.5 (P<0.01, Wilcoxon's signed rank test). After the UPLIFT and associated laparoscopic procedures, 63 patients (84%) reported essentially no pain (0 to 2), 5 (7%) reported mild pain (2 to 5), and 3 (4%) reported moderate pain (5 to 7). Four (5%) patient's reported pain as severe as the pain they had had prior to the surgery (7 to 10). Of the 20 patients who had a retroverted uterus as the only significant pathological finding at surgery, 18 (90%) reported immediate and sustained relief from their symptoms. The other two rated their pain as improved.

The passage of the suture into and next to the round ligament at its exit point into the inguinal canal provides the opportunity for the surgeon to obliterate the opening to the inguinal canal and in this manner repair a nonpalpable, occult hernia at the same time at the uterine positioning procedure.

The procedure is performed quickly and has had no complications in experienced hands.

Conclusions