Uterine Suspension to Prevent Adhesion
Formation in the Cul-De-Sac

In recent years, uterine suspension has been used in the treatment of a symptomatic retroverted uterus. The following case presents the application of laparoscopic uterine suspension in a patient at risk for adhesion reformation after procedures to restore fertility.

A 29-year-old nulliparous Asian woman sought treatment for infertility after trying to conceive for two years. The patient had regular cycles and a retroverted normal sized uterus. She did not report dyspareunia or dysmenorrhea after direct query. Lab results were negative for pelvic inflammatory disease and positive for chlamydia. The patient was treated with antibiotics. A reculture was negative.

A 1.1 x 1.5 cm in diameter inhomogenous structure located in the left lateral aspect of the uterus was seen during pelvic ultrasound. Hysterosalpingogram confirmed several polyps along the right and left lower aspects of the endometrial cavity as well as at the level of the internal os, right hydrosalpinx with accompanying right paratubal collection from adhesions. There was no evidence of free spillage of contrast from the left fallopian tube.

The preliminary diagnosis was primary infertility due to non-patent tubes, benign endometrial polyps, and a possible small fibroid. The treatment plan developed included hysteroscopy, diagnostic laparoscopy, dilatation and curettage, lysis of adhesions, neosalpingostomy, and possible uterine suspension.

Operatively, a hysteroscopic inspection demonstrated polyps in the lower segments and at the apex of the fundus. The polyps were removed, and dilatation and curettage was performed with medium-sized curettes. Laparoscopic examination showed a uterus that was bound down with adhesion. The round ligaments were very attenuated.

The adhesions over the right tube and ovary that were plastered down to the uterus and sidewall were freed using blunt dissection with bipolar and unipolar cautery scissors. Multiple ovarian cysts were cauterized and drained, and the adhesions were removed. A large area of endometriosis on the left uterosacral ligament that was causing the uterus to be scarred into the posterior cul-de-sac was lysed to free the uterus, so it could be manipulated freely. Spots of endometriosis in the posterior cul-de-sac were excised and/or cauterized. The left tube and ovary were fairly normal except that the left ovary was adherent to the left sidewall. The adhesion was excised. Some of the adhesions between the tube and ovary were also removed. A 2-cm x 2-cm myoma over the left cornual end was excised. Chromotubation was done. No dye was visible through the tubes. The adhesions pulling the uterus into the cul-de-sac were lysed and excised. The cul-de-sac adhesions were stripped off the rectosigmoid colon and right sidewall. An endometrial implant to the lateral aspect of the left uterosacral ligament was excised. Everything looked fairly normal after irrigation except the uterus flopped back into the pelvis. Uterine suspension was performed with the UPLIFT procedure and the Metra PSŪ kit (Inlet Medical, Eden Prairie, MN) to elevate the uterus out of the posterior cul-de-sac.

The patient had her first menses at 37 days after surgery and subsequently conceived with no postoperative fertility drug therapy. She had an uneventful pregnancy with the exception of minor anemia and was delivered vaginally at 37 weeks/4 days after her last menses or 42 weeks/6 days postsurgery.

Comment

Uterine suspension has usually been used to treat a symptomatic retroverted uterus. The case presented illustrates the use of uterine suspension in a patient at-risk for adhesion reformation.

Diagnostic procedures revealed that adhesions caused tubal edema and blockage. Normal anatomy was restored through lysis of adhesions and excision of endometriosis, cysts and a small fibroid. The UPLIFT procedure was performed to lift the uterus out of the cul-de-sac to prevent adhesion reformation. The patient subsequently conceived naturally and delivered vaginally without complications. An incidental finding was that the uterus remained suspended during the course of the pregnancy and was anteflexed at the postpartum exam.

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