- While performing the vaginal hysterectomy, the uterosacral ligaments are clamped, cut and ligated quite close to the uterus, so that maximum possible lengths of the ligaments is made available for use during anterior colporrhaphy. One end of a ligature on each ligament is kept long and held with a hemostat.
- Epinephrine in saline (1:300000) is infiltrated under the vaginal mucosa overlying the cystocele.
- A midline incision is made in the anterior vagina overlying the cystocele.
- A flap of the anterior vagina are raised on each side by sharp dissection, separating the vagina from the fascia overlying the urinary bladder.
- The dissection is carried out laterally up to the white lines on the two sides.
- Hemostasis is achieved. This is important, as a failure to do so may result in formation of a hematoma between the urinary bladder and the uterosacral ligaments fixed below it. Infection in the hematoma would result in formation of an abscess and its complications.
- The uterosacral ligaments are fixed under the urinary bladder.
- Two sutures of No. 1 polyglactin are passed through the terminal cut part of each ligament. They are then passed through the vagina lateral to the urethra. When the sutures are tied on each side, the ligaments get fixed under the urinary bladder.
- The gap between the two uterosacral ligaments is closed with interrupted sutures of No. 1-0 polypropylene passed through adjacent edges of the ligaments.
- Lateral edge of each uterosacral ligament is sutured to the white line of that side with interrupted sutures of No. 1-0 polypropylene.
- Redundant part of the vaginal mucosa is excised. The vaginal edges are sutured to each other in midline with interrupted sutures of No. 1-0 polyglactin.
- The center of the vault of the vagina is suspended from the uterosacral ligaments in midline with a suture of No. 1-0 polyglactin.
- The transverse edge of the anterior vagina is sutured to the transverse edge of the posterior vagina with interrupted sutures of No. 1-0 polyglactin.
Figure 1. Anterior colporrhaphy dissection has been done. The urinary bladder (U), left uterosacral ligament (LUSL) and the right uterosacral ligament (RUSL) are seen.
Figure 2. No. 1 polyglactin ligature on the RUSL is threaded on a curved needle.
Figure 3. The cystocele is reduced by pressure of a finger.
Figure 4. The RUSL ligament is drawn forward along the right side of the urethra.
Figure 5. The needle is passed through the right flap of the vaginal mucosa, from inside out, at the level a little posterior to the external urinary meatus.
Figure 6. Another suture of No. 1 polyglactin suture is passed through the terminal part of the RUSL and tied.
Figure 7. The suture is passed through the right flap of the vaginal mucosa, from inside out, 5 mm away from the first suture.
Figure 8. The LUSL ligament (aarows) is drawn forward along the left side of the urethra.
Figure 9. No. 1 polyglactin ligature on the LUSL is threaded on a curved needle.
Figure 10. The needle is passed through the left flap of the vaginal mucosa, from inside out, at the same level as the first suture on the right side.
Figure 11. Another suture of No. 1 polyglactin suture is passed through the terminal part of the RUSL and tied. It is passed through the left flap of the vaginal mucosa, from inside out, 5 mm away from the previous suture.
Figure 12. The two sutures on the left side are tied on the external surface of the left flap of vaginal mucosa. The sutures on the right side are tied similarly.
Figure 13. The RUSL (black arrows) and LUSL (white arrows) are seen to be drawn forwards under the base of the urinary bladder.
Figure 14. The two uterosacral ligaments are approximated in the midline with interrupted sutures of No. 1-0 polypropylene.
Figure 15. Approximation of the two uterosacral ligaments in the midline is complete.
Figure 16. The gap between the LUSL and right lateral pelvic wall is demonstrated by passing a finger between the two.
Figure 17. The left edge of the LUSL is sutured to the left white line with interrupted sutures of No. 1-0 polypropylene.
Figure 18. The right edge of the RUSL is sutured to the right white line with interrupted sutures of No. 1-0 polypropylene.
Figure 19. The end result: the two uterosacral ligaments have been sutured to each other in midline, and each one has been sutured to the white line of the respective side laterally.
- Milley PS, Nichols DH. The relationship between the pubocervical ligaments and the urogenital diaphragm in the human female. Anat Rec. 1969;163:433.
- Richardson AC, Lyon JB, Williams NL. A new look at pelvic relaxation. Am J Obstet Gynecol 1976;126:568.
- Richardson AC. Female pelvic floor support defects. Int Urogynecol J Pelvic Floor Dysfunct I 996;7(5):241.
- DeLancey JO. Pelvic organ prolapse: clinical management and scientific foundations. Clin Obstet Gynecol 1993;36:895.
- Johnston SL, Low JA. Anterior colporrhaphy. In Drutz HP, Herschorn S, Diamant NE. Eds Female Pelvic Medicine and Reconstructive Pelvic Surgery. 1st edition. London. Springer. 2017. pp 329-337.
- Karram MM. Vaginal operations for prolapse. In: Baggish MS, Karram MM, eds. Atlas of Anatomy and Gynecologic Surgery. Philadelphia: WB Saunders, 2001:394.
- Weber AM, Walters MD. Anterior vaginal prolapse: review of anatomy and techniques of surgical repair. Obstet Gynecol 1997;89:311.
- Kovac SR, Stubbs JTF. Repair of the Anterior Segment. in Advances in Reconstructive Vaginal Surgery. Kovac SR; Zimmerman CW. eds. Lippincott Williams & Wilkins. 1st Edition. 2007. pp 470-551.
- Zimmerman CW. New concepts in restoration of the anterior vaginal compartment. Operative Techniques in Gynecologic Surgery 2001;6:116.
- Link G, van Dooren IM, Wieringa NM. The extended reconstruction of the pubocervical layer appears superior to the simple plication of the bladder adventitia concerning anterior colporrhaphy: a description of two techniques in an observational retrospective analysis. Gynecol Obstet Invest 2011;72(4):274-280.
- Morse AN, O'dell KK, Howard AE, Baker SP, Aronson MP, Young SB. Midline anterior repair alone vs anterior repair plus vaginal paravaginal repair: a comparison of anatomic and quality of life outcomes. Int Urogynecol J Pelvic Floor Dysfunction. 2007;18:245-9.
- Hosni MM, El-Feky AEH, Agur WI, Khater EM. Evaluation of three different surgical approaches in repairing paravaginal support defects: a comparative trial. Arch Gynecol Obstet 2013;288(6):1341–1348.