LAUSR

Study Objective Because of the potential complications from artificialmesh, native tissue repair has regained its popularity during pelvic floor reconstruction surgery. Uterosacral ligament (USL) is the most important structures for level I support. However, the attenuated or broken USL in pelvic organ prolapse (POP) patients makes it difficult to get enough strong tissue for durable pelvic support, which result in the high recurrence rate after USL suspension for uterus or vagina cuff. Besides, the close anatomical relationship between USL and other important retroperitoneal structures (ureter, vessels, nerves) and rectum may sometimes limit the accessibility and suture bite during USL colpopexy/hysteropexy. In this video, we will demonstrate the important anatomical structures near the USL, and the technique to isolate it, that will make USL suspension safe and effective. Design Video clips from different patients were collected and edited. Setting single hospital, single surgeon. Patients or Participants Video clips from young patient with minimal endometriosis as normal control (demonstrate transperitoneal view), video clips from patients undergoing nerve-sparing radical hysterectomy as teaching model for detailed retroperitoneal structures, and video clips from patients undergoing USL hysteropexy were collected and edited. Interventions Ureter was identified transperitoneally first. Peritoneal window was developed between ureter and USL, entering the Okabayashi pararectal space. All the retroperitoneal structures (including ureter, uterine artery and vein, hypogastric nerve and pelvic plexus) were lateralized. Perirectal space and rectovaginal space were opened, dissecting the rectum away from the USL. Measurements and Main Results After USL isolation, USL suspension can be performed with maximal durability (big bite) and safety (minimal risk of ureter kinking, nerve injury, or rectum injury). Conclusion Isolation of uterosacral ligament (USL) is a safe and effective way for laparoscopic USL hysteropexy / colpopexy.