Robotic Uterosacral Ligament Suspension: Tips and Tricks to a Successful Suspension

Abstract

<h3>Study Objective</h3> The objectives of this film are to review pelvic anatomy and levels of pelvic support, present a technique for uterosacral ligament suspension done robotically at the time of hysterectomy, and discuss suture choices for long-lasting support. We discuss important points to consider when performing the procedure, and suggest a technique that results in a reliable outcome. <h3>Design</h3> N/A. <h3>Setting</h3> Operating room with patient in reverse Trendelenburg and Da Vinci Xi robot docked. <h3>Patients or Participants</h3> N/A. <h3>Interventions</h3> Uterosacral Ligament Suspension with barbed delayed absorbable suture and serpentine stitches. <h3>Measurements and Main Results</h3> The correction of an apical defect can be accomplished with uterosacral ligament suspension, which can also decrease the severity of cystocele and rectocele. Starting with a peritoneal releasing incision can mobilize the ureter and avoids kinking of the ureter when tugging on the ligament. Suture choices include barbed delayed absorbable sutures and permanent sutures. Barbed delayed absorbable suture dissolves in 180 days, which is enough time to form scar tissue that will continue to support the suspension. Serpentine stitches along the ligaments are made and tightened to shorten the ligament, which fixes it to the vagina allowing for elevation of the apex. A McCall's culdoplasty can be done with the same suture, reducing enterocele. Finally, plicating the uterosacral ligaments at the end brings them to the midline and strengthens the suspension. <h3>Conclusion</h3> In conclusion, uterosacral ligament suspension at the time of robotic hysterectomy can correct uterovaginal prolapse. Barbed delayed absorbable suture is a viable alternative to permanent sutures due to scar formation. Peritoneal releasing incisions between the ureter and uterosacral ligament protect the ureter from kinking. Serpentine bites around the uterosacral ligaments result in secure cinching of the tissue, which contributes to a reliable suspension.