dominal cavity. Morcellation within the abdominal cav-ity is time consuming and potentially increases the riskof content spillage. We also applied this technique tosmall simple cysts in patients who had undergonemultiple abdominal surgery, as such patients are athigh risk for abdominal adhesion. Minilaparotomy us-ing our technique may be preferable to close laparos-copy in these cases to prevent trocar injuries. In ourexperience, postoperative recovery after minilapa-rotomy was excellent, equivalent to that after laparo-scopic surgery in terms of hospital stay. Thus, webelieve that our technique is a viable alternative tolaparoscopic surgery when the latter procedure is con-sidered potentially problematic.

This technique has the potential to be extremelyuseful for managing large ovarian cysts. It may providean additional treatment option for small ovarian cysts,such as dermoid cysts, endometriomas, abscesses, andother cysts, in which leakage of the cyst contents mayprovoke an inflammatory reaction.

References

1. Trimbos JB, Hacker NF. The case against aspirating ovarian cysts.Cancer 1993;72:828–31.

2. McCormick JB, FitzGibbons JP. Instrument for aspiration of largeovarian cysts. Obstet Gynecol 1967;29:869–70.

3. Yamada T, Okamoto Y, Kasamatsu H. Use of the SAND ballooncatheter for the laparoscopic surgery of benign ovarian cysts.Gynaecol Endosc 1999;9:51–4.

4. Miyachi S, Negoro M, Okamoto T, Kobayashi T, Kida Y, Tanaka T,et al. Embolisation of cerebral arteriovenous malformations to

assure successful subsequent radiosurgery. J Clin Neurosci 2000;7:82–5.

5. Huang YH, Yeh HZ, Chen GH, Chang CS, Wu CY, Poon SK, et al.Endoscopic treatment of bleeding gastric varices by N-butyl-2-cyanoacrylate (Histoacryl) injection: Long-term efficacy and safety.Gastrointest Endosc 2000;52:160–7.

6. Maw JL, Kartush JM, Bouchard K, Raphael Y. Octylcyanoacrylate:A new medical-grade adhesive for otologic surgery. Am J Otol2000;21:310–4.

7. Lee KW, Sherwin T, Won DJ. An alternate technique to closeneurosurgical incisions using octylcyanoacrylate tissue adhesive.Pediatr Neurosurg 1999;31:110–4.

8. Mickey BE, Samson D. Neurosurgical applications of the cyanoac-rylate adhesives. Clin Neurosurg 1981;28:429–44.

9. Haisa T, Matsumiya K, Yoshimasu N, Kuribayashi N. Foreign-body granuloma as a complication of wrapping and coating inintracranial aneurysm. Case report [see comments]. J Neurosurg1990;72:292–4.

10. Mazur JB, Salazar JL. Late thrombosis of middle cerebral arteryfollowing clipping and coating of aneurysms. Surg Neurol 1978;10:131–3.

Address reprint requests to:Makio Shozu, MD, PhDDepartment of Obstetrics and GynecologyKanazawa University School of Medicine13-1 Takara-machiKanazawa 920-0934JapanE-mail: shozu@med.kanazawa-u.ac.jp

Received October 10, 2000.Received in revised form January 22, 2001.Accepted February 8, 2001.

Copyright © 2001 by The American College of Obstetricians andGynecologists. Published by Elsevier Science Inc.

Laparoscopic suturehysteropexy for uterineprolapse

Christopher F. Maher, FRANZCOG,Marcus P. Carey, FRANZCOG, andChristine J. Murray, RN

Objective: Vaginal hysterectomy remains the accepted sur-gical treatment for women with uterine prolapse. TheManchester repair is favored in women wishing uterinepreservation. Vaginal hysterectomy alone fails to addressthe pathologic cause of the uterine prolapse. The Manchester

repair has a high failure rate and may cause difficultysampling the cervix and uterus in the future. The laparo-scopic suture hysteropexy offers physiologic repair of uter-ine prolapse.

Method: At the laparoscopic suture hysteropexy, the pouchof Douglas is closed and the uterosacral ligaments areplicated and reattached to the cervix.

Results: Forty-three women with symptomatic uterineprolapse were prospectively evaluated and underwent lapa-roscopic suture hysteropexy with a mean follow-up of 12 6

7 months (range 6–32). The mean operating time for thelaparoscopic suture hysteropexy alone was 42 6 15 minutes(range 22–121), and the mean blood loss was less than 50 mL.On review, 35 women (81%) had no symptoms of prolapseand 34 (79%) had no objective evidence of uterine prolapse.Two women subsequently completed term pregnancies andwere without prolapse. Both underwent elective cesareandelivery.

Conclusion: The laparoscopic suture hysteropexy is effec-tive and safe in the management of symptomatic uterine

From the Urogynaecology Unit, Royal Women’s and Mercy Hospital,Melbourne, Australia.

1010 0029-7844/01/$20.00 Obstetrics & GynecologyPII S0029-7844(01)01376-X

prolapse. The result is physiologically correct, without dis-figuring the cervix. This may be an appropriate procedurefor women with uterine prolapse wishing uterine preserva-tion. (Obstet Gynecol 2001;97:1010–14. © 2001 by TheAmerican College of Obstetricians and Gynecologists.)

Uterine prolapse is a common and disabling conditioncaused by a break in the integrity of the uterosacral–cardinal ligament complex and a weakening of thepelvic floor musculature. The surgical options includevaginal hysterectomy with or without a vault suspend-ing procedure and uterine preservation. Vaginal hyster-ectomy alone fails to address the pathologic deficiencyof the uterosacral–cardinal ligament complex,1 resultsin the removal of a nondiseased organ, and removes thecervix, which has been described as the cornerstone ofthe upper vaginal pelvic fascia.2 Increasingly, womenare choosing to avoid hysterectomy.3 A delay in child-bearing to a later age, a belief that the uterus plays a rolein sexual satisfaction,4 and successful conservativetreatments for the control of menorrhagia5 all diminishthe need for hysterectomy. Retaining the cervix atprolapse surgery may be advantageous to offer a phys-iologic cornerstone to reattach the pubocervical fascia,rectovaginal fascia, and uterosacral–cardinal ligamentcomplex. In women requesting uterine preservation,the following surgical options are available: theManchester repair,6 sacrospinous hysteropexy7 (cervixto the sacrospinous ligament), and sacral hysteropexy8

(cervix secured to the sacrum). We describe laparo-scopic suture hysteropexy as a new procedure in themanagement of uterine prolapse. The surgical tech-nique is a simple, safe, and physiologic repair thataddresses the pathologic cause of uterine prolapsewhile allowing uterine preservation.

Methods

All women with symptomatic prolapse underwent astandardized history and examination. A site-specificvaginal examination was carried out in the left lateralposition using a Sims speculum during a Valsalvamaneuver. The prolapse was graded using a modifiedBaden-Walker classification.9 First-degree prolapse wasdefined as prolapse to the level of the mid-vagina.Second-degree prolapse was prolapse to the level of theintroitus, and third-degree prolapse was prolapse be-yond the introitus. Uterine preservation was consideredin all women with symptomatic uterine prolapse to orbeyond the introitus who had normal cervical cytologicfindings and no abnormal uterine bleeding. Exclusioncriteria included obesity (body mass index greater than30), women unfit for general anesthesia, and those not

interested in uterine preservation. Women suitable foruterine preservation (normal cervical cytologic featuresand no abnormal uterine bleeding) were offered lapa-roscopic suture hysteropexy. Urodynamic studies wereperformed preoperatively in those with urinary incon-tinence.

The two surgical authors performed all the surgery.Preoperatively, all women completed bowel prepara-tion to allow maximal bowel quiescence during sur-gery. In women undergoing concomitant vaginal repairsurgery, the vaginal surgery was completed initially,with attention to resecuring the fascia to the cervix. Atthe anterior and posterior colporrhaphy, wide lateraldissection of the underlying fascia from the vaginalepithelium and central plication of fascia using a de-layed absorbable No. 0 polydioxanone suture (Ethicon,Somerville, NJ) formed the basis of the repair. A perin-eorrhaphy was routinely incorporated in the posteriorcolporrhaphy.

Surgery was performed in a low lithotomy position.The bladder was drained with a Foley catheter and aPelosi uterine manipulator (Apple Medical, Bolton,MN) was used to obtain exaggerated anteversion of theuterus. A steep Trendelenburg position facilitated mo-bilization of the bowel from the pouch of Douglas.

An open Hassan laparoscopic technique was usedand two 5-mm ports (Apple Medical) were placedlateral to the inferior epigastric vessels. Once the loops

Figure 1. An expansive cul-de-sac and deficient uterosacral ligamentsare seen.

VOL. 97 NO. 6, JUNE 2001 Maher et al Laparoscopic Suture Hysteropexy 1011

of bowel were removed from the pouch of Douglas, thecourse of the ureters was followed from the pelvic brimalong the lateral side wall (Fig. 1). At this stage, thecul-de-sac is an expansive hernia-like area between thebowel posteriorly and the cervix and posterior vaginalwall anteriorly, with the uterosacral ligaments fre-quently nonexistent or deficient. Initially, a Moschcow-itz culdoplasty was performed using a No. 0 polydiox-anone purse-string suture tied using an extracorporealknot-tying technique. At this point, the uterosacralligaments should be readily apparent (Fig. 2) and areindependently plicated using two No. 1 Gore-Tex su-tures (CV-2 Gore, Flagstaff, AZ). Plication was begunmidway along the uterosacral ligament between thesacrum and the cervix, and the ligaments were reat-tached to their point of physiologic insertion on theposterior aspect of the cervix (Fig. 3). The uterineanteversion was relaxed while the Gore-Tex sutureswere tied using an extracorporeal knot-tying technique.At the completion of surgery, a 3–4-cm gap was leftbetween the sacrum and plicated uterosacral ligamentsto ensure normal large bowel function (Fig. 4). Thecourse of the ureters was checked, and if any kinkingwas present, a peritoneal releasing incision was per-formed between the ureter and uterosacral ligament.Laparoscopic Burch colposuspension and paravaginalrepairs were performed after the hysteropexy, as re-quired. At the completion of surgery, cystoscopy wasperformed to ensure ureteral patency.

The mean, standard deviation, and range are re-ported for all variables except parity, for which the

median and range are reported. The Fisher exact testand Student t test was used to analyze group differencesin categorical and continuous variables, respectively.An a level of 0.05 was deemed statistically significant.

Results

Between January 1997 and October 1999, 43 womenunderwent laparoscopic suture hysteropexy for themanagement of symptomatic uterine prolapse to or

Figure 2. A Moschcowitz culdoplasty is performed and the uterosa-cral ligaments become increasingly apparent. Figure 3. Plicated uterosacral ligaments are reattached to the poste-

rior aspect of the cervix.

Figure 4. At the completion of surgery a 3–4-cm gap is seen betweenthe sacrum and reconstructed uterosacral ligaments.

1012 Maher et al Laparoscopic Suture Hysteropexy Obstetrics & Gynecology

beyond the introitus with straining. All women wereprospectively evaluated and were independently eval-uated by a nonsurgical coauthor with a minimum of 6months of follow-up.

The mean age of the women was 45 6 10 years (range29–70), the median parity was 2 (range 0–6), and themean body mass index was 26 6 3.3 kg/m2 (range23–31). Thirty-three women (77%) were premeno-pausal. All women were sexually active, and two expe-rienced dyspareunia because of the prolapse. Sevenwomen requested uterine preservation to retain fertil-ity. The preoperative site-specific vaginal examinationfindings are recorded in Table 1 and the concomitantsurgery performed is presented in Table 2. All but twowomen underwent additional procedures for pelvicfloor relaxation.

The mean operating time for the laparoscopic suturehysteropexy alone was 42 6 15 minutes (range 22–121)and the mean blood loss was less than 50 mL (range10–1000). The mean operating time for the completesurgery was 99 6 33 minutes (range 22–180) and theblood loss was 148 6 162 mL (range 50–1000). Themean duration of hospitalization was 5 days (range2–10) and the mean time to return to activities of dailyliving was 25 6 20 days (range 7–90). Two womenunderwent laparoscopic suture hysteropexy only andwere both discharged on day 2 and returned to activi-ties of daily living on day 7 and 14.

The mean length of follow-up was 12 6 7 months(range 6–32). Postoperatively, 35 women (81%) had nosymptoms of prolapse and 34 (79%) had no objectiveevidence of uterine prolapse. Seven women (16%) un-derwent additional surgery, all for symptomatic uterineprolapse. No significant difference in age, parity, bodymass index, or degree of preoperative uterine prolapsewas found between the seven women requiring addi-tional surgery and those who did not (P , .01).

Three women underwent abdominal hysterectomyand abdominal sacral colpopexy, two underwent vagi-nal hysterectomy and sacrospinous vault fixation, andtwo underwent sacrospinous hysteropexy. Intraopera-tively, one woman had the left uterine artery inadver-tently lacerated as the suture was passed through theposterior aspect of the cervix, resulting in a large broadligament hematoma. Laparotomy was performed, theuterine artery was oversewn, and 2 units of blood weretransfused. Peritoneal releasing incisions were per-formed in two women in whom the ureter was kinkedmedially, close to the plicated uterosacral ligament. Nopostoperative complications were reported. Twowomen with preoperative dyspareunia had resolutionof the symptoms with correction of the prolapse. Twowomen subsequently completed term pregnancies, de-livered by cesarean section, and were without prolapseat last follow-up.

Discussion

The idea of uterine preservation at prolapse surgery isnot new. In 1934, Bonney10 stressed that the uterusplays a passive role in uterovaginal prolapse, and Ross2

described the pericervical fascia as the cornerstone ofpelvic reconstruction. Several surgical options are avail-able to women wishing uterine preservation at prolapsesurgery. The Manchester repair is quicker to performand has less blood loss than the vaginal hysterectomyfor uterovaginal prolapse.6 The problems with theManchester repair include prolapse recurrence in excessof 20% in the first few months,11 a decrease in fertility,and pregnancy wastage as high as 50%.12,13 Futuresampling of the cervix for cytologic analysis and theendometrium for histologic examination can be difficultbecause of vaginal re-epithelialization or cervical stenosis.

Limited numbers of sacrospinous hysteropexy7 andsacral hysteropexy8 have been reported in which thecervix is attached to the sacrospinous ligament orsacrum, respectively. These repairs rely on nonphysi-ologic support to the upper vagina and may result inincreased tension at other vaginal sites. Hysterectomyafter these procedures could be complicated by thedifficult dissection required to remove the cervix fromthe sacrospinous ligament or sacrum.

The technique of laparoscopic uterosacral ligamentplication and shortening has recently been briefly de-scribed for uterine prolapse, but no results, outcomes,or complications were reported.14 The present reportdescribes laparoscopic suture hysteropexy and out-comes for the management of symptomatic uterineprolapse. The major complication of the left uterineartery laceration occurred as the plicated uterosacralligament was sutured to the posterior aspect of the

Table 1. Preoperative Site-Specific Vaginal Defects

Prolapse Site Grade 2 Grade 3

Cystocele 22 3Uterine 38 5Enterocele 9 4Rectocele 23 1

Table 2. Concomitant Surgery

Procedure n

Laparoscopic suture hysteropexy 43Posterior colporrhaphy 28Anterior colporrhaphy 8Laparoscopic colposuspension 15Laparoscopic paravaginal repair 13

VOL. 97 NO. 6, JUNE 2001 Maher et al Laparoscopic Suture Hysteropexy 1013

cervix. This complication can be avoided by ensuringthat when suturing the cervix the uterus is not rotatedby the Pelosie manipulator, thus avoiding exposing theuterine artery to potential trauma. After laparoscopicsuture hysteropexy, 16% of women required surgery,all with cervical or uterine prolapse. Cervical elongationseemed to be a real entity in all of these women. Whyidentical surgery failed to be effective in some women isunclear. Conceivably, the connective tissue in the utero-sacral ligament is inherently weak in some women andfails to support the appropriate suture tension requiredfor repair.

Laparoscopic suture hysteropexy is effective and safein the management of symptomatic uterovaginal pro-lapse. The result is physiologically correct, withoutdisfiguring the cervix. This may be an appropriateprocedure for women with uterine prolapse wishinguterine preservation.

References1. Marana HR, Andrade JM, Marana RR, Matheus-de Sala M, Phil-

bert PM, Rodrigues R. Vaginal hysterectomy for correcting genitalprolapse. J Reprod Med 1999;44:529–34.

2. Ross JW. Apical vault repair, the cornerstone of pelvic vaultreconstruction. Int Urogynecol J 1997;8:146–52.

3. Wilcox LS, Koonin LM, Pokras R, Strauss LT, Xia Z, Peterson HB.Hysterectomy in the United States, 1988–1990. Obstet Gynecol1994;83:549–55.

4. Masters WH, Johnson V. Human sexual response. Boston: Little,Brown, 1966:238.

5. Barrington JW, Bowen-Simpkins P. The Levonorgestrel intrauter-ine system in the management of menorrhagia. Br J ObstetGynaecol 1997;104:614–6.

6. Thomas AG, Brodman ML, Dottino PR, Bodian C, Friedman F,Bogursky E. Manchester procedure vs. vaginal hysterectomy foruterine prolapse. J Reprod Med 1995;40:299–304.

7. Cruikshank SH, Cox IN. Sacrospinous fixation at the time ofvaginal hysterectomy. Am J Obstet Gynecol 1991;164:1072–6.

8. Costantini E, Lombi R, Micheli C, Parziani S, Porena M. Colpo-sacropexy with Gore-Tex mesh in marked vaginal and uterovagi-nal prolapse. Eur Urol 1998;34:111–7.

9. Baden WF, Walker TR. Genesis of the vaginal profile: a correlatedclassification of vaginal relaxation. Clin Obstet Gynecol 1972;15:1048–54.

10. Bonney V. The principles that should underline all operations forprolapse. J Obstet Gynaecol Br Empire1934;41:669–83.

11. Williams BFP. Surgical treatment in uterine prolapse in youngwomen. Am J Obstet Gynecol 1966;95:967–72.

12. O’Leary JA, O’Leary JL. The extended Manchester operation. Am JObstet Gynecol 1970;107:546–50.

13. Naya y Sanchez RM, Velasco VR, Garcia TL. Manchester opera-tion: late complications and obstetric future. Ginecol Obstet Mex1973;33:457–9.

14. Margossian H, Walters MD, Falcone T. Laparoscopic managementof pelvic organ prolapse. Eur J Obstet Gynecol Rep Biol 1999;85:57–62.

Address reprint requests to:Christopher F. Maher, FRANZCOGWesley Urogynaecology Unit, Suite 86Level 4 Sandford Jackson Building30 Chasely StreetAuchenflower, Queensland 4066AustraliaE-mail: chrismaher@urogynaecology.com.au

Received October 24, 2000.Received in revised form February 5, 2001.Accepted February 15, 2001.

Copyright © 2001 by The American College of Obstetricians andGynecologists. Published by Elsevier Science Inc.

1014 Maher et al Laparoscopic Suture Hysteropexy Obstetrics & Gynecology