Uterosacral Ligament Dissection during McCall Culdoplasty to Prevent Ureteral Kinking, and Round Ligament Fixation to Support Vaginal Vault: A New Surgical Technique

Abstract

Objective: This study aims to describe a new surgical technique to prevent ureteral kinking via dissection uterosacral ligament from parietal peritoneum before McCall culdoplasty suture placement, and vaginal cuff fixation to round ligament to prevent apical vaginal vault prolapse after vaginal hysterectomy. Materials and Methods: At the initial step of vaginal hysterectomy, a circumferential incision was done on vaginal tissue, which covers the uterine cervix. Then posterior cul-de-sac was entered. Bilateral uterosacral ligament was identified, separately clamped, cut and sutured. Classical vaginal hysterectomy was completed up to the round ligament, which was separately grasped, cut and sutured. After the vaginal hysterectomy, the uterosacral ligament dissected from cardinal ligament and parietal peritoneum to prevent ureteral kinking during McCall Culdoplasty suture placement. Two internal McCall sutures with non-absorbable sutures and one external suture with absorbable sutures were place on the uterosacral ligament. Then bilateral apical lateral vaginal walls were fixated to ipsilateral round ligament to further support to vaginal vault. Results: I have applied the new technique to my patients with pelvic organ prolapse for about one year. Ureteral kinking has not occurred in any patient. Early complications such as hemorrhage, bladder and ureter injury did not observed. Conclusion: Ureteral kinking is a challenging problem for gynecologists during suture placement on the uterosacral ligament. Dissection of the uterosacral ligament from the cardinal ligament and parietal peritoneum yielded the surgeon to safe suture passage during McCall Culdoplasty suture placement and eliminated the requirement of cystoscopy evaluation to check ureteral competency.