vNOTES Uterosacral Ligament Suspension: Anatomic Considerations

INTRODUCTION: Vaginal natural orifice transluminal endoscopic surgery (vNOTES) is a growing surgical approach in which the vaginal orifice is used as a surgical route for laparoscopic procedures. Uterosacral ligament suspension (USLS) using vNOTES has been demonstrated as a feasible and safe technique to address pelvic organ prolapse. When compared to conventional vaginal hysterectomy with USLS, it has demonstrated a lower incidence of intraoperative complications (ureteral ligation or kinking and neuropathy), shorter surgical time, and lower estimated blood loss. The vNOTES technique offers improved exposure and visualization, likely accounting for the improved safety profile but remains a fundamentally different skill as compared to the conventional method. OBJECTIVE: This video will identify and describe the anatomic structures relevant to vNOTES USLS. METHODS: Uterosacral ligaments: The uterosacral ligaments (USL) are made of smooth muscle, connective tissue, and autonomic nerves and represent the lateral boundaries of the posterior cul-de-sac. During conventional vaginal methods, an Allis clamp is often used to tent the USL, aiding in its identification. In vNOTES, an analogous marking of the USL is made with a laparoscopic needle driver. Ureter: Visualization of ureteral vermiculation, lateral to the USL, allows proper identification and decreases risk of injury. The mean distance of the ureter to the USL is closest at the cervical portion. Therefore, proximal uterosacral sutures risk direct and indirect tension injury to the ureter. Vasculature: The internal iliac artery and vein lie lateral to the USL. Pelvic sidewall venous tributaries of the internal iliac are at risk for perforation from USLS suture placement. Also lying inferiorly to the USL are the superior gluteal vein and the middle rectal artery. Rectum: The rectum lies medial to the USLs at an average distance of 11 mm from the medial aspect of the suspension suture to the lateral border of the rectal lumen. Nerves: Sacral parasympathetic fibers join sympathetic fibers from the superior hypogastric plexus to form the inferior hypogastric plexus, many of which travel near or through the USL. Suture placement often falls anterior or lateral to nerve roots between the first and third sacral foramina, with more cephalad placement increasing risk for sacral nerve entrapment. Neurologic complications may also arise from irritation of the nerve roots due to bleeding or from stretching of the autonomic nerves in the USL. Postoperative pain from nerve entrapment can be managed by removal of the sutures on the affected side through a transvaginal approach. RESULTS: Suture placement: The suspension sutures should be placed 1–1.5 cm apart through the USL at its mid-length—roughly at the level of the ischial spines or 6–7.5 cm from the internal retractor ring. We recommend using 0-PDS on a CT2 needle, thrown from lateral to medial to decrease risk of ureteral injury. CONCLUSIONS: In summary, vNOTES USLS has been demonstrated as a safe technique, and we hope to improve surgeon comfort with the knowledge of underlying anatomy (Figures 1 and 2).