pRophylactic utErosacral suspension AT Total lAparoscopiC Hysterectomy and the risk of prolapse occurrence – a randomised controlled trial (REATTACH)

Consistent with our standard technique of hysterectomy, gynaecological surgeons commence the exposure of the uterosacrals by developing the medial pararectal space of Okabayashi. By this stage the lateral pararectal space of Latzko already has already been developed, ureters identified and lysed if necessary, and uterine vessels secured at the origin of the internal iliacs. The ureter is identified separating these two potential spaces, with the medial dissection carried to expose the uterosacral through its entire extent, especially the junction of the upper and middle thirds. The inferior hypogastric nerve is identified and preserved whenever possible. If excision of deep infiltrating endometriotic deposits make the preservation of parts of the uterosacrals untenable, a proximal anchor towards the upper third of the ligament is chosen. A marking stitch may be appropriate in such cases for easy identification. The hysterectomy will then proceed per usual methods, including possible removal of associated adnexae. Uniformity of surgery will be ensured by a single surgical team performing all surgeries. For patients that are randomised to the high uterosacral suspension arm, following the hysterectomy ensuring adequate “pedicalisation” of the uterine vessels, the assistant places the uterosacral ligament ligament under stretch by lifting the vaginal angle. A 0 Prolene D7580 on a 26 mm CT2 needle is cut to 30 cm length (shorter if 2 separate suture packs used). The uterosacral ligament is plicated in an inside-out, outside-in fashion, always commencing within the medial rectal space with the ureter coursing laterally in view. This suture is then driven through the bulky attachment of the uterosacral to the peri-cervical ring. The next bite is taken lateral to the vaginal edge and medial to the uterine pedicle ensuring that the Prolene does not enter the vaginal mucosa throughout its entire course. This also prevents bunching or infolding of the vault edges which can make vault closure tricky. The suture carried anteriorly is then robustly anchored to the pubovesical fascia and then makes it way posteriorly past the anchor point to the uterosacral at the pericervical ring to incorporate a robust bite through the rectovaginal fascial attachment to this structure. Following this, the suture is tied intracorporeally with 5 squared knots. The procedure is then repeated on the other side. This will then be followed by vaginal closure of the vault is carried out using V-Loc 90 suture (Covidien, Dublin, Ireland) in 2 layers taking care to incorporate the pubovesical fascia and the rectovaginal fascia which is contiguous with the vaginal vault. The whole hysterectomy will take about 2 hours, the uterosacral suspension procedure will take approximately 10 more minutes. Technique will be documented in the operative notes recorded on electronic medical records (EMR)