James Presthus, MD

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I have a video here, I’m just going to start with that. This is an  ELEVEST that was done about eight weeks ago. I’ll just describe the  procedure as we go through it. The patient also had some mild  endometriosis, which I excised. She didn’t have rectocele, but she had  about a grade two uterine prolapse. This shows the trocar placement.  I  used three trocars: one for the scope and umbilicus and two 5’s  laterally. 
 
 Here is the patient’s uterus. You can see it’s typical of a retroflexed  uterus. It’s got a mottled appearance and is deep in the cul-de-sac. One  of the keys is to use a good computer manipulator when you do the  procedure. I use a RUMI uterine manipulator, but a Valtchev or Pelosi  are also good too. You can appreciate how wide and open this cul-de-sac  is. This is a relatively young patient. She’s 47, but she’s in excellent  health. She’s a runner and exercise fanatic. She really didn’t want to have a hysterectomy. 
 
 This is her right ureter. I identify the ureters right off the start.  Then I always do the urethrolysis to release the ureters. I open the  peritoneum and release the ureters, so that I do not have to worry about  where the ureters are for the rest of the case.
 
 It’s interesting that the patients I have been receiving have actually been very athletically fit, healthy  women that are active that are complaining of pelvic pressure, pain,  and dyspareunia. It’s estimated that about 50% of adult women   will  have some clinically insignificant level of prolapse. It may be  clinically insignificant, if all you have to offer them is a  hysterectomy or having to live with it. So offering them a uterine  suspension or something else to correct the defect is certainly an  option that they appreciate.
 
 Here again, I’m just releasing the uterosacral on the patient’s left  side. This was where there was some endometriosis along the uterosacral  on the sidewall that was excised. This is the right side. You can use  whatever energy source that you want. These are just unipolar scissors.  But certainly use a harmonic scalpel if you like, or bipolar scissors,  laser, or whatever. It doesn’t matter.
 
 You’ve go to understand that the camera adds at least two to four shakes  for every movement there, so I really didn’t have too much caffeine  that day. There is a 5-millimeter adaptor that allows the needle to go  through the 5-millimeter trocar without losing pneumo. With the uterus  well flexed with the uterine manipulator, we were able to identify where  the uterosacral ligaments are. I’m actually passing the needle through  with the suture. Karen and maybe Tom pass the needle without the suture,  then grasp the suture and pull it through the hole, which probably is  easier. But being from Minnesota, I like to suffer, so we like to make  it harder on ourselves. 
 
 This is a first pass. I do it a little differently. I do a helical type  stitch around the uterosacral ligaments here. So I’m going to take it,  and pass it around again and create this helix around the uterosacral  ligament. Others will reef in and out through the ligament, so you’re  not wrapping the ligament itself. I really don’t think it makes a whole  lot of difference. You can determine whatever technique works best for  you. You can see that there’s no detachment here at the cervix, those  uterosacral ligaments are well attached to the cervix. I work my way up  towards the insertion point. Now as you use this needle, you can see  there’s a fair amount of pressure that has to be applied. I think that’s  always something that will get better as the instrumentation is refined  a little bit. But you want to be careful as you pass this needle.  Usually I use my finger as a sort of a stop on the outside along the  trocar, so that I’m not going to make any sudden movement and go  through. Potentially I think your risk  would be with the rectum down below here. You don’t want to be gazing  at the rectum. I try to aim as much as possible towards the middle of  the pelvis. Maintain the ability to correct or stop the needle from  going through too suddenly. Now, once I’ve gotten up to the cervical  insertion, then I’m going back down and pulling it back through at the  point where I started. This is at the point where I’ll tie. It’s just an  extracorporeal knot. This is a 2-0 Ethibond suture that I’m using. You  want to use a fair amount of pressure. But most time, with any kind of  pelvic floor reconstruction, I think the tendency is always to  overcorrect. The tendency is to always try to make things too good, too  tight. You don’t want it to prolapse. So try not to create excessive  tension there, but enough tension to maintain the level of support that  you want.
 
 So I’ve done the left side. Now I’m going to go do the right side.  Basically the same technique. I use a little bit of a screwing motion to  kind of corkscrew the needle through. The grasper is important, because  you want to be able to try to stabilize that tissue as much as you can  when you’re passing that needle. You want to have a good grasper and try  to create some tension on the ligament itself, so that you’re not going  to be pushing half-way across the pelvis. You get a real appreciation  for just what this tissue is like. Obviously, if this was just nice,  soft tissue, it wouldn’t take much to be pushing this needle through.  But the fact that there is a lot of resistance in that tissue tells you  that this is pretty solid tissue that we’re dealing with. The suture is  going to reinforce that and create a stronger level of support for this  patient. Coming up closer to the insertion point. Here again, with the  proper traction on the uterus and traction on the ligament, you can  really tent that tissue to make it easier to pass the suture through.  Then as I go along, you want to continue to pull the suture down to give  you some slack in order to be able to tie it and bring the suture out  extracorporeally. So there’s the right side now.
 
 So I’ve done both sides. As I looked at it, it looked pretty good, but I  thought, I’m going to shorten just a little bit more. So I’m going to  do a plication here up by the insertion. To do this you have to come at  it from both sides, because it’s really tough for the angle to be able  to pass the suture through both sides of this ligament from just one  side of the abdomen. So what I’m doing is coming through with this  suture on the right side first. Then after I’ve dropped the suture, I  come back from the left side and pick it up and bring it through on the  left side. I don’t do a marked plication where I do several layers and  potentially constrict the posterior space here - just enough to shorten  the uterosacral ligaments to reinforce the repair. Again, extracorporeal  knots. So it’s relatively easy. You don’t have to do extracorporeal  knots, but if you want to, you can. Think about how much time you have  in the room.
 
 So here is the completed uterosacral portion of the case. Now they are  pulling on the uterus to see how much support and decensus there is. At  this point I can see that she’s got very good support from that part of  it.
 
 Now I’m going to do the UPLIFT procedure for repositioning. In the first  picture that you saw, the patient had a real retroflexed uterus.  Dyspareunia was one of her main complaints. This is really a positing  type operation. I’m not as dependent upon this for the support, but  mainly to maintain this uterus in an anterior, neutral position. I  always start with a needle and some Marcaine solution that I inject. I  use that as a way of guiding me to the entrance point that I want to  make with the UPLIFT needle. Then as I find that point, I make a skin  nick. You do a near and far insertion. In other words, you want to be  able to tie the suture over a fascial bridge. You want to make sure that  you are leaving yourself a fascial bridge there to tie over. Once the  suture is brought down the first time, it’s released. Then you come back  and then take a different path again now. I always start with my first  insertion and then the medial part of the stab wound. The second one  lateral and trace my way back down through the round ligament again,  exiting usually about one or two centimetres from the uterine fundus. Picking up the suture there and  pulling it back. Truncating that ligament now. So at this point I remove  the uterine manipulator. 
 
 I do it opposite of what Karen does. Karen does the UPLIFT portion of  the procedure first, then does the uterosacrals. I do the uterosacrals,  then do the UPLIFT. I remove the uterine manipulator to get an idea. I  don’t want to create too much tension with this suture. I just want to  position the uterus. I don’t want to overcorrect the situation.
 
 So now this is the end of the case. The uterus is now up out of the cul-de-sac. It’s got strong ligament support in the back.
 
 Well thank you.

Articles

I have a video here, I’m just going to start with that. This is an ELEVEST that was done about eight weeks ago. I’ll just describe the procedure as we go through it.

ELEVEST Procedure for Uterine Prolapse

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Author | James Presthus, MD

Articles

ELEVEST Procedure for Uterine Prolapse

ELEVEST Procedure for Uterine Prolapse Video