A useful accessory to reproductive surgery that corrects a uterine abnormality

Although it is generally advocated in old surgical textbooks, hysteropexy (uterine suspension) has been downplayed or ignored by modern surgeons. During my 40-year surgical career, following such a simple procedure I have seen many patients relieved from pain and/or go on to conceive spontaneously, which is naturally conceiving following a birth via in vitro fertilization (IVF). Hysteropexy is also often used to treat uterine prolapse.

Being convinced of the interest and sometimes its necessity, I feel compelled to explain to our patients – and to remind young surgeons – that they should not miss the opportunity to restore the natural anterior uterine position when the occasion arises.

The normal anatomical and physiological situation of the uterus is in the anteverted or anteflexed position, which means the uterus tips forward toward the bladder. It promotes proper menstrual drainage in erect and supine position. It also allows a direct fall of the fallopian tubes on the ovarian cortex (surface), facilitating proper ovum (egg) pick-up by the sweeping motion of the fimbriae (broom-like structure at the end of the tubes).

Twenty percent of women have a retro-displaced (tilted or tipped) uterus, meaning that it tips backward toward the rectum. Most of the time it is due to the fact that the woman is born with abnormally elongated round ligaments. If the ligaments were of a normal, shorter size they would pull the uterus in a normal anterior position.

However, the tilt can also be caused by pathologies of the posterior pelvis such as endometriosis, an inflammatory or adhesive (scars) disease. A tilted uterus can contribute to pelvic pain, including dysmenorrhea (painful menses), dyspareunia (painful intercourse) and a chronic backache. It is usually associated with the bulging of the veins (varicosities) that supply the uterus and ovaries. This phenomenon is also known as pelvic congestion.

Uterine Suspension

Uterine suspension is a harmless procedure that can be performed in conjunction with various other surgeries for treatment of endometriosis, tubal repair, fibroid or adhesions removal or simply to alleviate pelvic pain or backache. It helps to prevent post-operative scarring and entrapment in the posterior pelvis of tubes and/or ovaries that have just been repaired. Also, it improves the uterine and ovarian blood supply by correcting the pelvic varicosities.

It can be accomplished at the time of outpatient laparoscopy, robotic surgery or laparotomy (open surgery) by suspending or shortening the round ligaments with permanent sutures. The same procedure has also been used to treat conservatively and efficiently a prolapsed uterus.

The older textbooks generally refer to the Gilliam suspension that can only be performed during open surgery. I prefer the triplication technique that consists of shortening the round ligament by placating, or folding, it three times on itself using permanent sutures. Several methods of uterine suspension to be executed during outpatient laparoscopy or robotic surgery have been described over the years by different authors. They vary in complexity.

In 1978, I published a technique called ventrofixation that I have performed many, many times with a permanent suture attachment to the fascia under the abdominal muscles (1). It is simple and very efficient. An experienced laparoscopist or robotic surgeon should have no difficulty performing a ventrofixation or a triplication during an outpatient procedure.

In conclusion, the natural position of the uterus is in anteversion. Hysteropexy or uterine suspension is an innocuous, simple, useful and efficient operation that can be performed alone or in conjunction with more complex procedures when indicated or when the occasion arises.

 

References

  1. Servy, Edouard J., M.D., M. Feridun Aksu, M.D., and Vasillis A. Tzingounis, M.D. “24.” Endoscopy in Gynecology: Eds Jordan M. Phillips. American Association of Gynecologic Laparoscopists, 1978. Pp 87-89
  2. “Chronic Pelvic Pain: Clinical Dilemma or Clinician’s Nightmare.” — Ghaly and Chien 76 (6): 419. N.p., n.d. Web. 30 May 2016.
  3. Susan Sarajari, MD, PhD; Kenneth N. Muse Jr., MD; Michael D. Fox, MD. “Current Diagnosis & Treatment Obstetrics & Gynecology, Eleventh Edition (LANGE CURRENT Series) 11th Edition
  4. Barbara L. Hoffman, John O. Schorge, Joseph I. Schaffer, Lisa M. Halvorson, Karen D. Bradshaw, F. Gary Cunningham, Lewis E. Calver. “Williams Gynecology, 2e.” AccessMedicine. N.p., n.d. Web. 30 May 2016.

“Is Your Tilted Uterus Keeping You from Getting Pregnant?” Natural Fertility Ventrofixation (Servy 1978)