Endometriosis is commonly found in the cul-de-sac and in other peritoneal structures, resulting in pelvic pain and infertility. Endometrial implants in the cul-de-sac can also cause fixation of the uterus in a retroverted position. These patients may experience deep dyspareunia. In a study of 1,785 women treated surgically for endometriosis, Redwine found that 72.2% of the patients had involvement of the cul-de-sac. The uterosacral ligaments (left = 45%, right = 41%), broad ligaments (left = 52%, right = 43%) and bladder (33%) were also common sites of endometriosis.1
Laparoscopic resection is often performed to treat the disease with the goal being complete removal of all implants. Although the objectives of endometriosis surgery are to relieve symptoms and maintain or restore fertility, a woman's postoperative course may be complicated by adhesion formation that leads to decreased fecundity and failure to relieve the pain.2 Uterine suspension after endometriosis surgery restores normal anatomy, relieves dyspareunia and lifts the uterus away from the posterior cul-de-sac to help prevent adhesion formation.
In a report on the use of pelvic denervation and uterine suspension for the treatment of chronic pelvic pain, Steege states that in cases where extensive endometriosis is found in the cul-de-sac, uterine suspension may help reduce postoperative scarring by elevating the uterus and the adnexa.3h
Ivey performed laparoscopic uterine suspension as an adjunct procedure to help limit adhesion formation on 225 women treated for endometriosis involving the cul-de-sac and/or uterosacral ligaments.4 These sites were felt to offer the greatest opportunity for the ovaries and fallopian tubes to become adherent postoperatively. Questionnaires were mailed to all patients to assess pain relief and attempts to become pregnant. Ninety-four percent of the patients responding reported decreased severity of post-operative pain. In regard to infertility results, the cumulative pregnancy rate was 80% including a 15.58% monthly fecundity rate for women with minimal endometriosis. The study concludes that laparoscopic uterine suspension is an effective adjunctive procedure for use with both minimal and advanced endometriosis.
Buttram outlines his use of uterine suspension after endometriosis surgery in an article on the principles of conservative surgery for endometriosis.5 Uterine suspension is advocated to lift the adnexa out of the posterior cul-de-sac, because of the vulnerability of adhesion formation. His goals regarding durability of the procedure are modest. "If the suspension lasts only a few days we feel we have accomplished our task. By this time the healing process has been completed sufficiently that adhesions of the adnexa are unlikely."
Wilson states a retroverted uterus can be suspended in an attempt to reduce adhesion formation and to elevate the tubes and ovaries away from the cul-de-sac.6
Lifting the uterus out of the cul-de-sac can help prevent adhesion formation and reduce pelvic pain.