The patient is placed in the dorsal lithotomy position. Thorough examination of the pelvis is performed. The bladder is not catheterized because it can be identified and dissected with greater safety when partially filled than when empty.

The labia may be tacked to the perineum for retraction if they are redundant. A Jacobs tenaculum is placed on the anterior lip of the cervix. Downward traction on the cervix exposes the junction of the vagina and cervix where a 360° circumcision incision is made. The bladder is sharply and bluntly dissected off the lower uterine segment up to the vesicouterine fold.

A right-angle retractor is placed under the bladder to expose the vesicouterine peritoneal fold. This is picked up and opened.

The anterior cul-de-sac is opened, a finger is inserted, and the fundus and adnexa are explored.

A right-angle Heaney retractor is placed in the anterior cul-de-sac, allowing elevation of the bladder and ureter. The cervix is rotated anteriorly, and the posterior cul-de-sac is exposed. The peritoneum of the posterior cul-de-sac is picked up and opened.

The posterior cul-de-sac is opened. A finger may be inserted into the cul-de-sac, and the uterus and adnexa explored.

For demonstration purposes, two right-angle retractors are shown, with the upper elevating the vagina and bladder and the lower exposing the anterior cul-de-sac. The upper retractor is removed, and the lower retractor is utilized to elevate the bladder and ureter out of the surgical field. A right-angle retractor is used to expose the lateral vaginal fornix. The cervix is retracted to the contralateral side, exposing the uetrosacral and cardinal ligaments. A finger is used to explore the posterior cul-de-sac to ensure that bowel has not moved into this area prior to placing the Heaney clamp on the uterosacral and cardinal ligaments. The Heaney clamp should be placed immediately adjacent to the body of the lower uterine segment. The tips of the clamp should actually grasp a small portion of the lower uterine segment. The uterosacral ligament and a small section of the cardinal ligament are clamped and incised (dotted line). The pedicle is tied with No. 1 synthetic absorbable suture.

The right-angle Heaney retractors are seen in the anterior and posterior cul-de-sac, and right-angle lateral retractors have been moved to the left side of the vagina. The cervix is deviated to the patient's right and slightly anterior, exposing the uterosacral ligament on the left. The uterosacral ligament is clamped, incised, and tied with 2-0 synthetic absorbable suture.

Depending on the length of the cervix, several bites may be required to remove a long cervix while the right-angle Heaney retractor is elevating the bladder and ureter. A small portion of the cardinal ligament is clamped, incised, and tied with 2-0 synthetic absorbable suture.

The cardinal ligament on the opposite side is clamped, incised, and tied.

It is best to remove the cervix at the lower uterine segment, and the surgeon must judge how much of the cervix should be amputated.

The anterior right-angle Heaney retractor elevates the bladder and ureter, and the posterior right-angle Heaney retractor depresses the rectum. Traction is made on the cervix, and the amputation is made with a scalpel at the lower uterine segment.

An attempt is made to angulate the plane of the incision in the cervix so that it is "wedged out' rather than incised perpendicular to its surface. This facilitates coverage of the lower uterine segment with vaginal mucosa. The lower uterine segment is moved posteriorly; the cardinal and uterosacral ligaments are brought across the anterior surface of the cervix and sutured to the lower uterine segment with interrupted No. 1 synthetic absorbable sutures. The bladder and ureters are elevated out of the surgical field with the right-angle Heaney retractor.

The right uterosacral and cardinal ligaments have been sutured in place, and the left uterosacral and cardinal ligaments are exposed.

The left cardinal and uterosacral ligaments are sutured in place, overlapping those from the right side and creating a firm ligament band in front of the lower uterine segment. The lower uterine segment is held posteriorly, bringing the fundus anteriorly. The angle of the uterus is thus changed in the pelvic canal.

In most cases of second-and third-degree uterine descensus, there will be significant cystourethrocele. Therefore, the standard anterior repair as shown in Vagina and Urethra, would be performed at this time.

After the anterior repair has been performed, the vaginal mucosa is closed with interrupted No. 1 synthetic absorbable suture so that it covers the lower uterine segment with vaginal mucosa.

The row of interrupted synthetic absorbable sutures closing the vaginal mucosa is extended to the opposite side.

The finished procedure shows the uterine canal opened for drainage of mucus.

A Foley catheter is placed in the bladder and left in place for 4-5 days when an anterior repair and Kelly plication have been performed. If no anterior repair or Kelly plication was performed, a Foley catheter may not be necessary.