The Anatomy of Levator Ani Plication at the Time of Colpectomy

Objectives: The objective of this video is to review levator ani anatomy and to demonstrate puboperinealis muscle plication for narrowing of the genital hiatus at the time of colpectomy. Obliterative procedures have the highest success and satisfaction rates in repairing pelvic organ prolapse. As genital hiatus size correlates with prolapse severity; levator myorrhaphy or levator ani plication has been advocated to be used at the time of colpectomy to narrow the introitus. The levator ani plication can be performed without discrimination of the specific subdivisions of the levator ani muscle group. We argue that a critical step in this process is accurate identification and dissection of the puboperinealis muscle. Indiscriminate placement of the sutures in this area can lead to distal pudendal nerve entrapment and pain.

Methods: In this video, we will review the anatomy of the subdivisions of the levator ani muscles using diagrams and 3D ultrasound. After reviewing the anatomy, we demonstrate the process of identification and dissection of the puboperinealis muscles at the time of colpectomy. After dissection of the muscles, they are plicated. Plication of the puboperinealis significantly narrows the genital hiatus.

Clinical Relevance: We believe that anatomical identification and plication of the puboperinealis muscles achieves the same purpose of narrowing the genital hiatus as the traditional levator myorrhaphy approach, with less risk of nerve entrapment and pain to the patient.