After giving birth a resulting uterine prolapse with a concomitant enterocele can lead to decreased quality of life and big discomfort.
Especially in young women with pelvic floor disorder native tissue repair with uterus-sparing surgery is crucial. But it might also be of interest in older patients wanting to retain their uterus and avoiding a change of their physical integrity. 
To restore the pelvic support the peritoneum alone is not a sufficient structure. The best results can be obtained by obliteration of the pouch of Douglas combined with a support of the uterus. In our case this was achieved by native tissue repair with uterosacral ligament fixation.

Our video presents the case of a 28-year-old patient. One year before she had a caesarean section and three years before she had had a spontaneous delivery with damage of the musculus levator ani on the right side. Up to now she has been suffering from prolapse symptoms because of pelvic floor defect with an enterocele formation and uterine prolapse, POP-Q stage II. Preoperatively MRI defecography confirmed the defect.

Laparoscopy was performed using an umbilical port to insert the laparoscope and three other ports for the instruments. The laparoscopic view showed a deep and wide pouch of Douglas with a lack of prominent uterosacral ligaments. To obliterate the pouch of Douglas three non-absorbable 2-0 polyester sutures were placed through the right uterosacral ligament including the rectosigmoid serosa and incorporation of the posterior vaginal wall and the cervix. These three stitches must not be too close and before knotting the threads they were temporarily placed at the right abdominal wall. Then another two sutures were made in the same way but starting on the left side. These two stitches included the left uterosacral ligament, the rectosigmoid serosa, the posterior vaginal wall and the cervix on the left. Again after a temporary placement of the threads at the left abdominal wall all the stitches were knotted. 
The result was the desired obliteration of the pouch of Douglas combined with surgery to support the uterus using a uterosacral ligament hysteropexy. Additionally it is often necessary to open the retroperitoneal space on both sides of the rectum to reduce the peritoneal tension to avoid ureteral kinking. A final control rectoscopy is mandatory to exclude a stenosis of the rectum. In our patient the postoperative period was uneventful with a normal bowel function and definite improvement of quality of life.

The result of the above mentioned pelvic reconstructive surgery leads to sufficient pelvic support by native tissue repair without implantation of mesh. Uterus-sparing methods of reconstructive pelvic surgery fulfil the desire of uterus preservation in women of all ages. To prevent a recurrent prolapse it is important to maintain the normal vaginal axis.
We consider the combination of obliteration of the pouch of Douglas with uterosacral ligament hysteropexy as an optimal repair of a uterine prolapse combined with posterior vaginal wall prolapse, particularly an enterocele.

Paraiso MF, Falcone T, Walters MD. Laparoscopic surgery for enterocoele, vaginal apex prolapse and rectocele. Int Urogynecol J 1999; 10: 223-229
Restaino S, Rossini C, Minelli A, Santarelli A, Sambia G, Fanfani F. Laparoscopic approach for Shull repair of pelvic floor defects. J Minim Invasive Gynecology 2017; Dec 28. pii: S2553-4650 (17)31357-2