The cervix is circumscribed and the utero-vesical fold and pouch of Douglas opened. The uterosacral and cardinal ligaments are divided and ligated first, followed by the uterine pedicles and finally the tubo-ovarian and round ligament pedicles. In cases of procidentia, care should be taken to avoid kinking of the ureters which are often dragged into a lower position than normal. The most important part of the procedure is support of the vault since these women are at high risk for posthysterectomy vault prolapse. The uterosacral ligament sutures are therefore tied in the midline and brought through the posterior part of the vault and tied after the vault has been closed. For additional support, a high uterosacral ligament suspension can be performed by placing additional PDS sutures through the lateral aspects of the vaginal vault on each side and securing these to the ipsilateral uterosacral ligament. This procedure places the ureters at risk and therefore ureteric patency should be confirmed post-operatively by cystoscopy. These sutures are also tied after the vault has been closed. An alternative to the high uterosacral ligament suspension is a McCall suture. This is a pursestring suture that goes through both corners of the vaginal vault, through the uterosacral ligaments and also through the posterior peritoneum to obliterate the pouch of Douglas to prevent enterocele formation.
Uterine preservation procedures
Sacrohysteropexy (See a separate chapter on Sacrocolpopexy)
This technique involves attaching the uterus to the sacral promontory using a broad piece of prolene mesh. Through a Pfannenstiel incision the peritoneum over the sacral promontory is opened. The prolene mesh is attached to the posterior aspect of the uterus with the sutures secured at the level of insertion of the uterosacral ligaments. The mesh is then attached to the anterior aspect of the sacral promontory using either an Ethibond suture or screw tacks. The perioneum is then partially closed over the mesh. This operation can be combined with an abdominal paravaginal repair in a women with a cystocele and a colposuspension in a patient with stress incontinence.
Manchester repair (Fothergill repair)
This procedure is only rarely performed nowadays. Cervical amputation is followed by approximating and shortening the cardinal ligaments anterior to the cervical stump and elevating the uterus. This is combined with an anterior and posterior colporrhaphy. The operation has fallen from favour as long term problems include infertility, miscarriage and dystocia in addition to recurrent uterovaginal prolapse and enterocele formation.
An enterocele repair is normally performed using a vaginal approach. The vaginal epithelium is dissected off the enterocele sac which is then reduced using two or more polyglycolic (Vicryl, Ethicon) or polydioxanone (PDS, Ethicon) purse string sutures. It is not essential to open the enterocele sac although care should be taken not to damage any loops of small bowel which it may contain. The vaginal skin is then closed.
An abdominal approach may also be used although this is much less common. The Moschowitz procedure is performed by inserting concentric purse string sutures around the peritoneum in the pouch of Douglas thus preventing enterocele formation, although care must be taken not to ‘kink’ or occlude the ureters.
Vaginal Vault Procedures
Risk of post-hysterectomy apical prolapse is about 0.36% per year; or 1% (at 3yrs) and 5% (at 17yrs). The vaginal vault can be supported vaginally or abdominally.
Sacrospinous Ligament Fixation (SSF)
A longitudinal posterior or anterior vaginal wall incision is performed to expose the ischial spine using sharp and blunt dissection. The sacrospinous ligament may then be palpated running from the ischial spine to the lower aspect of the sacrum. A delayed absorbable suture (PDS) is passed through the ligament. A number of techniques are available to do this. A standard long needle holder or a specially designed Miya hook ligature carrier can be used. Most recently, the Capio® ligature carrier (see table) has been launched which makes the procedure significantly easier. Both right and left Sacrospinous ligaments can be used to support the vagina. Some surgeons employ only one ligament but there is no evidence to suggest that a uni-or bilateral is better.
Vaginal procedures that suspend the apex
Vaginal obliterative procedures
Abdominal procedures that suspend the apex
Care must be taken to avoid the sacral plexus and sciatic nerve which are superior to the ligament, and the pudendal vessels and nerve which are lateral to the ischial spine. The sacrospinous sutures are then tied to support the vaginal vault from the sacrospinous ligament. Since the vaginal axis is changed by the procedure there is a risk of post-operative dyspareunia and development of stress incontinence. Success rates for this procedure are in the region of 80-95%.
Complications of SSF:
- Buttock pain
- Nerve injury
- Rectal injury
- Stress incontinence
- Vaginal stenosis
- Anterior vaginal wall prolapse
In this procedure, the vaginal vault is fixed to the illiococcygeus muscle fascia on both sides, just anterior to the ischial spines. The procedure can be performed through either an anterior or posterior vaginal incision. A delayed absorbable suture is used and secured to the vaginal vault and is associated with a good anatomical result with an adequate vaginal length with no deviation. A trial comparing illiococcygeus fixation and sacrospinous fixation found similar outcomes and comparable complication rates.
See separate chapter
Colpocleisis is an excellent option in patients who are certain that they will not want to be sexually active in the future. This is often a last resort in many women who have had recurrent procedures for vaginal prolapse. In partial colpocleisis (so-called Le Fort colpocleisis), the vagina is obliterated by excising rectangles of vaginal epithelium from the anterior and posterior aspects of the prolapse. These raw areas are then sutured together, thereby burying the cervix and obliterating the vagina. In total colpocleisis all the vaginal skin is removed and the anterior and posterior vaginal walls approximated. In both these procedures, an aggressive perineorrhaphy is performed. There is a high incidence of stress incontinence (up to 42%) following these procedures and therefore a concomitant midurethral tape is mandatory. These procedures are performed on an outpatient basis with an immediate return to normal activities, and success rates as high as 100% have been described.