After isolating and excising the enterocele sac, place up to 3 modified McCall stitches, each one slightly higher than its predecessor. Each suture should incorporate the full thickness of the posterior vaginal wall, the cul-de-sac peritoneum, the remains of the uterosacral-cardinal complex bilaterally, and the fascial tissue lateral and posterior to the upper vagina and rectum (FIGURE 2).
Once they are in place, tie the sutures in the opposite order in which they were placed. These stitches fix the prolapsed vaginal vault to the uppermost portion of the endopelvic fascia at the same time as they accomplish a high closure of the culdesac peritoneum.
The evidence. Sze and Karram5 found an 11.5% incidence of recurrent vault prolapse and an associated 22% incidence of new-onset dyspareunia.
FIGURE 2 Classic vs modified McCall culdoplasty
In the classic McCall culdoplasty shown here, only the distal-most suture incorporates the posterior vaginal wall. With the “modified” technique, however, all sutures incorporate the full thickness of the posterior vaginal wall, as well as the cul-de-sac peritoneum, the remnants of the uterosacral-cardinal complex bilaterally, and the fascial tissue lateral and posterior to the upper vagina and rectum.
High uterosacral ligament suspension with fascial reconstruction
This approach is based on the observations of Richardson,14 who suggested that the endopelvic fascial supports (uterosacral/cardinal complex) do not stretch and attenuate over time, as some have hypothesized, but break at definable points. By identifying these points, the surgeon can reattach the prolapsed vagina to the intact uterosacral complex cephalad to the break.
Technique. Grasp the vaginal apex with 2 Allis clamps and incise it with a scalpel. If an enterocele sac is present, dissect it off the vaginal epithelium to the neck of the hernia, open it, and then excise it. Place a delayed absorbable or permanent pursestring suture about the neck of the hernia to close the peritoneal defect. If an anterior colporrhaphy or sling is required, perform them at this time.
Place a moist laparotomy pad in the cul-de-sac, and insert and elevate a Deaver retractor to remove the intestines from the cul-de-sac and improve exposure. Next, palpate the ischial spines transperitoneally.
Once the spines are identified, the remnants of the uterosacral ligaments can be identified posterior and medial to the spines and can be palpated transperitoneally or transrectally. Remember that the ureters are also quite close to the ischial spines at this location, running along the lateral pelvic sidewall 2 to 5 cm ventral and lateral to the ischial spines.
After identifying the uterosacral ligaments, grasp their remnants with Allis clamps and place 2 to 3 delayed absorbable or permanent sutures through the rectovaginal fascia of the inner posterior vaginal wall epithelium at one lateral vaginal apex, through the ipsilateral plicated uterosacral ligament complex, and then through the pubocervical fascia of the anterior vaginal wall of the ipsilateral vaginal apex. Hold these sutures while performing the same procedure contralaterally (FIGURE 3). Close the apex and tie these sutures in place, suspending the corners of the vaginal apex from the uterosacral complex bilaterally, and restoring the continuity of the paracervical ring (FIGURES 4, 5).
Benefits of this technique include:
- creation of an anatomically appropriate and correctly positioned midline vaginal axis,
- preservation of adequate vaginal length,
- reduced risk of nerve injury, and
- restored continuity of the paracervical ring when the pelvic pararectal, uterosacral, and pubocervical fascia are reapproximated circumferentially.
Risks include the potential for ureteral kinking or obstruction. Thus, it is prudent to perform cystoscopy after this procedure to rule out occult injury.
FIGURE 3 Suspend apical corners bilaterally
The corners of the vaginal apex are suspended from the cardinal-uterosacral complex bilaterally, with all sutures placed posterior and medial to the ischial spines. Copyright 1998 by C.G. Bachofen.
FIGURE 4 Suture placement penetrates multiple layers
Sagittal view of correct suture placement. PS=pubic symphysis, B=bladder, PCF=pubocervical fascia, USL=uterosacral ligaments, AD=apical defect, RVF=rectovaginal fascia, R=rectum. Copyright 1998 by C.G. Bachofen.
FIGURE 5 Suspend the fascia from uterosacral ligaments
Sagittal view after tying of sutures. Note restoration of the normal anatomic axis. PS=pubic symphysis, B=bladder, PCF=pubocervical fascia, USL=uterosacral ligaments, RVF=rectovaginal fascia, R=rectum. Copyright 1998 by C.G. Bachofen.
Posterior intravaginal slingplasty
This investigative technique, also known as infracoccygeal sacropexy, is a minimally invasive, transperineal approach to vaginal vault prolapse. The anatomic and physiologic concepts are similar to those of the tension-free vaginal tape (Gynecare, Somerville, NJ) in the treatment of stress incontinence. However, because it is a new procedure, further evaluation is needed before it can be adopted into clinical practice.