Lecture in HUGI Jakarta

1. PREVENTION OF VAULT
PROLAPSE AFTER
HYSTERECTOMY
DR ARUKU NAIDU MD, FRCOG, CU
Consultant Urogynaecologist
HRPB Malaysia
aruku-naidu.blogspot.com
HUGI, JAKARTA

2. A/P Roy Ng Snr Cons & Head Urogynaecology &
Pelvic Reconstructive Surg Dept O&G National
University Hosp S'pore 2
MCH IPOH

3. MCH IPOH

4. VAGINAL VAULT PROLAPSE
 Complication of :
 Hysterectomy (abdominal = vaginal)*
 ?LAVH / TLH
 Other pelvic surgery
 Manchester repair (enterocoele)
 Burch colposuspension ± TAH (enterocoele / vault prolapse)
 Incidence:
 0.2 – 43%**
 < 5%***
* Morley GN, Delancey JO. Am J Obstet Gynecol 1988; 158: 872-879
** Cruikshank SH. Am J Obstet Gynecol 1991; 162: 1611-1619
***Scott R. Am J Obstet Gynecal 1992; 166: 1022

5. ENTEROCOELE &
VAGINAL VAULT PROLAPSE
Enterocele and vaginal vault prolapse
account for 16% mid- to long-term
complications following curative surgery
for uterovaginal prolapse in vaginal
hysterectomy*
* Ranney B (1983) Enterocele, vaginal prolapse, pelvic hernia:
recognition and treatment. Am J Obstet Gynecol 140:53-57

6. DEFINATION: POST HYSTERECOTMY
VAGINAL PROLAPSE ( PHVH)
Descent of vagianl cuff scar (point C) below a point
that is 2 cm less than the total vaginal length above
the plane of the hymen (ICS)

7. VAGINAL VAULT PROLAPSE
Can it be prevented?
Abdominal hysterectomy (AH)
Vaginal hysterectomy (VH) /
Laparoscopic assisted VH (LAVH)
Total laparoscopic hysterectomy
(TLH)

8. De Lancey’s 3 Levels of Pelvic Support
(Delancey JOL: Am J Obstet Gynecol 166: 1717, 1992)
 Level I consists of the
cardinal and uterosacral
ligaments, and suspends
the vaginal apex.
 Level II consists of the
endopelvic fascia
connections to the arcus
tendineus fascia pelvis,
which attaches the vagina
to the aponeurosis of the
levator ani.
 Level III consists of the
perineal body and includes
interlacing muscle fibers
of the bulbospongiosus,
transverse perinei, and
external anal sphincter

9. 9

10. Vault prevention after TAH

11. Prevention of vault prolapse at TAH – Re-anchor uterosacral ligament
pedicles to vaginal vault during vault closure
Peritonisation of the pelvis: ½
purse-string suture
transfixes ant leaf of
peritoneum, round lig, ovarian
lig, uterosacral lig, vag walls
of vault, post peritoneum &
this is repeated on the
opposite side
Abdominal Hysterectomy for Benign
Gynae Conditions. Shaw’s
Textbooks in Operative
Gynaecology 5th Edition (1983)
Fig.9.17 pp . 136

12. Prevention of vault prolapse at TAH
 In 1929, Richardson* described cuff angle
closure incorporating the broad and
uterosacral ligaments to support the vault
during abdominal hysterectomy
 No prospective studies in living subjects
 2 studies in cadavers
*Richardson E. A simplified technique for abdominal nhysterectomy.
Surg 392 Gynecol Obstet 1929; 48: 248-52. (Evidence Class III)

13. Prevention of vault prolapse at TAH
 The efficacy of Richardson’s cuff angle
suture at TAH was reported in a study of
unembalmed cadavers using hanging weights
attached to the vaginal apex.
 There was equal resistance following
 TAH with a Richardson angle stitch
 and after supracervical hysterectomy where
the uterosacral ligament was left intact*
* Rahn DD, Marker AC, Corton MM, et al. Does supracervical
hysterectomy provide more support to the vaginal apex than total
abdominal hysterectomy? Am J 421 Obstet Gynecol 2007;197:650 e1-
4. (Evidence Class III)

14. Prevention of vault prolapse at TAH
Another cadaveric study assessing vaginal apical
descent before and after tying the Richardson
angle stitch found that the distance of apical
descent was significantly reduced with
incorporation of the cardinal and uterosacral
ligaments*
* Rahn DD, Stone RJ, Vu AK, White AB, Wai CY. Abdominal
hysterectomy with or without angle stitch: correlation with
subsequent vaginal vault prolapse. Am J 424 Obstet Gynecol
2008;199:669 e1-4. (Evidence Class III)

15. Prevention of vault prolapse at TAH
 One retrospective study evaluating 250 women having
prophylactic uterosacral ligament suspension to
prevent post-hysterectomy vault prolapse at the time
of abdominal hysterectomy*
 This study reports
 a single complication (a rectovaginal hematoma that
resolved spontaneously)
 no cases of postoperative vaginal vault prolapse
 The results – largely qualitative
 no objective measures such as POP-Q or Baden-Walker
exams postoperatively)
* Ostrzenski A. A new, simplified posterior culdoplasty and vaginal vault
402 suspension during abdominal hysterectomy. Int J Gynaecol Obstet
1995;49:25-34. 403 (Evidence Class II-3)

16. AN angle clamp & ligation technique

17. Characteristics Cases (n = 62) Percentage (%)
Age
< 50 years old 42
> 50 years old 20
67.74
32.26
Menapause status
Premenapausal 50
Postmenapausal 12
80.6
19.4
Parity
Para 1 2
Para 2 – 5 40
Para 6 and above 20
3.2
64.5
32.3
indications
Fibroids 37
Endometriosis 17
PID 3
others 5
59.6
27.4
4.9
8.1
Patient characteristics SURGERY DONE BETWEEN 2010-2012
( 73 PATIENTS, analyzed 62 in end of 2016 patients rest lost on follow-up)

18. Type of complication n = 62 Percentage (%)
Perioperative complication
Indwelling catheter more than 24 hours
Blood transfusion
Haematoma
Return to theatre
29
4
1
1
46.8
6.5
1.6
1.6
Late complication
Persistant vaginal discharge
Recurrent UTI
Secondary infection
DVT
Haematoma
Vault prolapse:
stage 1
stage 2
Stage 3
Stage 4
3
4
0
0
0
3
1
0
0
4.8
6.5
0
0
0
4.8
1.6
0
0
Distribution of complication after TAH &
AN angle clamp support & ligation technique

19. Vault prevention after VH/LAVH

20. Prevention of vaginal vault prolapse
at Vaginal Hystertectomy
 Milton L. McCall in
1957 as a cure for
enterocele, to be
done after Vaginal
hysterectomy
 Aims to prevent
vault prolapses
after vaginal
hysterectomy

21. Posterior Culdeplasty (McCall Culdoplasty). Milton L.
McCall. Obstetrics Gynecology. Volume 10,
December 1957, Number 6

22. Posterior Culdeplasty (McCall Culdoplasty) Milton L. McCall. Obstetrics
Gynecology. Volume 10, December 1957, Number 6.

23. McCall Posterior Culdeplasty. Milton L. McCall. Obstetrics
Gynecology. Volume 10, December 1957, Number 6
45 cases, no recurrence at 3 years follow-up

24. Mc Call Culdoplasty
Matthew D. Barber. Difficult Vaginal Hysterectomy. Chapter 8, pp 158. In:
Hysterectomy for Benign Disease . Eds.: Mark D.Walters , Matthew D.Barber.
Pub.: SAUNDEWRSELSEVIER, 2010.

25.  Only one randomized trial comparing techniques to
prevent vault prolapse after vaginal hysterectomy
performed for non-prolapse related gynecologic
disease
 It compared peritoneal closure of the cul-de-sac, a
vaginal Moschowitz operation, McCall’s culdoplasty
for prevention of post-hysterectomy enterocele in
100 women undergoing vaginal hysterectomy*
* Am J 427 Obstet Gynecol 1999;180:859-65. (Evidence Class I)

26. Closing the cul-de-sac and peritoneal cavity during
vaginal hysterectomy & vaginal Moschowitz
Moschowitz: Double purse-string sutures,
1st purse-string suture tied
Peritoneal closure of
cul-de-sac

27. The authors found significantly fewer cases
of posterior-apical vaginal prolapse (stage 2)
three years following
 The McCall’s culdoplasty 2/32 (6%) than with
 either peritoneal closure 13/33 (39%)
 or the vaginal Moschowitz procedure 10/33
(30%) (p=.004)*
* Am J 427 Obstet Gynecol 1999;180:859-65. (Evidence Class I)

28. AN modified vault support technique

29. Objective assessment preoperative and post operative after vault
support technique ( 2010-2012)

30. Vault prevention after TLH

31. Prevention of vault prolapse at TLH: Incision of vaginal
cuff cranial to pericervical ring of fibromuscular tissue
(where transverse cervical + uterosacral ligaments
attach)
C.Y. Liu, Harry Reich. Surgical Techniques of Total Laparoscopic Hysterectomy. Chapter
10, pp 168-193, PLATE 15. In: Laparoscopic Hysterectomy and Pelvic Floor
Reconstruction. Ed.: C.YH. Liu. Pub.: Blackwell Science, Inc., 1996.

32. Prevention of vault prolapse at TLH
Under direct visualisation of the left ureter (dissection / infra-
red ureteric stent), the left uterosacral ligament is sutured to
the left corner of the vaginal cuff laparoscopically. C.Y. Liu, Harry
Reich. Surgical Techniques of Total Laparoscopic Hysterectomy. Chapter
10, pp 184, FIG 10.12, PLATE 16. In: Laparoscopic Hysterectomy and Pelvic
Floor Reconstruction. Ed.: C.YH. Liu.Pub.: Blackwell Science, Inc., 1996.

33. Prevention of vault prolapse at
laparoscopic hysterectomy
 The only study evaluating 22 laparoscopic uterosacral
ligament suspension in comparison to 96 vaginal
uterosacral ligament suspension retrospectively found
 no significant difference in recurrent apical prolapse
 6% in the vaginal group
 0% in the laparoscopic group [47]
 This study identified no statistical significance in the
ureteral compromise recognized intraoperatively 4%
in the vaginal group, 0% in the laparoscopic group
* Rardin CR, Erekson EA, Sung VW, Ward RM, Myers DL. Uterosacral
colpopexy 443 at the time of vaginal hysterectomy: comparison of
laparoscopic and vaginal 444 approaches. J Reprod Med 2009;54:273-80.
(Evidence Class II-2 )

34. Other Vault preventive techniques

35. Prevention of enterocoele ± vault prolapse after TAH +
Burch colposuspension MOSCHOWITZ SUTURES
(Circumferential sutures to obliterate a deep cul-de-sac)

36. Halban cul-de-sac closure
(Abdominal, uterus removed)
A. Lateral view attaching sigmoid to vagina. B. Superior view of cul-
de-sac of Douglas. C. Lateral view of completed closure. (Nichols
DH: Vaginal Surgery, p 349. Baltimore, Williams & Wilkins, 1996.)

37. Modified Halban uterosacral plication
* Native tissue suture repair of vaginal vault prolapse: abdominal approach:
James L Whiteside & Mickey Karram . Chapter 42 Demonstration Account
September 15, 2016

38. Conclusion (Learning Points)
 Uterosacral ligament suspension may be performed
at the time of abdominal and laparoscopic
hysterectomy to reduce the risk of post-
hysterectomy vaginal vault prolapse (Grade B)
 McCall’s culdoplasty may be performed at the time
of vaginal hysterectomy for non-prolapse related
disease to reduce the risk of postoperative apical
prolapse for upto 3 years (Grade A)
* Post-hysterectomy Vaginal vault prolapse, Green-top guidelines No 46, July
2015

39. Conclusion (Learning point)
 Sacrospinous ligament fixation & abdominal sacral
colpopexy are not recommended for the
prevention of prolapse at the time of
hysterectomy for non-related disease (Grade C)
 SLF can be added to a post vaginal hysterectomy
and McCall culdoplasty if the cuff (point C) is ≥
Stage 2 to prevent vault prolapse (Grade B)
* Post-hysterectomy Vaginal vault prolapse, Green-top guidelines No 46, July
2015

40. Sacral colpopexy & Sacrospinous fixation

41. Thank you / Terima kasih