The document describes the Manchester Repair procedure, which is designed to correct uterine prolapse while preserving the uterus. The key steps are: 1) preliminary dilation and curettage of the uterus, 2) amputation of the cervix, 3) plication of the Mackenrodt's ligaments in front of the cervix, 4) anterior colporrhaphy, and 5) colpoperineorrhaphy. Additional details provided include techniques for covering the amputated cervix with vaginal flaps and suturing the Mackenrodt's ligaments to the cervix to elevate it. Potential complications of the surgery are also outlined.

1. Yapa Wijeratne
Faculty of Medicine
University of Peradeniya

2. • The operation is designed to correct uterine
descent associated with cystocele and
rectocele where the preservation of the
uterus is desirable.
• The indications are :
1. Preservation of reproductive function.
2. When the symptoms are due to vaginal
prolapse associated with elongation of the
(supravaginal) cervix.

3. Composite steps of Manchester Repair
1. Preliminary D + C.
2. Amputation of cervix.
3. Plication of Mackenrodt's ligaments in front
of cervix.
4. Anterior colporrhaphy.
5. Colpoperineorrhaphy.

4. The principal steps of the operation are
• (a) Preliminary dilatation and curettage —
• Uterine sound gives the idea about elongation of
cervix.
• Dilatation of the cervical canal is done to facilitate the
passage of the sutures passing through the cervical
canal during covering of the amputated cervix by
vaginal flaps.
• It also ensures adequate uterine drainage and prevents
cervical stenosis during healing of the external os.
• Curettage is done to remove the unhealthy
endometrium.

5. • (b) Amputation o f the cervix — Where future
reproduction is required, low amputation is to be
done.
• (c) Plication of the Mackenrodt's ligaments in
front of the cervix. This facilitates their
shortening raising the cervix so as to place it in its
normal position.
• (d) Anterior colporrhaphy.
• (e) Colpoperineorrhaphy.
• If the family is completed, vaginal sterilisation is
to be done.

6. STEPS OF OPERATION
• Preliminaries
• The preliminaries are the same as those followed
in anterior colporrhaphy.
• Actual steps
• Preliminary D + C.
• The next step is like that of anterior colporrhaphy
upto the pushing up the bladder.
• The posterior lip of the cervix is to be held with
vulsellum and the cervix is drawn upwards.

7. o A pair of Allis forceps is placed in the midpoint of the posterior
cervicovaginal junction.
o The anterior transverse incision is now extended posteriorly
across the posterior cervicovaginal junction.
o The lateral and posterior vaginal wall is dissected off from the
o cervix by scissors and finger dissection.
o The Mackenrodt's ligament with descending cervical artery of
either side is clamped at a higher level of amputation, cut and
replaced by ligature (chromic catgut No. ‘1’ )
o The presence of enterocele should be searched for and if
detected, to be repaired.
o The cervix is now amputated at the calculated level.
o Anterior lip of the amputated cervix is now held with single-
toothed vulsellum.
o The posterior lip of the amputated cervix is covered by the
vaginal flap using a Sturmdorff suture or by Bonney’s method.

8. • In Bonney's method, a catgut stitch is fixed at
the apex of the posterior vaginal flap.
• The ends of the ligature are passed through the
cervical canal and are taken out laterally on
either side of new posterior fornix.
• The ends of the ligature are tied in the midline.
• The cut ends of the Mackenrodt's ligament are
sutured to the anterior surface of the cervix.
• Alternatively, the ligaments are fixed using
Fothergill’s stitch, Fothergill’s stitch is used to
make the uterus anteverted.

9. • The stitch passes through the following tissues
in sequence.
• Vaginal skin at the level of the FothergilTs lateral
point → Mackenrodt's ligament →through the
cervical tissue from outside inwards → cervical
tissue from inside outwards → Mackenrodt's
ligament of the other side → vaginal skin
(Fothergill’s lateral point) of the other side.
• Pubocervical fascia is approximated as in anterior
colporrhaphy.

10. • Redundant portion of the vaginal mucosa is
excised.
• The cut margins of the vagina are apposed by
interrupted sutures.
• Posterior colpoperineorrhaphy is performed.
• Toileting the vagina is done.
• Vaginal pack is given.
• Self retaining catheter is introduced.

11. Complications of surgery
During operation 1. Haemorrhage
2. Injury to the bladder and
rectum
Postoperative 1. Retention of urine or cystitis
2. Haemorrhage: primary or
secondary
3. Infection
Late 1. Dyspareunia
2. Cervical stenosis-
hematometra
3. Infertility
4. Cervical incompetency
5. Cervical dystocia in labor

12. Reference
• Gynaecology by Ten Teachers 19th Ed
• Dutta-Gynecology
• Bonney Gynaecological Surgery 11E