Manchester repair (Fothergill’s Operation)


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Manchester repair (Fothergill’s Operation)

  1. 1. Yapa Wijeratne Faculty of Medicine University of Peradeniya
  2. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 12. Reference • Gynaecology by Ten Teachers 19th Ed • Dutta-Gynecology • Bonney Gynaecological Surgery 11E