Native Tissue Suture Repair of Vaginal Vault Prolapse: Laparoscopic, Robotic, and Open Abdominal Approaches

More than 400,000 hysterectomies are performed annually in the United States (a decline of more than 200,000 in annual procedure numbers from the peak in 2002). In 2018 the most common route of hysterectomy was laparoscopic (to include both traditional and robotic), followed by the abdominal and vaginal approaches. Although most hysterectomies are done for reasons other than lost vaginal support, some data demonstrate that failure to suspend the cuff risks future development of vaginal prolapse. This chapter reviews a variety of techniques that can be performed abdominally, laparoscopically, or robotically to either support the vaginal cuff at the time of hysterectomy or manage posthysterectomy prolapse with a native tissue repair.

Given support of the vaginal apex contributes to both apical and anterior wall vaginal support, posthysterectomy prolapse could manifest in multiple vaginal compartments. Prophylactic support of the vagina at the time of hysterectomy relies on recreating level 1 support by connecting the vaginal cuff to the uterosacral cardinal ligament complex ( Fig. 40.1 ). This can be done either as individual sutures passed from each uterosacral ligament to the vaginal cuff (akin to a uterosacral ligament suspension) or as a loop of suture from uterosacral ligaments to the vaginal cuff (akin to a McCall culdoplasty). Both approaches seek to create unity between the supportive tissues of the anterior and posterior vaginal wall with the uterosacral ligament that itself was the principle fascial support of the uterus (it is acknowledged that the muscular support rendered by the levator ani is the most important support of the pelvic organs).

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Overview of pelvic anatomy after hysterectomy demonstrating the detached uterosacral ligaments and their relationships to the ureter, ischial spines, and vaginal cuff.

Three techniques (Moschcowitz culdoplasty, Halban culdoplasty, transverse uterosacral ligament plication) have been described to surgically obliterate the female pelvic cul-de-sac, one of which includes transverse plication of the uterosacral ligaments with fixation to the vaginal cuff (i.e., McCall culdoplasty). The reasons to perform these procedures all relate to preventing future enterocele and vaginal vault prolapse.