Full details of the anatomy of vaginal vault support are discussed in Chapter 4-2. It is important to realize that there are multiple components to vaginal vault support, including uterosacral and cardinal ligaments, endopelvic fascial envelopes, and lateral paravaginal attachments. Many surgical techniques for vault prolapse are designed to utilize one, or a combination of those structures. It is possible to restore attachment of the vaginal apex to the uterosacral ligaments. Specific restoration of cardinal ligament support of the vaginal apex is less likely and not currently within our armamentarium. As such, most surgical approaches to vaginal vault prolapse rely on compensatory techniques rather than restoration of previously existing support mechanisms. The creation of a central attachment site at the vaginal apex is crucial to achieving vault support and integrity of the anterior and posterior vaginal fascial envelopes (Figure 8-2.1). In the nonhysterectomized woman, the cervix acts as the central attachment site. In a woman undergoing a hysterectomy, the vaginal cuff anatomy should be restored by attaching the uterosacral ligaments firmly to the vaginal apex during the course of the procedure. Prevention of vaginal vault prolapse or development of a posterior enterocele should be a goal during every hysterectomy by performing a McCall culdo-plasty or other form of attachment of the uterosacral ligaments to the vaginal apex.

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