McCall7 described the technique of surgical correction of enterocele and deep cul-de-sac during vaginal hysterectomy. The McCall culdoplasty closes the redundant cul-de-sac and associated enterocele, provides apical support, and lengthens the vagina. In a randomized study, Cruikshank and Kovac8 demonstrated the superiority of McCall culdoplasty to uterosacral plication and simple peritoneal closure in the prevention of posthysterectomy enterocele. For this reason, we advocate using this procedure as a part of every vaginal hysterectomy, even in the absence of ente-rocele, to minimize future vaginal vault prolapse and ente-rocele formation. With posthysterectomy prolapse and enterocele, we may perform a modified, high McCall-type culdoplasty with a four-point attachment to the vaginal cuff.
The technique is as follows (Figure 8-4.2):
1. After the vaginal hysterectomy is completed, the surgeon places a finger into the posterior cul-de-sac to evaluate its depth and ensure accessibility of the uterosacral ligaments. Lateral traction is placed on the previously tagged uterosacral ligaments. In cases of posthys-terectomy prolapse, the enterocele is identified and entered as described above.
2. With the patient in Trendelenburg position, a large, moist pack is placed in the posterior cul-de-sac and hollow of the sacrum. A wide Deaver or Breisky-Navratil retractor is used to elevate the pack and the intestines out of the operative field.
3. The ischial spines are palpated. The remnants of uterosacral ligaments are found posterior and medial to the ischial spines. They can be identified more easily by using Allis or Kocher clamps attached to the vaginal epithelium at approximately 4 o'clock and 8 o'clock (at the old hysterectomy scar) to place tension on structures of the pelvic sidewall. The clamp is elevated straight upward placing tension on the uterosacral ligament. The contralateral index finger is simultaneously used to palpate the connective tissue condensations along the side of the pelvis (uterosacral ligaments). A long Allis clamp is placed high on each uterosacral ligament.
4. A stitch of delayed-absorbable No. 0 suture is taken on each side at the level of the Allis clamp on the uterosacral ligament and held for later passage out of the apex bilaterally. The needle is passed from lateral to medial to reduce the risk of ureteral entrapment. Next, a permanent No. 0 suture is passed through the uterosacral ligament as high as possible, cephalad to the previous stitch. Successive bites are then taken at 1- to 2-cm intervals through the anterior serosa of the sigmoid colon until the opposite uterosacral ligament is reached and incorporated. This suture is left untied. Occasionally, one to three more identical sutures are placed caudally, progressing toward the posterior vaginal cuff. The need for additional internal sutures depends on the size and depth of the enterocele or cul-de-sac. The goal is obliteration of the entire dependent portion of the cul-de-sac. After the internal permanent sutures have been placed, their ends are held laterally without tying.
5. A delayed-absorbable, No. 0 suture is placed from the vaginal lumen just below the middle of the cut edge of the posterior vaginal cuff, through the peritoneum, and through the left uterosacral ligament. Successive bites are taken across the cul-de-sac as before and into the right uterosacral ligament. This suture is passed through the peritoneum and vaginal epithelium, adjacent to the point of entry.
6. The permanent sutures are tied sequentially. A suture of delayed-absorbable, No. 0 suture is placed through the plicated uterosacral ligaments and held long, to be positioned in the anterior vaginal epithelium at the point of the new vault.
7. After the McCall sutures have been placed, the gauze pack and retractors are removed. Cystocele repair and/or bladder neck suspension or sling is performed as needed. The vaginal epithelium is trimmed as appropriate and the anterior vaginal wall closure is begun and carried to a point just short of the apex.
8. The lateral delayed-absorbable, No. 0 uterosacral sutures are then positioned bilaterally through the lateral apex. Next, the anterior delayed-absorbable, No. 0 McCall suture is positioned bilaterally through the anterior vaginal muscularis and epithelium just lateral to midline, at the level of the new apex. The anterior wall and apical closure is completed and all four delayed-absorbable, No. 0 suspension sutures are tied, bringing the anterior, posterior, and lateral vagina up to the level of the uterosacral ligaments.
9. Cystoscopy is performed after intravenous indigo carmine is given to inspect for bilateral ureteral patency after all sutures have been tied. Rectocele and perineal repair are completed as necessary.
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