Normally, the vaginal axis in an erect woman is nearly horizontal in the upper half of the vagina, with the uterus and upper 3 or 4 cm of the vagina lying over the levator plate in the hollow of the sacrum (Fig. 21-1). Funt et al. (1978) found that the vagina is directed toward the S3 and S4 vertebras and extends approximately 3 cm past the ischial spines in most nulliparous women. Increases in intra-abdominal pressure compress the vagina anteriorly to posteriorly over the contracted levator muscles in the midline (levator plate). Diminished muscle tone may result in loss of stability of the levator plate, widening of the levator hiatus, and loss of an adequate base to support the upper vagina and uterus in the normal axis. Distortion of the normal vaginal axis during reconstructive pelvic surgery predisposes women to the development of pelvic organ prolapse at an anatomic site opposite to where the repair was performed. Examples of this are the development of posterior vaginal wall prolapse after colposuspension procedures for stress incontinence and the development of anterior vaginal wall prolapse after suspension of the vaginal apex to the sacrospinous ligament.

Figure 21-1 Normal vaginal axis of nulliparous woman in the standing position. Note that the upper third of the vagina is nearly horizontal and is directed toward the S3 and S4 sacral vertebras.

(From Funt MI, Thompson JD, Birch H. Normal vaginal axis. South Med J 1978;71:1534, with permission.)

Connective tissue defects have been found in women with uterine prolapse and stress incontinence. In several studies, Mädakinen et al. (1986), 1987) identified abnormal histologic changes in the pelvic connective tissue in 70% of women with uterine descent, compared with 20% of normal controls. Decreased cellularity (fibroblasts) and an increase in collagen fibers were observed. Ulmsten et al. (1987) reported 40% less total collagen in the skin and round ligaments of women with stress incontinence when compared with that of continent women. These studies and others suggest that abnormal connective tissue may be associated with pelvic organ prolapse and stress urinary incontinence.

PREVALENCE AND DEMOGRAPHICS

Because the prevalence of pelvic organ prolapse increases with age, the changing demographics of the world’s population will result in even more affected women. Based on projections from the U.S. Census Bureau, the number of American women age 65 and over will double in the next 25 years to more than 40 million women by 2030. One study by Luber et al. (2001) noted that the demand for health care services, related to pelvic floor disorders, will increase at twice the rate of the population itself.

Using data from a large U.S. Northwest health maintenance organization database, Olsen et al. (1997) reported the risks of pelvic organ prolapse or urinary incontinence surgery by age 80 as 11.1%. Surgery for pelvic organ prolapse with continence surgery (22%) or without (41%) accounted for 63% of this risk, or a lifetime risk of 7%. Boyles et al. (2003) reported that over a nearly 24-year period reviewed, the rate of procedures to correct prolapse decreased slightly, but not significantly, and that the surgical indication for approximately 7% to 14% of hysterectomies is listed as pelvic organ prolapse. Data from the U.S. National Hospital Discharge Survey (NHDS) indicate that approximately 200,000 women undergo surgery for pelvic organ prolapse annually. A study by Brown et al. (2002), using data from the NHDS for surgical rates, indicated that approximately 22.7 per 10,000 women had some form of pelvic organ prolapse surgery in a year. As expected, surgical rates vary with age peaking in the sixth decade, with an average age of surgery of 55 years. Racial differences were also reported, with Caucasian women having a threefold greater rate of pelvic organ prolapse surgery than African American women. Pelvic organ prolapse is common worldwide. Samuelsson et al. (1999) reported a prevalence of pelvic organ prolapse of 30.8% among Swedish women ages 20 to 59, with 2% having prolapse to the introitus. In the United Kingdom two hospitalizations per 1000 person-years for pelvic organ prolapse occur by age 60 (Mant et al., 1997). Sajan and Fikree (1999) reported that 19.1% of women in Pakistan who were under age 30 reported feeling symptoms of prolapse.

ENTEROCELE

Definition and Types

Enterocele is a hernia in which peritoneum and abdominal contents displace the vagina and may even be in contact with vaginal mucosa. The normal intervening endopelvic fascia is deficient or absent, and small bowel fills the hernia sac.

Generally, enteroceles have been divided into four types: congenital, traction, pulsion, and iatrogenic. Congenital enterocele is rare. Factors that may predispose to the development of congenital enterocele include neurologic disorders, such as spina bifida and connective tissue disorders. Traction enterocele occurs secondary to uterovaginal descent, and pulsion enterocele results from prolonged increases in intra-abdominal pressure. The two latter types of enterocele may coexist with apical vaginal prolapse, cystocele, or rectocele. Iatrogenic enterocele occurs after surgical procedures that elevate the normally horizontal vaginal axis toward a vertical direction; examples include colposuspension and needle urethropexy operations for stress incontinence, or hysterectomy, with or without repair, when the vaginal cuff and cul-de-sac are not managed effectively.

Clinically, enteroceles are best classified based on their anatomic location. Apical enteroceles herniate through the apex of the vagina, posterior enteroceles herniate posteriorly to the vaginal apex, and anterior enteroceles herniate anteriorly to the vaginal apex (Fig. 21-2).

Figure 21-2 Cross-section of pelvic floor showing various anatomic locations of enteroceles. A. Anterior enterocele—defect in the pubocervical fascia near its attachment to the vaginal apex. The peritoneal sac with its contents protrudes anterior to the vaginal cuff. B. Apical enterocele—defect at the vaginal apex; the peritoneal sac protrudes between the pubocervical fascia anterior and the rectovaginal fascia posterior. C. Posterior enterocele—defect posterior to the vaginal cuff. The peritoneal sac protrudes through the defect in rectovaginal fascia, posterior to the vaginal cuff.

Diagnosis

Enteroceles may commonly occur in association with rectocele and/or cystocele. When these hernias coexist with rectoceles, the rectovaginal examination may demonstrate the rectocele as distinct from the bulging sac that arises from a higher point in the vagina. Visual inspection of the posterior vaginal wall may reveal a transverse furrow between the two hernias. However, in many posthysterectomy prolapse patients, it is difficult to preoperatively determine whether an enterocele sac coexists with a large rectocele or cystocele. For this reason, in cases of advanced anterior or posterior vaginal wall prolapse, the surgeon should attempt to determine whether a portion of the prolapse is secondary to an enterocele. This should include routine dissection of the vagina from its underlying structures all the way to the apex of the vagina. The enterocele sac can usually be visually or digitally identified as a sac of peritoneum separate and distinct from the wall of the bladder or rectum. At times, a finger in the rectum or retrograde filling of the bladder may assist the surgeon in safely isolating and entering an enterocele sac.

Surgical Repair Techniques

Surgical repair of enterocele can be performed vaginally or abdominally. No data exist comparing the various types of repairs. The approach and type of procedure performed depend on the surgeon’s preference and whether there is concomitant vaginal or abdominal pathology. Vaginal surgical techniques described herein are the traditional vaginal enterocele repair and the McCall culdoplasty, and abdominal approaches discussed include the Moschcowitz procedure, Halban procedure, and uterosacral ligament plication.

VAGINAL ENTEROCELE REPAIR

Patients rarely have an isolated enterocele; hence, concurrent vaginal vault suspension, with or without cystocele and rectocele repair, is often necessary. The technique of vaginal repair of an apical or posterior enterocele is as follows:

1. The patient is positioned as for a posterior colporrhaphy. A midline posterior vaginal wall incision is made over the enterocele sac up to the vaginal apex and extended to the perineum, if a rectocele is also present. Dissection of the posterior vaginal wall from the enterocele sac, the anterior rectal wall, and the rectovaginal fascia is accomplished sharply and bluntly. The dissection should extend laterally to the medial margins of the levator ani muscles (Fig. 21-3, A).

2. The enterocele sac should be mobilized from the vaginal walls and rectum. When the enterocele sac is difficult to distinguish from the anterior rectum, differentiation is aided by a rectal examination with simultaneous dissection of the enterocele sac from the anterior rectal wall (Fig. 21-3, B). At times, distinguishing the enterocele sac from a large cystocele may prove difficult. In this situation, placement of a probe into the bladder or transillumination with a cystoscope may prove helpful.

3. After the enterocele sac has been dissected from the vagina and rectum, traction is placed on it with two Allis clamps and the sac is entered sharply (Fig. 21-3, C). The enterocele sac is explored digitally to ensure that no small bowel or omental adhesions are present (Fig. 21-3, D); if encountered, they are dissected to the level of its neck.

4. Under direct visualization, two or three circumferential, nonabsorbable, purse-string sutures are used to close the enterocele sac (Fig. 21-3, E). The cardinal-uterosacral ligaments are incorporated as well. Once placed, the sutures are tied in sequence. Care should be taken to avoid kinking the ureter.

5. Posterior colporrhaphy and vaginal vault suspension are performed as indicated (Fig. 21-3, F).

Figure 21-3 Dissection and vaginal repair of enterocele. A. The enterocele sac has been completely mobilized of the vaginal epithelium. B. A finger in the rectum facilitates sharp dissection of the enterocele sac off the anterior wall of the rectum. C. The enterocele sac is sharply entered. D. The peritoneum has been excised and the cul-de-sac is exposed. E. A series of purse-string sutures incorporating the distal ends of the uterosacral ligaments are placed to close the defect at its neck. F. The vaginal apex is attached to the plicated uterosacral ligaments.

MCCALL CULDOPLASTY

McCall (1957) described the technique of surgical correction of enterocele and a deep cul-de-sac at the time of vaginal hysterectomy. The advantage of the McCall culdoplasty is that it not only closes the redundant cul-de-sac and associated enterocele but also provides apical support and lengthening of the vagina. Many authors advocate using this procedure as part of every vaginal hysterectomy, even in the absence of enterocele, to minimize future hernia formation and vaginal vault prolapse.

The technique is as follows (Fig. 21-4):

1. After the vaginal hysterectomy is completed, the surgeon places a finger into the posterior cul-de-sac to evaluate vaginal depth. Lateral traction is placed on the previously tagged uterosacral ligaments.

2. With the patient in Trendelenburg’s position, a large pack is placed intraperitoneally to prevent descent of the omentum or bowel into the field. A permanent suture is initially passed through one uterosacral ligament as high as possible. Successive bites are then taken at 1- to 2-cm intervals through the anterior serosa of the bowel, until the opposite uterosacral ligament is reached. This suture is left untied, and successive identical sutures are placed as needed, progressing toward the posterior vaginal cuff. The number of internal McCall sutures placed 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.

3. After all of the internal permanent sutures have been placed and their ends held laterally without tying, one or two sutures of delayed absorbable No. 0 suture are placed. These are inserted from the vaginal lumen just below the middle of the cut edge of the posterior vaginal cuff, through the peritoneum, and through the right uterosacral ligament. Successive bites are taken across the cul-de-sac as before and into the left uterosacral ligament. This suture is passed through the peritoneum and vaginal epithelium, adjacent to the point of entry.

4. The permanent sutures are tied in sequence. The vaginal cuff is then closed. Finally, the delayed absorbable sutures are tied in a manner to bring the posterior vagina up to the level of the uterosacral ligaments.

Figure 21-4 McCall culdoplasty technique. Internal and external McCall sutures are placed. The lowest suture (external McCall) incorporates the posterior vaginal wall, providing additional support.

The complications as reported by Given (1985) after McCall culdoplasty are shown in Table 21-1. He reported ureteral injury in 1 of 48 McCall culdoplasty procedures. Stanhope et al. (1991) also found that culdoplasty sutures were implicated in ureteral obstruction after vaginal surgery. To ensure ureteral patency, cystoscopy should be routinely considered after the McCall culdoplasty.

Table 21-1 Complications After McCall Culdoplasty ^*

Complication	Percent of Patients (N = 48)
Removal of silk suture	10
Postoperative cuff infection	4
High rectocele	4
Partial prolapse of vaginal vault	4
Shortened vagina	4
Introital stenosis	2
Pulmonary emboli	2
Nerve palsy	2
Ureteral obstruction	2

* Follow-up was 2 to 22 (average 7) years.

From Given FT. “Posterior culdeplasty”: revisited. Am J Obstet Gynecol 1985;153:135, with permission.

When there is excessive redundancy of the posterior vaginal wall and peritoneum, a modification of the McCall culdoplasty, in which a wedge of posterior vaginal wall and peritoneum is excised, can be considered (Fig. 21-5).

Figure 21-5 Modified McCall culdoplasty. A. The cul-de-sac is digitally palpated, and excessive peritoneum and posterior vaginal wall are noted. B. A wedge of tissue (dotted line), which includes full thickness vaginal wall and peritoneum, is excised to decrease the caliber of the upper portion of the posterior vaginal wall. C. External McCall stitches are placed in a traditional fashion. D. Tying of these sutures obliterates the cul-de-sac, supports the vaginal cuff, and increases posterior vaginal wall length.

ABDOMINAL ENTEROCELE REPAIRS

Three techniques of abdominal enterocele repair have been described: Moschcowitz and Halban procedures and the uterosacral ligament plication. The Moschcowitz procedure is performed by placing concentric purse-string sutures around the cul-de-sac to include the posterior vaginal wall, the right pelvic side wall, the serosa of the sigmoid, and the left pelvic side wall (Fig. 21-6, A). The initial suture is placed at the base of the cul-de-sac. Usually, three or four sutures completely obliterate the cul-de-sac. The purse-string sutures are tied so that no small defects remain that could entrap small bowel or lead to enterocele recurrence. Care should be taken not to include the ureter in the purse-string sutures or to allow the ureter to be kinked medially when tying the sutures.

Figure 21-6 Techniques of enterocele repair via the abdominal route. A. Moschcowitz procedure. B. Halban procedure. C. Uterosacral ligament plication.

Halban described a technique to obliterate the cul-de-sac using sutures placed sagittally between the uterosacral ligaments. Four or five sutures are placed sequentially in a longitudinal fashion through the serosa of the sigmoid, into the deep peritoneum of the cul-de-sac, and up the posterior vaginal wall (Fig. 21-6, B). The sutures are tied, obliterating the cul-de-sac.

Transverse plication of the uterosacral ligaments can be used to obliterate the cul-de-sac (Fig. 21-6, C). Three to five sutures are placed into the medial portion of one uterosacral ligament, into the back wall of the vagina, and into the medial portion of the opposite uterosacral ligament. The lowest suture incorporates the anterior rectal serosa to bring the rectum adjacent to the uterosacral ligaments and vagina. Care must be taken to avoid entrapment or kinking of the ureter. Relaxing incisions can be made in the peritoneum lateral to the uterosacral ligaments to release the ureters, if necessary.

VAGINAL PROCEDURES THAT SUSPEND THE APEX

When mild forms of isolated uterovaginal prolapse (descent of the cervix not beyond the midportion of the vagina) are present, vaginal hysterectomy and culdoplasty, with anterior and posterior colporrhaphy, are usually sufficient to relieve the patient’s symptoms and restore normal vaginal function. However, more severe apical prolapse requires separate operations to re-suspend the apex. In Figure 21-7, A an isolated apical enterocele is shown with a wells-supported anterior and posterior vaginal walls. In such a case, no formal vaginal vault suspension is necessary because simple excision and closure of the enterocele sac will result in a well-supported vagina of adequate length. As more of the anterior and posterior vaginal walls become everted, the more complex the repair becomes (Fig. 21-7, B, C).

Figure 21-7 Various degrees of vaginal vault eversion. A. Isolated enterocele with well-supported anterior and posterior vaginal walls. Note that surgical repair would only require excision of the sac and closure of the defect because the vaginal cuff is already at the level of the ischial spine. B. Note that vaginal cuff is at −4.5 cm; thus, surgical repair should ideally require suspension of vaginal cuff to or above the level of the ischial spine. C. Note complete eversion of the vagina, with the vaginal cuff prolapsed well beyond the hymen; also note coexistent cystocele and rectocele. Surgical repair becomes much more complicated if the goal is to create a well-supported vagina of sufficient length.

Sacrospinous Ligament Suspension

SURGICAL ANATOMY

To perform this procedure correctly and safely, the surgeon must be familiar with pararectal anatomy as well as the anatomy of the sacrospinous ligament and its surrounding structures (Fig. 21-8).

Figure 21-8 Close-up view of the coccygeus-sacrospinus complex to demonstrate close proximity of various nerves and blood vessels.

The sacrospinous ligaments extend from the ischial spines on each side to the lower portion of the sacrum and coccyx. Nichols and Randall (1989) described the sacrospinous ligament as a cordlike structure lying within the substance of the coccygeus muscle. However, the fibromuscular coccygeus muscle and sacrospinous ligament are basically the same structure and thus called the coccygeus-sacrospinous ligament (C-SSL). The coccygeus muscle has a large fibrous component that is present throughout the body of the muscle and on the anterior surface, where it appears as white ridges. The C-SSL can be identified by palpating the ischial spine and tracing posteriorly and medially the flat triangular thickening to the sacrum The fibromuscular coccygeus is attached directly to the underlying sacrotuberous ligament.

Posterior to the C-SSL and sacrotuberous ligament are the gluteus maximus muscle and the fat of the ischiorectal fossa. The pudendal nerves and vessels lie directly posterior to the ischial spine. The sciatic nerve lies superiorly and laterally to the C-SSL. Also superiorly lies an abundant vascular supply that includes inferior gluteal vessels and hypogastric venous plexus.

SURGICAL TECHNIQUE

Before this operation is initiated, one should have preoperatively recognized the ischial spine and C-SSL on pelvic examination. Preoperative estrogen replacement therapy should be given liberally, if appropriate. We prefer to use a preoperative vaginal estrogen cream for 4 to 6 weeks.

The performance of this operation almost always requires simultaneous correction of the anterior and posterior vaginal walls and enterocele repair. Displacing the prolapsed vaginal apex to the sacrospinous ligament to see whether the anterior and posterior vaginal wall prolapse disappears with a Valsalva maneuver helps determine whether cystocele and rectocele repairs are needed. The patient should be consented routinely for these repairs because many times it is difficult preoperatively to discern the extent of the various defects.

The technique of unilateral sacrospinous fixation is as follows:

1. With the patient in dorsal lithotomy position, the vaginal area is prepped and draped. Prophylactic perioperative antibiotics are given routinely.

2. The apex of the vagina is grasped with two Allis clamps, and downward traction is used to determine the extent of the vaginal prolapse and associated pelvic support defects. The vaginal apex is then reduced to the sacrospinous ligament intended to be used. Although bilateral sacrospinous fixations have been described, most surgeons prefer unilateral fixation of the vaginal vault. At times, the apex of the vagina is foreshortened and will not reach the intended area of fixation. This is commonly associated with a shortened anterior vaginal wall and a prominent enterocele. The apex should be moved to a portion of the vaginal wall over the enterocele, thus allowing sufficient vaginal length for suspension to the sacrospinous ligament. The intended apex is tagged with two sutures for its later identification.

3. If the patient has complete eversion of the vagina and requires anterior vaginal wall repair and/or bladder neck suspension, we prefer doing this portion of the operation first. During this procedure, one can separate the bladder base away from the vaginal apex, thus lowering the risk of cystotomy. After these procedures are completed, the anterior vaginal wall is closed with a continuous running suture.

4. The posterior vaginal wall is then incised. After a transverse perineal incision, a midline posterior vaginal wall incision is made just short of the apex of the vagina, leaving a small vaginal bridge approximately 3 or 4 cm wide. In the majority of cases, an enterocele sac is present. This sac should be dissected off the posterior vaginal wall and closed with a high purse-string suture, as previously described (see Fig. 21-3). Once the enterocele has been incised and ligated, one is ready to begin the sacrospinous fixation.

5. The first step is entry into the perirectal space. The right rectal pillar separates the rectovaginal space from the right perirectal space. The rectal pillar is areolar tissue that extends from the rectum to the arcus tendineus fasciae pelvis and overlies the levator muscle. It has two layers and may contain a few small muscle fibers and blood vessels. In the majority of cases, entry into the perirectal space is best achieved by breaking through the fibroareolar tissue just lateral to the enterocele sac at the level of the ischial spine. This maneuver can usually be accomplished bluntly by mobilizing the rectum medially. At times, however, the use of gauze on the index finger or a tonsil clamp is necessary to break through into this space.

6. Once the perirectal space is entered, the ischial spine is identified and, with dorsal and medial movement of the fingers, the C-SSL is palpated.

7. Blunt dissection is used to further remove tissue from this area. The surgeon should take great care to ensure that the rectum is adequately retracted medially. At this time, we recommend performing a rectal examination to ensure that no inadvertent rectal injury has occurred.

8. Two techniques have been popularized for the actual passage of sutures through the ligament (Fig. 21-9). The first is the technique of Randall and Nichols (1971), using a long-handled Deschamps ligature carrier and nerve hook (Fig. 21-10, A). Long, straight retractors are used to expose the coccygeus muscle. Heaney retractors or Breisky-Navratil retractors (Fig. 21-10, B) are preferred. One must take great care not to let the tip of the retractor be pushed across the anterior surface of the sacrum, risking potential damage to vessels and nerves. If the right sacrospinous ligament is to be used, the middle and index fingers on the left hand are placed on the medial surface of the ischial spine and, under direct vision, the tip of the ligature carrier penetrates the C-SSL at a point two fingerbreadths medial to the ischial spine. When pushing the ligature carrier through the body of the C-SSL, considerable resistance should be encountered; this must be overcome by forceful yet controlled rotation of the handle of the ligature carrier. If visualization of the C-SSL is difficult, the muscle and ligament can be grasped in the tip of a long Babcock or Allis clamp, which helps isolate the tissue to be sutured from underlying vessels and nerves. After suture passage, the fingers of the left hand are withdrawn. The retractor is suitably repositioned, and the tip of the ligature carrier is visualized. The suture is then grasped with a nerve hook (see Fig. 21-10, A). A second suture is similarly placed 1 cm medial to the first. To avoid a second passage of the ligature carrier, the original long suture can be cut in the center and each end of the cut loop paired with its respective free suture. This obtains two sutures through the ligament, with only one penetration of the ligature carrier. To ensure that an appropriate bite of tissue has been obtained, one should be able to gently move the patient with traction of the sutures.