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Vagina and Urethra

Anterior Repair and Kelly Plication
Site Specific Posterior Repair
Sacrospinous Ligament Suspension of the Vagina
Vaginal Repair of Enterocele
Vaginal Evisceration
Excision of Transverse Vaginal Septum
Correction of Double-Barreled Vagina
Incision and Drainage of Pelvic Abscess via the Vaginal Route
Sacral Colpoplexy
Le Fort Operation
Vesicovaginal Fistula Repair
Transposition of Island Skin Flap for Repair of Vesicovaginal Fistula
McIndoe Vaginoplasty for Neovagina
Rectovaginal Fistula Repair
Reconstruction of the Urethra
Marsupialization of a Suburethral Diverticulum by the Spence Operation
Suburethral Diverticulum via the Double-Breasted Closure Technique           
Urethrovaginal Fistula Repair via the Double-Breasted Closure Technique
Goebell-Stoeckel Fascia Lata Sling Operation for Urinary Incontinence
Transection of Goebell-Stoeckel Fascia Strap
Rectovaginal Fistula Repair via Musset-Poitout-Noble Perineotomy

Sigmoid Neovagina

Watkins Interposition Operation

Le Fort Operation

The Le Fort operation is an excellent procedure for complete prolapse in elderly women who have had adequate sexual counseling and who under no circumstances expect to have intercourse in the future. Failure or recurrent prolapse after the procedure is extremely rare.  If the procedure removes excessive anterior vaginal wall, however, the urethrovesical angle may be brought down to the posterior fourchette, and some patients will have either stress or overflow incontinence of urine. To avoid this problem, we have modified the operation to include the upper two-thirds of the vagina but not the lower third of the anterior vaginal wall. Although a slight urethrocele may remain, this generally causes no discomfort to the patient and at the same time reduces the incidence of postoperative urinary incontinence.

Physiologic Changes. The vagina is obliterated except for two small drainage canals on the lateral side for discharge of vaginal mucus. Sexual intercourse is not possible after this operation.

Points of Caution. Possible pitfalls of the procedure include (1) failure to adequately dissect the anterior vaginal mucosa off the pubovesical cervical fascia and inadvertently entering the bladder or (2) penetrating the perirectal fascia and entering the rectum. Care must be exercised in placing the sutures in the pubovesical cervical fascia anteriorly and the perirectal fascia posteriorly in order not to penetrate the bladder or rectum.


The patient is placed in the dorsal lithotomy position and carefully examined under anesthesia. The vulva and perineum are prepped and draped.

The labia are anchored laterally with interrupted 2-0 synthetic absorbable suture.

The cervix is grasped with a Jacobs tenaculum and prolapsed from the vagina. A brilliant green marking pen is used to outline the area of the anterior vaginal mucosa that is to be undermined and removed.

In a similar manner, a brilliant green marking pen is used to outline the posterior vaginal mucosa.

With a scalpel, the posterior vaginal mucosa is incised transversely at its junction with the cervix.

The blades of curved Mayo scissors are inserted underneath the posterior vaginal mucosa and on top of the perirectal fascia, and the vaginal mucosa is freed to the lateral margins of the marked area.

The posterior vaginal mucosa is then cut along the prescribed marking lines with curved Mayo scissors and removed.


A similar transverse incision is made in the anterior vaginal mucosa at its junction with the cervix. The blades of curved Mayo scissors are inserted underneath the anterior vaginal mucosa to dissect laterally and upward toward the urethral meatus until the limits of the marked area are reached. This procedure is facilitated if traction is held on the Jacobs tenaculum.

The anterior vaginal mucosa is removed from the underlying pubovesical cervical fascia.


The surgeon progressively approximates the pubovesical cervical fascia anteriorly and the perirectal fascia posteriorly with Lembert inverting sutures.

When this suture is tied, a tunnel is created along each lateral margin for drainage of cervical mucus, thereby preventing the formation of mucocele. The cross section underneath Figure 11 demonstrates how this tunnel is formed.

Several sutures are placed in a similar manner to complete the tunnel.

Lembert 0 absorbable sutures are placed from the pubovesical cervical fascia anteriorly to the perirectal fascia posteriorly over the portio of the cervix.

After several of these sutures have been placed, the surgeon inverts the portio of the cervix.

After several rows of sutures have been completed, the cervix is totally inverted, and the pubovesical cervical fascia anteriorly and the perirectal fascia posteriorly are plicated.

A final row of 0 synthetic absorbable sutures is placed between the remaining vaginal mucosa anteriorly and posteriorly. Note that a small wire probe can be inserted into the tunnel laterally on each side.

The vaginal mucosal sutures are completed. Note that the urethra and the urethrovesical angle are not included in the procedure and are not sutured to the posterior fourchette. Such a procedure would distort the urethrovesical angle and in many cases lead to postoperative urinary incontinence.

Although the finished operation leaves the patient with a slight urethrocele or bulge, the surgeon should make no attempt to close off the entire vagina.

Copyright - all rights reserved / Clifford R. Wheeless, Jr., M.D. and Marcella L. Roenneburg, M.D.
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