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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

Sacral Colpopexy

Sacral colpopexy is a surgical procedure designed for correction of prolapse of the vagina. It is an ideal procedure for those women who are sexually active but who have total prolapse of the vaginal canal. Prolapse of the vagina can occur following a hysterectomy or with the uterus in place. If the uterus is still in place and the patient is menopausal, it is best to remove it by a hysterectomy (Uterus) prior to performing sacral colpopexy, unless there are compelling reasons to leave it in situ. Sacral colpopexy is an alternative procedure to sacrospinous ligament suspension of the vagina (see Sacrospinous Ligament Suspension of the Vagina). In some clinics, sacral colpopexy is reserved for those patients who have recurrent prolapse following sacrospinous ligament suspension of the vagina, since sacral colpopexy involves a pelvic laparotomy, whereas the sacrospinous ligament suspension of the vagina can be performed through the vagina. To date, there are no prospective, randomized studies showing that one procedure is more efficacious than the other. Both procedures have their advocates.

The strap material used in the sacral colpopexy varies. There are some who prefer synthetic permanent mesh material made from Prolene (Marlex and Mersilene). We prefer the patient's own fascia. Our preference for the patient's own fascia (rectus fascia or fascia lata) stems from our desire to avoid the sequelae of putting a foreign body into or around the bacteria-contaminated vagina. The additional effort to obtain fascia lata or rectus fascia is small compared to the long-term sequelae of an infected foreign body.

Physiologic Changes.   Vaginal prolapse is an incapacitating and debilitating problem for women. The exposed vaginal mucosa can become ulcerated with associated bleeding and infections.

Replacing the vagina back into the pelvis in its proper anatomical configuration is important. The normal vagina is shaped somewhat like a backward hockey stick. The upper one-half to one-third of the vagina should tilt posteriorly back upon the rectum. If the surgeon creates a situation for the apex of the vagina to be in the midplane of the pelvis, intra-abdominal pressure will produce recurrent prolapse.

Points of Caution. Sacral colpopexy is not a difficult operation to perform. Several points need to be emphasized, however, if the procedure is to be done successfully.

First, after entering the abdomen, identification of the right ureter is vital. It should be mobilized and retracted laterally. The rectosigmoid colon should also be mobilized and retracted laterally.

The vascular plexus on the periosteum of the sacrum can be associated with copious bleeding if it is not properly managed.

The material used for the strap (natural fascia or synthetic mesh) should be of the proper length and width to support the apex of the vagina. The strap must be retroperitonealized and not cross the pelvis like a "clothesline." Such a situation is an invitation to internal herniation and incarceration of the small bowel, leading to obstruction and necrosis.


For the surgeon to harvest the fascia lata, the patient is placed in the lateral decubitus position with flexion of both the hips and knees at approximately 60°. A pillow should be placed between the knees to abduct the thigh until it is level. Two large pieces of tape are used to stabilize the patient and prevent her from moving to either side. The lateral thigh is prepped and draped. The solid line marks the site of the initial incision, and the dotted line marks the direction of the tunneled Masson fascia stripper.

The Masson fascia stripper consists of two hollow metal tubes-one inside, one outside. The inner tube has a narrow opening, "the eye," near one end; the edge of the outer tube is sharpened to allow cutting of the fascia strip at the desired level.

The incision is open; the base of the fascia strap is started by hand with a scalpel. The handle of the scalpel is used to perform blunt dissection of the fascia strap off its bed. The finger is used to tunnel underneath the subcutaneous fat on top of the fascia. The base of the strap should be 4 cm wide. At least 6 cm of the strap should be taken by the knife before applying the Masson stripper.

The Masson fascia stripper is moved into position. The strap that has been formed by sharp dissection is placed through the opening of the fascia stripper. Two straight Kocher clamps are placed across the strap, and a suture is placed adjacent to the Kocher clamps as a safety suture to retrieve the strap if it breaks and retracts up the thigh.

The surgeon retracts the Kocher clamps caudally as the Masson fascia stripper is advanced cephalad. A point is reached where the Masson fascia stripper will advance no farther. At that point, the surgeon unscrews the handle of the Masson fascia stripper and evulses the strap. The strap is brought out through the leg wound.

The fascia strap is shown. The suture at the end of the strap is removed.

The patient is changed to the dorsal lithotomy position. The prolapsed vagina is noted. Two Allis clamps are placed on the vaginal apex. If a hysterectomy has previously been performed, the suture line will be noted in the vaginal apex.

A midline incision-Pfannenstiel or midline-is made. The peritoneal cavity is entered.

After packing the bowel away with moist gauze, the surgeon identifies the right ureter and the rectosigmoid colon. An incision is made in the posterior peritoneum from the sacral promontory (P). This incision is carried down over the cul-de-sac and the vaginal apex. The vagina is replaced into the abdominal cavity by either a 4-cm obturator or a sponge stick held in an ovum forceps.

The fascia strap is sutured to the periosteum of the sacrum. Sutures should be placed into the periosteum of the sacrum and then brought through the fascia as shown here. Three to four sutures are placed. The distal end of the strap is sutured to the apex of the vagina. Three sutures are placed in the anterior vaginal wall with interrupted synthetic permanent sutures. The strap is placed over the dome of the vagina, and additional sutures are applied if needed. The cul-de-sac is obliterated by suturing the uterosacral ligaments in the midline.

The peritoneum is sutured over the strap to reperitonealize the pelvis and prevent the "clothesline" effect.

A sagittal view shows the suspension covered by the peritoneum. The strap is sutured to the periosteum of the sacrum and ultimately over the dome of the vaginal apex. The vagina should lie posteriorly over the rectosigmoid colon.

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