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Reich modification of the McCall Culdeplasty to prevent and/or repair Prolapse during Total Laparoscopic Hysterectomy
 Reich modification of the McCall Culdeplasty to prevent and/or repair Prolapse during Total Laparoscopic Hysterectomy
INTRODUCTION
Laparoscopic surgery provides excellent visualization and magnification of pelvic structures, decreased post operative pain, and reduced hospitalization and recovery time. Laparoscopic vault suspension to restore Level I support can be attained by either the laparoscopic uterosacral ligament suspension techniques or via laparoscopic sacral colpopexy. The major drawback of the latter is the use of mesh. We prefer not using mesh.
Reich advocates doing a uterosacral ligament suspension as part of every total laparoscopic hysterectomy. Mesh is never used. The evolution from McCall’s original culdeplasty to its laparoscopic counterpart will be described, including methods to lessen the effects of a high cystocele on urinary retention.
Various laparoscopic techniques are described to prevent prolapse at the time of hysterectomy and to repair prolapse occurring after hysterectomy (DeLancey Level I support), without using mesh.
In 1957 McCall described repair of an enterocele at the time of vaginal hysterectomy. McCall reported on forty-five patients in his landmark paper and described no recurrence of enterocele. His technique describes using internal and external sutures. The internal sutures are nonabsorbable (described as silk, cotton, or linen) to obliterate the enterocele sac by taking bites of both uterosacrals and posterior peritoneum. More specifically, his first suture takes the left uterosacral ligament, then the enterocele sac “at intervals of 1-2 cm” until the right uterosacral is reached. Next, the suture passes through the right uterosacral ligament. This suture is left untied to help guide more similarly placed sutures above the first suture. The number of internal sutures depends on the size of the enterocele sac. These internal sutures are not tied until the external sutures are placed. Three external sutures are then placed. McCall inserted a “No. 1 catgut suture from the vaginal side just right of the midline of the vagina about 2 cm above its posterior cut edge”. Next the right uterosacral is taken, followed by the left uterosacral and out the vaginal wall at the same level as this suture was entered, but just left of the midline. The suture is not tied. Two more sutures are placed, each higher than the last. The top suture brings the vault to its highest level. Next the internal sutures are tied then the external sutures are tied. The peritoneum is closed in the usual fashion. McCall states that his method maintains vaginal length and does not narrow the vault as it obliterates the cul-de-sac.[i] [ii]
There have been several modifications to McCall’s original technique. The Mayo Clinic version, pioneered by Richard Symmonds, described a modified endopelvic fascia repair. A wedge of vaginal mucosa is excised from both the anterior and posterior wall to allow access to the lateral vaginal supports. After the enterocele is excised, one to three internal McCall sutures are placed. Next, external sutures are placed incorporating the posterior vaginal wall, cul-de-sac peritoneum, and uterosacral-cardinal ligament complex. More external sutures can be placed based on the length of the vault.[iii] [iv] [v] 15
Cruikshank and Kovac showed in a prospective clinical trial that a modified McCall culdoplasty that reattaches the uterosacral ligaments to the apex of the vaginal is very effective at preventing future apical defects. At three years, the incidence of apical defects in the McCall group was 6% versus 30% in the control group.[vi]
The McCall culdeplasty is a vaginal procedure. (By today’s terminology, culdeplasty is colpoplasty or culdoplasty). It was applied through an abdominal incision by Thomas Elkins with good results. Early experience with a total laparoscopic approach to hysterectomy was accompanied by various methods of cuff closure. These can be simplified into the traditional transverse cuff closure and the vertical cuff closure. The transverse closure should be accompanied by uterosacral ligament suspension on each side. The vertical closure almost always is done with a McCall type stitch, bringing the uterosacral ligaments together across the midline. We call this laparoscopic vertical closure a Laparoscopic high McCall Culdoplasty.
Reich adapted the McCall culdeplasty to laparoscopic hysterectomy surgery after listening to a lecture by Thomas Elkins in 1992, soon after he developed the concept of total laparoscopic hysterectomy. This technique addressed posterior vaginal wall and vault support, but failed to mention the frequently occurring high cystocele in the anterior vaginal wall that often results in urinary retention. By 1994, the high McCall technique had undergone major modifications per Reich to include the anterior vagina.
He notes four laparoscopic operations using this technique or its modifications. The first two are done at the time of hysterectomy and the last two are for post hysterectomy vaginal cuff prolapse or possible pathology of the cuff:
(1) prophylactic technique to prevent prolapse at time of hysterectomy (Laparoscopic high McCall {LHM})
(2) repair of prolapse or occult prolapse with urinary retention (high cystocele) at time of hysterectomy (Reich modification of HM)
(3) repair of vaginal cuff prolapse after hysterectomy (Reich modification of HM)
(4) post hysterectomy excision of vaginal cuff scar (endometriosis or adhesions) followed by elevation onto uterosacral ligaments for pain and/or dyspareunia (Reich modification of HM).
(1) Laparoscopic technique to prevent prolapse at the time of hysterectomy (TLH)
This procedure is indicated when minimal or no prolapse is present and the patient has no urinary complaints, especially retention related. It is considered a part of every total laparoscopic hysterectomy.
The vaginal delineator or a sponge packed in a glove is placed back into the vagina occluding it to maintain pneumoperitoneum for closure of the vaginal cuff. The uterosacral ligaments are identified by bipolar desiccation markings or with the aid of a rectal probe. The left uterosacral ligament is elevated and a 0-Vicryl suture on a CT-1 needle is placed through it using an oblique Cook needle holder. The suture is then placed through the left cardinal ligament, located at the posterolateral vagina just below the uterine vessels, then through the posterior peritoneum and rectovaginal fascia along the posterior vaginal epithelium, to and through the right posterolateral vagina and cardinal ligament to the right uterosacral ligament. This suture is tied extracorporeally and provides excellent support to the vaginal cuff apex, elevating it superiorly and posteriorly toward the hollow of the sacrum. The rest of the vagina and the overlyingpubocervicovesicularfascia are closed vertically with one or two 0-Vicryl interrupted sutures. In most cases the peritoneum is not closed.
Cystoscopy is routinely done after vaginal closure to assure ureteral patency, 8-10 minutes after intravenous administration of one ampule of Indigo Carmine dye. This is especially necessary when the ureter is identified but not dissected. Blue dye should be visualized through both ureteral orifices. The bladder wall should also be inspected for suture and thermal defects.
This technique for vaginal vault closure at the time of TLH has been used by Reich in all cases over the last 10 years, and no cuff prolapses have come to his attention.
(2) Repair of prolapse or occult prolapse with urinary retention (high cystocele) at total laparoscopic hysterectomy
Urinary retention may be present from a high cystocele adjacent to the cervix.
The symptoms of urinary retention are seldom volunteered by the patient seeking hysterectomy and should be ascertained by the physician during the history. Many patients will, however, describe the improvement in micturition at their post operative visit. The simple question is “Do you feel like you are completely emptying your bladder or do you feel that you still have to go after urinating?”
The technique to be described not only addresses the posterior wall, but the anterior wall as well. This method brings the anterior vagina much higher than the posterior wall. This procedure can be done during the same surgery following hysterectomy or in a patient with a previous hysterectomy. It is termed a “high McCall” suspension because after the first suture brings the uterosacral and cardinal ligaments and posterior vagina together in the midline, subsequent sutures, bring the lateral and anterior vagina onto the uterosacral ligaments working progressively towards the sacrum.
At the time of hysterectomy, after the uterus is removed, a vaginal delineator or probe is placed in the vagina to maintain pneumoperitoneum. Vaginal hemostasis is obtained until complete, so as to not be dependant on compression by sutures. The left uterosacral ligament and posterolateral vagina are elevated. Going from left to right using the same 0-Vicryl suture, it is placed through the left uterosacral ligament, then through the left cardinal ligament followed by posterior vaginal tissue including the rectovaginal fascia but excluding vaginal epithelium. The suture exits near the midline, then back through rectovaginal fascia and vagina on the right followed by the right cardinal ligament and right uterosacral ligament. Extracorporeal knot tying is done, pulling up the vaginal apex and elevating it both posteriorly and superiorly towards the hollow of the sacrum. The first suture is placed below the level of the uterine artery pedicle as the cardinal ligament is identified as the thick band of connective tissue beneath the ligated uterine vessels.
The second suture is placed through the uterosacral ligaments closer to the sacrum and the endopelvic fascia just above the uterine vessel pedicle. The third suture is placed well above the cardinal ligament and through the uterosacral ligaments even closer to the sacrum resulting in vaginal vertical closure. All sutures after the first use 0-Ethibond. The last suture is usually placed into anterior vagina above the cuff at 12 o’clock to bring the anterior vagina much higher than the posterior wall. The last suture also is placed at the highest level toward the sacral area. As with any suspension, special care must be taken to ensure the integrity of the rectum and ureters. The sutures must not constrict the rectum, which is identified throughout the procedure with a rectal probe inside it. This suspension achieves a physiologic position of the vagina. In addition, it provides the vagina with good depth since the vagina can go high towards the sacral region where the uterosacrals originate. The closure of the vagina in a vertical fashion avoids the ureters as the sutures stay in the midline. [vii] [viii]
Uterosacral ligaments are sometimes isolated before TLH by putting the flexed uterus on upward tension and placing a Vicryl suture around them near their sacral portion. These sutures can be left long to aid those surgeons more comfortable doing a LAVH. During LAVH, the suture can be pulled out with a finger and used with a free needle to attach the vaginal vault apex to the uterosacral ligaments.
(3) Repair of vaginal cuff prolapse after hysterectomy (Reich modification of HM).
Vaginal vault prolapse can usually be repaired by the technique described above.
(4) Post hysterectomy excision of vaginal cuff scar (endometriosis or adhesions). followed by elevation onto uterosacral ligaments for pain and/or dyspareunia (Reich modification of HM).
Some patients present with pain and discomfort without obvious prolapse. If the cuff is excised and elevated, many patients experiences relief of pain. The exact mechanism is unclear.
CONCLUSION
There are many different methods to address vaginal vault prolapse and reduce its incidence at the time of hysterectomy and thereafter. Whichever method is employed, it is important to remember the principals of anatomy to guide reconstruction. In order to repair prolapse, the pubocervical and rectovaginal fascia must be reapproximated to each other and to the cardinal-uterosacral complex at the level of the ischial spine, hopefully at the time of hysterectomy. Reich’s adaptation of the vaginal McCall culdeplasty addresses both the posterior and anterior wall near the vaginal apex. It brings the anterior vagina higher than the posterior wall. His application does not use mesh so as to minimize rejection and all the shortcomings of mesh. Although this chapter only addresses Level I DeLancey support procedures, it is important to understand that other compartment defects coexist. (Level I support provides the most superior suspension of the vagina by the cardinal uterosacral complex.) We understand the philosophy of Wattiez et al that a global approach to pelvic reconstruction must be instituted. In addition to Level I support defects, level II and III defects must also be addressed in the same procedure.[ix] Thus, because multiple compartment defects coexist, and this occurs in the majority of cases, it is important to repair all the pelvic floor defects concomitantly. But the future of mesh remains to be determined, and time and reimbursement issues for multiple procedures during the same operation will limit this approach in the immediate future, at least in the USA.
[i] McCall ML. Posterior Culdeplasty. Surgical correction of enterocele during vaginal hysterectomy; a preliminary report. Obstet Gyn 1957;10;6:595-602.
[ii] Karram MM, Kleeman SD. Vaginal vault prolapse: In Te Linde’s Operative Gynecology. 9th Ed.: Lippincott Williams & Wilkins: Philadelphia, 2003; 999-1020.
[iii] Symmonds RE, Pratt JH. Vaginal prolapse following hysterectomy. Am J Obstet Gyn 1960;79;5:899-909.
[iv] Symmonds RE, Williams TJ, Lee RA, Webb MJ. Posthysterectomy enterocele and vaginal vault prolapse. Am J Obstet Gyn. 1981;140;8:852-859.
[v] Lee AL, Symmonds RE. Surgical repair of posthysterectomy vault prolapse. Am J Obstet Gyn 1972;112:953-956.
[vi] Cruikshank SH, Kovac SR. Randomized comparison of three surgical methods used at the time of vaginal hysterectomy to prevent posterior enterocele. Am J Obstet Gynecol 1999;180:859-865.
[vii] Liu CY, Reich H. Correction of genital prolapse. J Endourol. 1996; 10;3;259-265.
[viii] Reich H, Vancaillie TG. Recent advances in laparoscopic hysterectomy and pelvic floor reconstruction. Surgical Technology International III.
[ix] Wattiez A, Mashiach R, Donoso M. Laparoscopic repair of vaginal vault prolapse 2003;15:315-319.
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