CHAPTER 41 Weakness in the support of the cervix or the vaginal vault can lead to uterovaginal prolapse or posthysterectomy vault prolapse. These defects are usually associated with an enterocele, a defect that results in attenuation or breakage of the rectovaginal or pubocervical fascia and thus allows the peritoneum to come into direct contact with the vaginal epithelium. The posterior cul-de-sac (Fig. 41–1) should be addressed routinely when abdominal hysterectomy is performed, as well as in selected cases of retropubic urethropexy. At the time of abdominal hysterectomy, it is important to reconnect the vaginal vault to the cardinal uterosacral ligament complex (Fig. 41–2). Also, the continuity of the pelvic floor must be reinstated by approximating the fascia of the anterior vaginal wall (Figs. 41–3 and 41–4) to the fascia of the posterior vaginal wall (Fig. 41–5). Three techniques of abdominal enterocele repair have been described: the Moschcowitz and Halban procedures and 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 sidewall, the serosa of the sigmoid, and the left pelvic sidewall (Figs. 41–6 and 41–7). 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 the sutures are tied. Halban described his technique to obliterate the cul-de-sac by using sutures placed sagittally between the uterosacral ligaments. Four or five sutures are placed in a longitudinal fashion sequentially through the serosa of the sigmoid, into the deep peritoneum of the cul-de-sac, and up the posterior vaginal wall (Figs. 41–8 through 41–10
Abdominal Enterocele Repair
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