Vaginal Repair of Enterocele

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.

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, which are very rare, herniate anterior to the vaginal apex ( Fig. 25.2 A – C ).

Cross-section of the pelvic floor showing various anatomic locations of enteroceles. A , Anterior enterocele , a 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 , a defect at the vaginal apex; the peritoneal sac protrudes between the pubocervical fascia anterior and the rectovaginal fascia posterior. C , Posterior enterocele , a defect posterior to the vaginal cuff. The peritoneal sac protrudes through the defect in rectovaginal fascia posterior to the vaginal cuff.

Most apical prolapse after hysterectomy occurs with apical or posterior enterocele and almost always occurs in association with a 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 patients with prolapse after hysterectomy, 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.

Patients rarely have an isolated enterocele; hence, concurrent vaginal vault suspension, with cystocele and rectocele repair, is often necessary. Figure 25.3 A shows an isolated apical enterocele with well-supported anterior and posterior vaginal walls. In such a case, no formal vaginal apex suspension is necessary because simple excision and closure of the enterocele sac results 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. 25.3 B and C ). 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; it is extended to the perineum if a rectocele is also present. The posterior vaginal wall is dissected off the enterocele sac and the anterior rectal wall. The dissection should extend laterally to the medial margins of the levator ani muscles ( Fig. 25.4 A ).

  
  

  
  

  
  

  

  
  

  
  

  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.

  
  
  
  
• 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. 25.4 B ). At times, distinguishing the enterocele sac from a large cystocele may prove difficult. In this situation, placing a probe into the bladder or transilluminating the area 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 peritoneal sac is entered sharply ( Fig. 25.4 C ). The enterocele sac is explored digitally to ensure that no small bowel or omental adhesions are present ( Fig. 25.4 D ); if encountered, they are dissected back to the level of its neck.

  
  
• 4.
  

  At this point the surgeon must choose the technique that will be used to address the enterocele and suspend the vaginal vault. The factors that influence this decision include the extent of the prolapse and whether an intraperitoneal or extraperitoneal suspension is to be performed. The enterocele should be closed if the enterocele is an isolated prolapse (which is a relatively rare situation) or an extraperitoneal vaginal vault suspension is to be performed. Under direct visualization, two or three circumferential, nonabsorbable, purse-string sutures are used to close the enterocele sac ( Fig. 25.4 E ). The cardinal-uterosacral ligaments are incorporated in these purse-string sutures. Once placed, the sutures are tied in sequence. Care should be taken to avoid kinking the ureter.

  
  
• 5.
  

  Posterior colporrhaphy and vaginal apex suspension are performed as indicated ( Fig. 25.4 F ).

Various degrees of vaginal apex 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 coexisting cystocele and rectocele. Surgical repair becomes much more complicated if the goal is to create a well-supported vagina of sufficient length.

McCall Culdoplasty

When mild forms of uterovaginal prolapse are present, vaginal hysterectomy and culdoplasty with appropriate vaginal repairs are usually sufficient to relieve the patient’s symptoms and restore normal vaginal function. described a technique for the 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. 25.5 ).

• 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 the Trendelenburg position, a large pack is placed intraperitoneally to prevent the omentum or bowel from descending into the field. A permanent suture is initially passed through one uterosacral ligament as high as possible. Successive bites at 1- to 2-cm intervals then are taken 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 delayed absorbable No. 0 sutures 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. As described in step 2, successive bites are taken across the cul-de-sac 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 then is closed. Finally, the delayed absorbable sutures are tied in a manner that brings the posterior vagina up to the level of the uterosacral ligaments.

  
  
• 5.
  

  Cystoscopy is performed to assure ureteral patency.

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

(Illustration by Ross Papalardo. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2012–2013. All rights reserved. From Walters MD, Ridgeway BM. Surgical treatment of vaginal apex prolapse. Obstet Gynecol . 2013;121(2 pt 1):354.)

Modified McCall Culdoplasty (Endopelvic Fascia Repair)

Between 1952 and 1981, two groups of investigators performed a total of 367 surgeries for vaginal eversion by suturing the prolapsed vagina to the endopelvic fascia ( ). more recently reported 660 women who underwent primary endopelvic fascia repair for vault prolapse after hysterectomy between 1976 and 1987. The technique of this repair is as follows.

• 1.
  

  An elliptical wedge of vaginal mucosa is excised initially from the anterior and posterior walls of the prolapsed vagina to narrow the vault and allow access to the lateral apical supports of the vagina and rectum. The width and length of the excised wedge are determined by the desired dimensions of the reconstructed vagina.

  
  
• 2.
  

  The enterocele sac is isolated and excised, and the ureters are identified by palpation or dissection.

  
  
• 3.
  

  Up to three modified McCall stitches are placed (see Fig. 25.6 ). Each suture incorporates the full thickness of the posterior vaginal wall, the cul-de-sac peritoneum, the remains of the uterosacral–cardinal complex laterally, and the fascial tissue lateral and posterior to the upper vagina and rectum.

  
  

  
  

  
  

  

  
  

  
  

  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 these sutures obliterates the cul-de-sac, supports the vaginal cuff, and increases posterior vaginal wall length.

  
  
  
  
• 4.
  

  Sutures then are tied, resulting in fixation of the prolapsed vaginal vault to the uppermost portion of the endopelvic fascia as well as high closure of the cul-de-sac peritoneum.

  
  
• 5.
  

  Cystoscopy after intravenous injection of indigo carmine is recommended to document bilateral ureteral patency.

Uterosacral Ligament Colpopexy

A popular transvaginal approach to the management of apical prolapse is bilateral uterosacral ligament colpopexy. The procedure is based on the anatomic observations of , who believed that the connective tissue of the vaginal tube does not stretch or attenuate but rather breaks at specific definable points. In the authors’ opinion these repairs have advantages over extraperitoneal repairs in that the surgery can be tailored to the amount of prolapse present, with more advanced amounts of prolapse requiring higher placement of sutures ( Fig. 25.7 ), and it suspends the apex of the vagina into the hollow of the sacrum and thus does not create any significant distortion of the vaginal axis. While the procedure can be performed abdominally or laparoscopically, the transvaginal route is most common.

• 1.
  

  The vaginal apex is grasped with two Allis clamps ( Fig. 25.8 A ) and incised with a scalpel. The vaginal epithelium is dissected off the enterocele sac up to the neck of the hernia. The enterocele is opened, and the hernia sac is excised ( Fig. 25.8 B ). If intraperitoneal access cannot be obtained, one may consider an extraperitoneal uterosacral ligament colpopexy; however, in such a situation we prefer to proceed with either a sacrospinous or ileococcygeus suspension.

  
  

  
  

  
  

  

  
  

  
  

  

  
  

  
  

  Technique for high uterosacral vaginal vault suspension. A , The most prominent portion of the prolapsed vaginal vault is grasped with Allis clamps. B , The vaginal wall is opened, and the enterocele sac is identified and entered. C , The bowel is backed high up into the pelvis using laparotomy sponges. The retractor lifts the sponges up out of the lower pelvis, thus completely exposing the cul-de-sac. When appropriate downward traction is applied on the uterosacral ligaments with an Allis clamp, the uterosacral ligaments are easily palpated bilaterally. D , Delayed absorbable sutures are passed through the uppermost portion of the uterosacral ligaments on each side and are individually tagged. E , Each end of the previously passed sutures is brought out through the posterior peritoneum and the posterior vaginal wall. A free needle is used to pass both ends of these delayed absorbable sutures through the full thickness of the vaginal wall. F , The anterior colporrhaphy is begun by initiating a dissection between the prolapsed bladder and the anterior vaginal wall. G , The anterior colporrhaphy has been completed. H , The vagina has been appropriately trimmed and closed with interrupted or continuous delayed absorbable sutures. After closing the vagina, the delayed absorbable sutures that were previously brought out through the full thickness of the posterior vaginal wall are tied, thereby elevating the prolapsed vaginal vault high up into the hollow of the sacrum.

  
  

  (From Baggish MS, Karram MM. Vaginal repair of vaginal vault prolapse. In: Atlas of Pelvic Anatomy and Gynecologic Surgery . 3rd ed. Saunders: St. Louis; 2011:713-714.)

  
  
  
  
• 2.
  

  Several moist tail sponges are placed in the posterior cul-de-sac. A wide Deaver retractor is used to elevate the packs and the intestines out of the operative field.

  
  
• 3.
  

  The ischial spines are palpated transperitoneally. The remnants of the uterosacral ligaments are found posterior and medial to the ischial spine, and the ureter can sometimes be palpated or visualized along the pelvic side wall, anywhere from 2 to 5 cm ventral and lateral to the ischial spine.

  
  
• 4.
  

  Traction on Allis clamps placed at approximately the 5 o’clock and 7 o’clock positions allows palpation of the uterosacral ligaments ( Fig. 25.8 C ). One end of the Allis clamp should be intraperitoneal and the other in the lumen of the vagina.

  
  
• 5.
  

  Usually, two to three delayed absorbable sutures are passed through the ligament on each side. To ensure adequate vaginal length, the highest suture should be close to the level of the ischial spine ( Fig. 25.8 D ). When placed slightly medial and cephalad to the ischial spine the needle may, via a transperitoneal approach, penetrate a portion of the coccygeus–sacrospinous ligament (C-SSL) complex ( Fig. 25.7 ).

  
  
• 6.
  

  In situations where the cul-de-sac is very deep and wide, internal McCall-type sutures can be placed, plicating the distal remnants of the uterosacral ligaments across the midline. However, we believe this is rarely indicated.

  
  
• 7.
  

  The delayed absorbable sutures that had been passed high up through the uterosacral ligaments then are passed either through the full thickness of the posterior vaginal wall ( Fig. 25.8 E ) or through the full thickness of both the anterior and posterior vaginal walls ( Fig. 25.9 ).

  
  

  
  

  
  

  

  
  

  
  

  Uterosacral ligament colpopexy. A , The uterosacral ligament at about the level of the ischial spine is grasped with an Allis clamp. B , Three sutures are placed through the ipsilateral uterosacral ligament and then through the vaginal apex. C , Sutures are placed bilaterally and tied, suspending the apex.

  
  

  (Illustration by Ross Papalardo. Reprinted with permission, Cleveland Clinic Center for Medical Art and Photography © 2012–2013. All rights reserved. From Walters MD, Ridgeway BM. Surgical treatment of vaginal apex prolapse. Obstet Gynecol . 2013;121(2 pt 1):354.)

  
  
  
  
• 8.
  

  If necessary, an anterior colporrhaphy is performed. The vagina is trimmed and closed with a 3-0 delayed absorbable suture ( Fig. 25.8 F and G ).

  
  
• 9.
  

  Tying the vault suspension sutures elevates the vagina high up into the hollow of the sacrum ( Fig. 25.8 H ).

  
  
• 10.
  

  Cystoscopy after intravenous injection of indigo carmine is recommended to document bilateral ureteral patency.

Cross-section of the pelvic floor demonstrating intraperitoneal placement of sutures for (1) McCall culdoplasty, (2) traditional uterosacral suspension, and (3) modified high uterosacral suspension. Note that high uterosacral suspension may involve passage of the suture through the coccygeus muscle–sacrospinous ligament (CSSL) complex because a portion of the uterosacral ligament inserts into this structure.

Sacrospinous Ligament Colpopexy

To perform sacrospinous ligament colpopexy correctly and safely, the surgeon must be familiar with pararectal anatomy as well as the anatomy of the ischial spine, ileococcygeus and coccygeus muscles, sacrospinous ligament, and the surrounding structures ( Fig. 25.10 ). The sacrospinous ligaments extend from the ischial spines on each side to the lower portion of the sacrum and coccyx. The fibromuscular coccygeus muscle and sacrospinous ligament are basically the same structure and thus can be called the C-SSL. The coccygeus muscle has a large fibrous component in the body of the muscle and on the anterior surface, where it appears as white ridges. The C-SSL is identified by palpating the ischial spine and tracing the flat triangular thickening medial and posterior to the sacrum. The fibromuscular coccygeus is attached directly to the underlying sacrotuberous ligament.

Anatomy surrounding the coccygeus muscle–sacrospinous ligament complex.

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 superior and lateral to the C-SSL. Also, an abundant vascular supply that includes inferior gluteal vessels and hypogastric venous plexus lies superiorly.

Before initiating a sacrospinous ligament colpopexy, one should have preoperatively recognized the ischial spines and C-SSL during pelvic examination. The sacrospinous ligament colpopexy is done for moderate to severe apical prolapse after hysterectomy; it can also be done with simultaneous vaginal hysterectomy or even as a hysteropexy (see Chapter 26 ). We usually perform the apical suspension unilateral to the right C-SSL, but surgeons occasionally use the left C-SSL or do a bilateral suspension. This operation usually requires simultaneous correction of the anterior and posterior vaginal walls and an enterocele repair. Placing the prolapsed vaginal apex to the sacrospinous ligament to see whether the vagina is long enough to complete the repair and whether the anterior and posterior vaginal wall prolapse disappear helps to determine whether cystocele and rectocele repairs are needed. Patient consent to these repairs should be routinely received because many times it is difficult to discern the extent of the various defects in the office. The technique of unilateral sacrospinous colpopexy is as follows.

• 1.
  

  If the uterus is present, a vaginal hysterectomy is done and the peritoneum is closed, as previously described. Sacrospinous cervicopexy or hysteropexy could also be done using similar technique, if desired (see Chapter 26 ).

  
  
• 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 vaginal support defects. The vaginal apex then is reduced to the sacrospinous ligament intended to be used. At times the true apex of the vagina at the hysterectomy scar is foreshortened and will not reach the intended area of fixation, as with a shortened anterior vaginal wall and a prominent posterior enterocele. The “new” apex should be moved to a portion of the vaginal wall over the most severe prolapse, thus allowing sufficient vaginal length for suspension to the C-SSL. The intended apex is tagged with two sutures for later identification.

  
  
• 3.
  

  The C-SSL can be accessed via a posterior vaginal dissection, through the apex, or by an anterior approach dissecting at the base of a paravaginal dissection. In the posterior approach 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 rectum and posterior vaginal wall and apex, the peritoneum entered, and the sac closed with a high purse-string suture ( Fig 25.4 ).

  
  
• 4.
  

  The perirectal space or the space along the peritoneum near the apex then is entered by breaking through the fibroareolar tissue just lateral to the enterocele sac at the level of the ischial spine. This can usually be accomplished with blunt dissection after mobilizing the rectum medially. At times, however, the use of gauze on the index finger or a tonsil clamp is necessary to break into this space.

  
  
• 5.
  

  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. 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.

  
  
• 6.
  

  Several techniques are used for the actual passage of sutures through the ligament.

  
  

  Our preferred technique for passing the sutures through the C-SSL uses a device that captures transvaginal sutures ( Fig. 25.11 A ). The proposed advantage of this technique is that it is safer and easier because the device enters the C-SSL under direct palpation of distinct landmarks, proceeding top to bottom, and then is pulled down into the safe perirectal space below. Other popular instruments for placing the C-SSL sutures are the long-handled Deschamps ligature carrier and nerve hook, the Miya hook, and even direct suturing.

  
  

  
  

  
  

  

  
  

  
  

  Sacrospinous ligament colpopexy. A , Passage of Capio ligature carrier with suture through the coccygeus muscle–sacrospinous ligament complex (C-SSL). Note that needle tip is passed downward from above. B , Three sutures are placed through the C-SSL; the middle suture is nonabsorbable, so is passed through the muscularis and the knot buried. C , Final attachment of the vagina to the C-SSL.

  
  

  (Illustration by Ross Papalardo. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2012–2013. All rights reserved. From Walters MD, Ridgeway BM. Surgical treatment of vaginal apex prolapse. Obstet Gynecol . 2013;121(2 pt 1):354.)

  
  
  
  

  To perform this technique on the right, the left middle fingertip is placed on the C-SSL just below its superior margin, approximately 3 cm medial to the ischial spine or in the midposition of the C-SSL. A long retractor such as a Breisky–Navratil retractor can be placed medially to mobilize and protect the rectum if needed. Great care should be taken when retracting in this area to prevent bleeding and nerve and rectal damage. The suture-capturing device, held in the right hand in a closed position, is slid along the palmar surface of the left hand. With the tip of the middle finger, the suture-capturing device notch is placed 3 cm medial to the ischial spine, approximately 0.5 cm below the superior edge. With the middle and index fingers, firm downward pressure is applied and the device is engaged at the handle, so the needle passer penetrates the C-SSL ( Fig. 25.11 A ). The handle is released and the device is removed with the suture and the suture is tagged. Depending on the size of the ligament, most authorities place between two and four sutures through the C-SSL to attach it to the vaginal apex ( Fig. 25.11 B ). There is no consensus about suture type; a combination of delayed absorbable and nonabsorbable monofilament sutures are commonly used.

  
  
• 7.
  

  If the patient requires an anterior vaginal wall repair, we prefer performing an anterior colporrhaphy at this point in the operation.

  
  
• 8.
  

  The surgeon then brings the stitches out to the apex of the vagina, either with the use of a pulley stitch for permanent sutures or simply passing each pair of sutures through the apex for delayed absorbable sutures ( Fig. 25.11 B ). After the sutures have been brought out through the vagina, the upper portion of the posterior vaginal wall is closed with continuous absorbable No. 2-0 sutures. The vaginal apex suspension stitches then are tied, thus elevating the apex of the vagina to the C-SSL ( Fig. 25.11 C ). It is important that the vagina comes into contact with the C-SSL and no suture bridge exists, especially if delayed absorbable sutures are being used. While tying these sutures, it may be useful to perform a rectal examination to detect any suture bridges.

  
  
• 9.
  

  After these sutures are tied, an anti-incontinence procedure and a posterior colpoperineorrhaphy are completed, as needed. The vagina can be packed with moist gauze for 24 h, if desired.

  
  
• 10.
  

  The risk of ureteral obstruction or kinking is extremely low with sacrospinous ligament colpopexy. However, cystourethroscopy should be performed if a concomitant enterocele repair, anterior colporrhaphy, or anti-incontinence procedure is performed.

Iliococcygeus Fascia Suspension

In older women who are having transvaginal colpopexy, if the vagina is not long enough to reach either the C-SSL or if scarring makes it impossible or unsafe to suture into the C-SSL, then bilateral fixation of the prolapsed vaginal apex to the iliococcygeus fasciae just below the ischial spines is a useful and effective technique. It also can be used if the vagina is somewhat foreshortened, but the posterior apex needs additional support during rectocele repair. The technique of this repair is as follows.

• 1.
  

  The posterior vaginal wall is opened in the midline as for a posterior colporrhaphy, and the rectovaginal spaces are dissected widely to the bilateral levator muscles.

  
  
• 2.
  

  The dissection is extended bluntly toward the ischial spines.

  
  
• 3.
  

  With the surgeon’s nondominant hand depressing the rectum downward and medially, an area 1 to 2 cm caudad and posterior to the ischial spine in the iliococcygeus muscle and fascia is exposed ( Fig. 25.12 ). A single No. 0 delayed absorbable suture is placed deep into the levator muscle and fascia. Both ends of the suture are then passed through the ipsilateral posterior vaginal apex and held with a hemostat. This is repeated on the opposite side.

  
  

  
  

  
  

  

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