Vaginal Hysterectomy

Mccall Culdoplasty Technique

Urogynecology & Pelvic Floor Surgery

Department Obstetrics & Gynecology
 NORMAL VAULT SUPPORT
ANATOMY
• THE VAGINA APEX REPRESENT A SITE
WHERE MULTIPLE IMPORTANT
SUPPORT STRUCTURES COALESCE

• THE CERVIX SERVES AS AN OBVIOUS

STRONG ATTACHMENT POINT
• IN WOMAN WHO HAS HAD TVH

• THE SUPPORT STRUCTURE LACK A
STRONG ATTACHMENT SITE

• RESULTING IN SUPPORT WEAKNESS
AND PROLAPSE
 LIGAMENTS & ENDOPELVIC
FASCIA

MAINTAINS INTERGRITY OF ANTERIOR AND POSTERIOR VAGINAL WALLS

• IF THE FASCIA LAYER DETACHED
FROM THE VAGINAL APEX

• A TRUE HERNIA CAN DEVELOPED :
ENTEROCELE, ANTERIOR OR POST

• CAN LEAD, IN TURN TO FURTHER
WEAKENING OF VAGINAL INTERGRITY
 NEW CONCEPT
• RECONSTRUCTIVE SURGEONS RECENTLY
HAVE BEGUN TO ESPOUSE THE CONCEPT

• MANY CYSTOCELES & RECTOCELES

• ACTUALLY ORIGINATE AS DETACHMENT OF
ENDOPELVIC FASCIA FROM THE VAGINAL
APEX
 CULDOPLASTY
• A SURGICAL PROCEDURE TO REMEDY
RELAXATION OF THE POSTERIOR
FORNIX OF THE VAGINA

• PROCEDURE IS EFFECTIVE, SAFE,

SIMPLE TO LEARN, EASY TO CARRY
OUT AND ADDS VERY LITTLE ON THE
OVERALL SURGICAL TIME
 CULDOPLASTY
• RESTORATION OF PELVIC TOPOGRAPHY ,
FUNCTIONAL ANATOMY, PREVENTION OF
DYSFUNCTIONAL VAGINA

• THE TECHNIQUE OF PLICATION THE UTERO

SACRAL LIGAMENTS IN THE MIDLINE WHILE
REEFING PERITONEUM IN THE CUL DE SAC

• COMBINED WITH A POSTERIOR CULDOPLASTY

WAS INTRODUCE BY McCALL
Culdoplasty
 McCALL CULDOPLASTY
• MOST COMMONLY PERFORMED AT THE
TIME OF VAGINAL HYSTERECTOMY
• USES THE NONABSORBABLE SUTURE TO
INCORPORATE BOTH UTEROSACRAL
LIGAMENTS
• INTERVENING CUL-DESAC PERITONEUM
• FULL THICKNESS APICAL VAGINAL MUCOSA
 PROCEDURE
THE TECHNIQUE INVOLVE OPENING THE
VAGINA WALL FROM ANTERIOR TO
POSTERIOR OVER THE APICAL DEFECT AND
IDENTIFIED THE PUBOCERVICAL FASCIA,
RECTOVAGINAL FASCIA AND UTEROSACRAL
LIGAMENTS
 1. Bladder
1
2. Ant leaf of vaginal endopelvic
fascia
3. Uterosacral ligament
4. Vaginosacral ligament
5. Rectum
6. Post leaf of vaginal endopelvic
fascia
• ONE PERMANENT 1-0 SUTURE & ONE
DELAYED ABSORBABLE 1-0 SUTURE
ARE PLACED IN THE POSTEROMEDIAL
ASPECT OF EACH UTEROSACRAL LIG.

1 – 2 CM PROXIMAL MEDIAL TO EACH
ISCHIAL SPINE
• ONE ARM OF EACH PERMANENT
SUTURE IS PLACED THROUGH THE
PUBOCERVICAL AND RECTOVAGINAL
FASCIA
• ONE ARM OF EACH DELAYED
ABSORBABLE SUTURE IS PLACED IN A
SIMILAR FASHION BUT ALSO
INCORPORATING THE VAGINAL
EPITHELIUM