Prosthodontia Repair, incorporating a modified McCall vault suspension. Post-hysterectomy vaginal vault prolapse is a bothersome and fairly prevalent condition following hysterectomy. Studies have shown that vaginal vault prolapse can affect 0.2 to 43% of women following hysterectomy for pelvic organ prolapse. This can be prevented by supporting the vaginal cuff at the time of hysterectomy and one of several surgical techniques can be utilised. The McCall Coldoplasty is performed to support the vaginal cuff at the time of a vaginal hysterectomy. This is achieved by attaching the utero-sacral and cardinal ligaments to the vaginal vault with suture material such that when tied they are drawn towards the midline helping to close off the cul-de-sac. This technique has several modifications and there is clinical debate whether it should be used in advanced prolapse. It has been suggested that the prophylactic sacro-spina suspension should be used as a preferred technique at the time of hysterectomy whenever there is a marked utero-vaginal prolapse. We present the case of a 60 year old Para 1 who presented with a mass descending per vagina for 20 years. She also reported urge urinary incontinence and difficulties passing urine. On examination she had a soft non-tender abdomen with an umber-like lahunia and on vaginal examination she had a stage 4 scarred, ulcerated, irreducible prosidentia. A pelvic ultrasound scan identified a right adnexal cyst and bilateral hydronephrosis. The following video demonstrates the management of a large prosidentia with a vaginal hysterectomy, vaginal wall repair and incorporating a modified McCall Coldoplasty for vault suspension. A teardrop incision is made from beneath the bladder neck, encircling the cervix posteriorly with excision of the redundant anterior vaginal mucosa. Blunt dissection is performed circumferentially to facilitate identification of the surgical planes. The peritoneum is entered posteriorly, then anteriorly where a hydrosalpinx is identified. The utrosacral cardinal ligament complex is identified and exposed using blunt and sharp dissection with a high placement of the pedicle. A routine vaginal hysterectomy is then completed with a bilateral selpinjectomy. All pedicles were secured with a 1-vicral suture. The peritoneum is closed using a 2-ovicral suture which is tagged for later attachment to the anterior endopelvic fascia. The cystocele is dissected off the vaginal mucosa using sharp dissection and diathermy. A fascial placation is performed using interrupted 2-O PDS sutures and the mucosa is trimmed. The McCall's Coldoplasty is performed using a 1-vicral suture in the following manner. The suture is passed through the posterior vaginal mucosa, then through the utrosacral cardinal ligament complex above the pedicle on the patient's left side. It is attached to the posterior vault centrally, then through the contralateral ligament complex before being brought through the posterior vagina on the patient's right side. This suture is tied in the midline. A second pass is then made through and through the vaginal vault mucosa with the knot buried beneath the mucosa. These sutures close the inferior margin of the vaginal vault. The utrosacral pedicle sutures are tied in the midline, then brought through the vault mucosa using a mayo needle and tied to complete the vault closure. This contributes to the vault elevation. The anterior vaginal mucosa is closed using interrupted 2-O vitral sutures which tack the mucosa onto the underlying fascia and are tied beneath the mucosa. A posterior vaginal repair has been performed. The vaginal mucosa has been dissected using blunt and sharp dissection. The levator muscles have been identified and these were brought together for a meticulous closure of a large levator hiatal defect. This was followed by a midline placation with interrupted 2-O PDS. The posterior vaginal mucosa was closed with 2-O vitral. The end result is a 7cm functional vagina. Postoperatively, the indwelling catheter has been removed. The end result is a 7cm functional vagina. Postoperatively, the indwelling catheter was left for 2 days and the patient successfully passed a trial of VOID. 6 weeks following surgery, the patient was free of bladder, bowel and prolapse symptoms and no prolapse was diagnosed on examination at 6 weeks and 3 months follow up. The McCall technique for vault suspension should be considered as an alternative technique to the sacrospinous fixation for vault suspension at the time of hysterectomy. It results in a low intraoperative risk of ureteric injury and a functional vaginal length. We have experienced good long term success rates for this technique in advanced prolapse. We have modified the McCall coldoplasty by placing the sutures higher and more lateral into the uterusacral cardinal ligaments extraperitoneally to re-support the vaginal cuff at the time of vaginal hysterectomy. Meticulous closure of large levator hiatal defects at the time of prostodentia repair as it is essential for good surgical success.

prosidentia

vaginal vault prolapse

vaginal hysterectomy

McCall vault suspension

teardrop incision