The general principles of the repair should include management of the specific apical defects: 1.
If present, the attenuated part of the upper vaginal wall (fibromuscular defect) should be repaired or covered by graft material.
2.
The vaginal cuff or, in some instances, the cervix should be suspended without excessive tension.
3.
Any defect in the attachment of the upper vagina to the rectum at or below its sigmoid junction should be corrected.
Enterocele repairs may include: 1.
Removal of the peritoneal sac with closure of the peritoneal defect, followed by closure of the fascial or fibromuscular defect or both below it 2.
Dissection and reduction of the peritoneal sac and closure of the defect 3.
Obliteration of the peritoneal sac from within with transabdominal Halban or Moschcowitz type procedures or transvaginal McCall or Halban procedures (52).
Historically, the treatment for symptomatic uterine prolapse has been hysterectomy, which is performed vaginally or abdominally in combination with an apical suspension procedure, and repair of coexisting defects. Apical support procedures that have been described for use when the uterus or cervix is to be kept in place include Manchester and Gilliam procedures and fixation of the cervix to the sacrospinous ligament . The other procedures described in this section may also be used in women who desire uterine conservation. Adequate outcome data on such uterine-sparing procedures are not yet available. When the cervix is absent, in addition to repair of fibromuscular defects, both fibromuscular planes anterior and posterior to the vaginal cuff should be attached to whatever suspension is employed.
The fixation of the vaginal apex to the sacrospinous ligament, the tendineus component of the coccygeus muscle, was first described in 1958 and was subsequently modified in Europe and the United States (53–56). Access is traditionally extraperitoneal via the rectovaginal space with penetration of the pararectal (Denonvillier’s fascia) at the level of the ischial spine to expose the muscle and ligament. Variations in this approach to the ligament include entrances through an anterior lateral access, an apical passage posterior to the uterosacral ligament, and a laparoscopic approach (57–59). Bilateral sacrospinous ligament suspensions have also been advocated; however, these techniques may impose a greater degree of tension on the sutures and, at times, create a band of apical vagina across the rectum at the level of the suspension (60,61). Whether this can cause defecatory dysfunction remains unknown. The advantages of the sacrospinous fixation procedure include (i) its transvaginal extraperitoneal approach, (ii) resultant posterior vaginal deﬂection, and (iii) the fact that it is a durable repair if performed correctly. Reported success for apical support has been good (89%–97%) with follow-up times ranging from 1 month to 11 years (51,62). However, there have been subsequent reports of high rates of anterior vaginal prolapse (63,64). It is not clear whether this observation is related to the procedure and its exaggerated posterior vaginal deﬂection or to the fact that many patients with apical descent also have defects in the upper vaginal fibromuscular tissue. Failure to address an anterior defect concurrently with suspension of the posterior apical vagina may predispose the patient to such a defect postoperatively. Other disadvantages of the procedure include (i) relative difficulty in adequately exposing the ligament, (ii) an unnatural lateral vaginal deﬂection toward the fixation site, (iii) an inability to perform without excessive tension when the vaginal length is compromised, as may be the case in repeat procedures, (iv) potential risk for injury to the sciatic nerve or pudendal nerve or vessel, and (v) occasional need to shorten or narrow the upper vagina when a fibromuscular defect involves much of the apical area.