An Approach to Apical Support: Laparoscopic McCall’s Culdoplasty

Table of Contents

• Procedure Summary
• Authors
• Youtube Video
• What is An Approach to Apical Support: Laparoscopic McCall’s Culdoplasty?
• What are the Risks of An Approach to Apical Support: Laparoscopic McCall’s Culdoplasty?
• Video Transcript

Video Description

Prevalence of pelvic organ prolapse is 41%–50%. It negatively impacts the quality of life due to associated urinary, ano-rectal, and sexual dysfunction. This educational video reviews pelvic support levels and pelvic organ prolaspe, discusses indications for the procedure, demonstrates laparoscopic McCall’s culdoplasty technique, and discusses possible intra- and post-operative complications. The five steps of laparoscopic McCall’s include (1) marking uterosacral ligaments, (2) vault closure with interrupted angle sutures, (3) vault hemostasis, (4) McCall’s placement, and (5) cystoscopy. McCall’s culdoplasty at the time of hysterectomy is superior at preventing future prolapse compared with other techniques. Laparoscopic approach is efficient, safe, and can be easily learned by surgeon.

Presented By

Affiliations

St. Michael’s Unity Health Toronto

University of Toronto

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What is An Approach to Apical Support: Laparoscopic McCall’s Culdoplasty?

An Approach to Apical Support: Laparoscopic McCall’s Culdoplasty is a minimally invasive surgical procedure used to treat pelvic organ prolapse, specifically by providing support to the vaginal apex (the top of the vaginal vault). This technique is particularly beneficial for patients experiencing prolapse after a hysterectomy, where the vaginal apex may lack sufficient support.

• Objective: The primary goal of McCall’s culdoplasty is to restore pelvic support and prevent prolapse recurrence by securing the vaginal apex to supportive structures in the pelvis, often the uterosacral ligaments, which offer stable anchorage.

• Technique: During the laparoscopic approach, the surgeon uses small incisions and laparoscopic instruments to access the pelvis. The vaginal apex is anchored to the uterosacral ligaments or other pelvic ligaments using sutures, which provide both apical support and prevent future prolapse. The laparoscopic approach is less invasive than traditional open or vaginal methods, offering quicker recovery and less postoperative discomfort.

• Applications: This technique is especially suited for patients who have undergone hysterectomies, as well as those experiencing apical prolapse (prolapse of the top portion of the vagina). It may also be used in conjunction with other prolapse repairs, such as cystocele or rectocele repair, for a more comprehensive treatment.

What are the Risks of An Approach to Apical Support: Laparoscopic McCall’s Culdoplasty? 

Video Transcript: An Approach to Apical Support: Laparoscopic McCall’s Culdoplasty

An Approach to Apical Support. Laparoscopic McCall’s Culdoplasty. In this video, we’re going to overview pelvic support levels and pelvic organ prolapse, and review indications of prophylactic uterosacral ligament suspension of vaginal vault at the time of total laparoscopic hysterectomy. We will also demonstrate laparoscopic McCalls’s culdoplasty technique and review possible intra and postoperative complications.

Pelvic support consists of three levels. Level One support provides vaginal support via cardinal and uterosacral ligaments. Level Two support is provided by the arcus tendineus fasciae pelvis and rectovaginal septum. Level Three support consists of the perineal body and the perineal membrane.

Overall prevalence of pelvic organ prolapse is 41 to 50% and is more common in older women. Pelvic organ prolapse has a negative impact on quality of life, and lifetime incidence of surgery is up to 19%. Major risk factors include number of vaginal deliveries, age and obesity.

Incidence of post-hysterectomy vault prolapse is up to 43%, and the risk is similar for all surgical approaches. Potential mechanisms involved in post-hysterectomy pelvic organ prolapse include possible injury to innervation and vascularisation of pelvic floor muscles, alterations in connective tissues, and loss of Level One support. Presence of prolapse at the time of surgery predisposes to its recurrence.

Indications for vault suspension at the time of hysterectomy include presence of pelvic organ prolapse and associated symptoms. However, if pelvic organ prolapse is asymptomatic, it is important to discuss prophylactic vault suspension at the time of hysterectomy. It is a shared decision-making and the counselling should include benefits of preventing subsequent pelvic organ prolapse, as well as risk associated with an additional procedure.

According to recent systematic reviews, performing variations of McCall’s culdoplasty at the time of hysterectomy might be the most effective prophylactic surgical procedure for preventing post-hysterectomy pelvic organ prolapse. McCall’s culdoplasty is superior when compared with the simple peritoneal closure or the Moschcowitz culdoplasty in which uterosacral and cardinal ligaments are sutured and peritoneum is closed.

The McCall’s culdoplasty attaches the vaginal wall to the uterosacral ligaments which are plicated in the midline, and obliterates the posterior cul-de-sac.

It is well-established that prophylactic vaginal McCall’s prevents future prolapse, although there are limited studies comparing McCall’s culdoplasty performed vaginally and laparoscopically. The data suggests that there is no substantial difference in recurrent apical prolapse with either approach, and there is no statistically significant difference between ureteral compromise.

Step One. Marking uterosacrals. Before starting the hysterectomy, identify and mark uterosacral ligament with monopolar cautery, 2 to 3 cm cephalad from the uterus. This will aid in their identification once the uterus has been removed.

Step Two. Vault closure. Securing each angle separately with interrupted sutures will allow the surgeon to apply traction to the vaginal vault and facilitate placement of the McCall’s suture.

Step Three. Hemostasis. Excellent hemostasis of the vault is essential prior to the McCall’s, as ultimately, it will be covered and not accessible for additional cauterisation.

Step Four. McCall’s placement. Suture through the right vaginal angle, anterior to posterior, and then the right uterosacral at previously marked sites. Take superficial bites of the peritoneum in the cul-de-sac and skip over the rectum.

This will obliterate the posterior cul-de-sac. Pass the needle through the left uterosacral ligament and then the left vaginal vault, posterior to the anterior. Finally, incorporate anterior peritoneum. The commonly used suture is Number 0 absorbable. Here we perform intracorporeal knot-tying.

However, one can use extracorporeal knot-tying technique as well. The same technique can be employed during a robotic hysterectomy for the prevention of post-hysterectomy vault prolapse.

Step Five. Cystoscopy. Once the McCall’s suspension is completed, cystoscopy should be performed to rule out bladder or ureteric injury. Possible complications include ureteric injury. This can be prevented with anatomical landmarking of uterosacrals, placing suture through the middle of the uterosacral ligament, avoiding being too lateral, and routine use of cystoscopy.

In summary, the five steps of laparoscopic McCall’s include marking uterosacrals, vault closure with interrupted sutures, vault hemostasis, McCall’s placement, and cystoscopy. Prophylactic laparoscopic McCall’s culdoplasy at the time of hysterectomy can prevent future vault prolapse.