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Fig1. Vaginal incisions for classical and minimally invasive Manchester
operations. Note the classical Manchester takes the incision to within
1.5cm of the urethra “U” and around cervix “CX”. The minimal
vertical incision method is always 1cm below bladder neck, in order to
avoid “tethered vagina syndrome”. A=anus.
Fig2 Anatomy of uterine prolapse
Uterosacral (USL) and cardinal (CL) ligaments overstretched at
childbirth or weakened by collagen loss after the menopause cannot
support the uterus, so it prolapses. Clearly both CL and USL need to
repaired during reconstructive surgery.
Fig3 Identifying and suturing laterally displaced cardinal ligaments.
Left figure Displaced cardinal ligament’s (CL) The dilatation by
the head to 10 cm has fractured the CL’s attachment to the cervix and
displaced it laterally. Also torn is the pubocervical facsia (PCF)
attachment of vagina to CL. The vagina now rotates downwards like a
trapdoor to cause cystocele (“transverse defect”). The sutures “S”
re-attach CL to the cervix.
Right figure Identifying a dislocated CL. The cervix (CX) is
pulled to the right to show the vagina on the lateral wall of CX
Fig4. CL dislocation with prior hysterectomy. Broken lines =hysterectomy
scar, identified by “dimples”. E= enterocele; Arrow indicates the
bulge of the dislocated cardinal ligament (CL).
Fig5 Approximation of uterosacral ligaments (USL). Schematic view into
the vagina. A transverse incision (broken red lines) is made at the apex
of the enterocele or 4cm below the cervix or hysterectomy scar. The
incision is opened out (broken diamond-shaped lines) and USLs are
located A strong needle with No2 polyester suture is inserted laterally
to at least 1cm depth, taking a segment of tissue. This suture is held
and another suture is inserted. The sutures are approximated.
USL=uterosacral ligament.
Fig6 Central cystocele is shiny and usually accompanies a transverse
defect cystocele. Broken lines with arrows indicate ruptured and
prolapsed cardinal ligaments. BN=bladder neck. CX=cervix.
Fig7 Re-attachment of dislocated vaginal epithelium to underlying fascia
with continuous or interrupted fascial attachment suture. Excess vaginal
tissue was shrunken by suturing the vaginal epithelium onto the deep
fascial layer. With each suture, the fore and middle fingers are placed
around the descending suture, to push down the vaginal epithelium into
the fascia.