Background
Poor cure rates for prolapse repair reported by the PROSPECT TRIAL (as low as 26%) [1] total mesh bans after the Cumberlage Report [2] leave few options for vaginal surgery in the UK. One remaining option, the Fothergill-Manchester Repair began as a modification of the Donald operation [3]. Fothergill emphasized the role of cardinal ligament (CL) and uterosacral (USL) ligaments in uterine prolapse repair [4]. The classical Manchester operation involves full thickness inverted V-shaped vaginal excisions, fig1. The cervix is dilated and if elongated, it is amputated. CLs are severed and sutured to the anterior part of cervix. USLs may also be severed. Sturmdorf sutures bring vaginal flaps into the cervical canal. Vagina is repaired. The operation can be traumatic, with blood loss as high as mean 850ml. [5], possibly related to severing of CLs which contains uterine artery branches and also, failure of Sturmdorf sutures to control bleeding from cervical amputation.
Our less invasive Fothergill repair is based on Fothergill’s original vision which emphasized CL/USL as structural components, figs2-6. However, we did not excise vagina, sever CLs or USLs, or use Sturmdorf sutures. We re-attached vagina directly to the amputated cervix. Excess vaginal tissue was re-assigned by suturing the vaginal epithelium onto the deep fascial layer, fig7. We considered that these steps decreased the likelihood of intra-operative and immediate post-operative bleeding.
We describe transverse and vertical vaginal incision methodology. Otherwise, the techniques are identical, each with advantages and disadvantages. The vertical incision method is more familiar for those trained in the traditional Manchester operation. The transverse incision is advantageous as brings the surgeon directly onto the CL and USL ligaments, which are sometimes difficult to locate.