All elderly women who have high-risk medical problems must be cleared for surgery, with the necessary cardiac and pulmonary workup completed before the procedure.
Because colpocleisis is an extraperitoneal procedure, we have adapted use of over-the-counter enema products on the day before surgery in lieu of mechanical bowel preparation, which may lead to dehydration in very elderly women.
Coordinated consultation between the surgeon and anesthesiologist is necessary to determine the type of anesthesia to be used. Sedation and local anesthesia can be adequate for extremely high-risk women.14,15 Antibiotic prophylaxis is conventional for all patients.
Surgical technique
The LeFort method involves denudation and approximation of the midportions of the anterior and posterior vaginal walls.8 This operation creates a longitudinal vaginal septum with bilateral channels on each side, which serve as conduits for any secretion or bleeding from the apical vagina (FIGURE 1A AND B). Aggressive perineorraphy is also needed to shorten the genital hiatus. The following description incorporates perineorraphy into the LeFort technique.
FIGURE 1 Principles of LeFort colpocleisis
The depiction here is not anatomically precise: The vagina is illustrated as a rectangular prism to clarify the relationship between tissues.
Patient positioning
Place the patient in the dorsal lithotomy position, using stirrups to support the entire leg up to the knee. Let the patient’s buttocks overhang the edge of the table by 1 to 2 inches. A slight Trendelenburg position is imperative, especially when operating on the anterior compartment of the vagina. The bladder should be only partially emptied because the leakage of urine from the bladder makes it easier to identify inadvertent cystotomy. Infiltration of local anesthetic solution to develop the surgical planes is acceptable.
Initiating the procedure
Remove a rectangular piece of vaginal epithelium from the anterior vaginal wall, beginning 2 to 3 cm distal to the vaginal apex (or cervix, if the uterus is present) and ending immediately proximal to the urethrovesical junction to leave space for midurethral sling placement. Remove a similarly sized piece of epithelium from the posterior vaginal wall. This posterior rectangle is an almost geometric projection of the anterior rectangle, but is somewhat longer (2 to 3 cm) (FIGURE 1).
When removing the vaginal epithelium, it may be helpful to use the skills developed for anterior and posterior colporraphy. Our operation begins with a 5- to 6-cm transverse incision at the anterior vaginal apex, which creates the proximal side of the anterior rectangle described above (FIGURE 2A).
As you develop the plane between the epithelium and fibromuscular layer, make a midline sagittal incision and extend it to the urethrovesical junction (FIGURE 2B). Dissect the epithelium off the fibromuscular layer approximately 3 cm bilaterally, then make a transverse incision at the urethrovesical junction. Finally, remove the anterior rectangle in two pieces by cutting along the lateral sides (FIGURE 2C AND D). Remove the posterior rectangle using the same technique, but also excise a triangular piece of skin from the posterior fourchette for the perineorraphy portion of the procedure (FIGURE 2E).
FIGURE 2 LeFort technique, step by step
Begin with a 5–6 cm transverse incision at the anterior vaginal apex.
Dissect the epithelium off the fibromuscular layer, with a midline sagittal incision extending to the urethrovesical junction.
After dissection is completed, make a transverse incision at the urethrovesical junction, and remove the anterior rectangle in two pieces by cutting along the lateral sides.
Denude the posterior rectangle using the same technique. In addition, excise a triangular piece of skin from the perineum.
The posterior rectangle is ready for removal.
Suturing
Suture the apical sides of the anterior and posterior rectangles together using a continuous running technique (FIGURE 2F). Then approximate the lateral sides bilaterally using continuous sutures.
To ensure adherence of the anterior and posterior rectangles, stitch the raw surfaces together in three rows (FIGURE 2G). Do not include the distal 2 cm of the posterior vagina because you will need to leave room for perineorraphy.
Using several sutures, reapproximate the torn perineal fibromuscular structures in the midline to perform perineorraphy (FIGURE 2H). Close the distal vagina, beginning at the midpoint of the anterior transverse side, which lies at the urethrovesical junction (FIGURE 2I). Continue this suture on the posterior vagina and then the perineal body, sagittally, creating a small invagination in the distal vagina (FIGURE 2J).
FIGURE 2 LeFort technique, step by step
Suture all but the distal sides of the rectangles between the anterior and posterior vaginal walls.
Also stitch together the raw surfaces in three rows in an imbricating fashion.
Perform perineorraphy.
Close the distal vagina, starting at the midpoint of the anterior transverse side. If indicated, place a midurethral sling.
