1. Yapa Wijeratne
Faculty of Medicine
University of Peradeniya

2. • The operation is designed to correct uterine
descent associated with cystocele and
rectocele where the preservation of the
uterus is desirable.
• The indications are :
1. Preservation of reproductive function.
2. When the symptoms are due to vaginal
prolapse associated with elongation of the
(supravaginal) cervix.

3. Composite steps of Manchester Repair
1. Preliminary D + C.
2. Amputation of cervix.
3. Plication of Mackenrodt's ligaments in front
of cervix.
4. Anterior colporrhaphy.
5. Colpoperineorrhaphy.

4. The principal steps of the operation are
• (a) Preliminary dilatation and curettage —
• Uterine sound gives the idea about elongation of
cervix.
• Dilatation of the cervical canal is done to facilitate the
passage of the sutures passing through the cervical
canal during covering of the amputated cervix by
vaginal flaps.
• It also ensures adequate uterine drainage and prevents
cervical stenosis during healing of the external os.
• Curettage is done to remove the unhealthy
endometrium.

5. • (b) Amputation o f the cervix — Where future
reproduction is required, low amputation is to be
done.
• (c) Plication of the Mackenrodt's ligaments in
front of the cervix. This facilitates their
shortening raising the cervix so as to place it in its
normal position.
• (d) Anterior colporrhaphy.
• (e) Colpoperineorrhaphy.
• If the family is completed, vaginal sterilisation is
to be done.

6. STEPS OF OPERATION
• Preliminaries
• The preliminaries are the same as those followed
in anterior colporrhaphy.
• Actual steps
• Preliminary D + C.
• The next step is like that of anterior colporrhaphy
upto the pushing up the bladder.
• The posterior lip of the cervix is to be held with
vulsellum and the cervix is drawn upwards.

7. o A pair of Allis forceps is placed in the midpoint of the posterior
cervicovaginal junction.
o The anterior transverse incision is now extended posteriorly
across the posterior cervicovaginal junction.
o The lateral and posterior vaginal wall is dissected off from the
o cervix by scissors and finger dissection.
o The Mackenrodt's ligament with descending cervical artery of
either side is clamped at a higher level of amputation, cut and
replaced by ligature (chromic catgut No. ‘1’ )
o The presence of enterocele should be searched for and if
detected, to be repaired.
o The cervix is now amputated at the calculated level.
o Anterior lip of the amputated cervix is now held with single-
toothed vulsellum.
o The posterior lip of the amputated cervix is covered by the
vaginal flap using a Sturmdorff suture or by Bonney’s method.

8. • In Bonney's method, a catgut stitch is fixed at
the apex of the posterior vaginal flap.
• The ends of the ligature are passed through the
cervical canal and are taken out laterally on
either side of new posterior fornix.
• The ends of the ligature are tied in the midline.
• The cut ends of the Mackenrodt's ligament are
sutured to the anterior surface of the cervix.
• Alternatively, the ligaments are fixed using
Fothergill’s stitch, Fothergill’s stitch is used to
make the uterus anteverted.

9. • The stitch passes through the following tissues
in sequence.
• Vaginal skin at the level of the FothergilTs lateral
point → Mackenrodt's ligament →through the
cervical tissue from outside inwards → cervical
tissue from inside outwards → Mackenrodt's
ligament of the other side → vaginal skin
(Fothergill’s lateral point) of the other side.
• Pubocervical fascia is approximated as in anterior
colporrhaphy.

10. • Redundant portion of the vaginal mucosa is
excised.
• The cut margins of the vagina are apposed by
interrupted sutures.
• Posterior colpoperineorrhaphy is performed.
• Toileting the vagina is done.
• Vaginal pack is given.
• Self retaining catheter is introduced.

11. Complications of surgery
During operation 1. Haemorrhage
2. Injury to the bladder and
rectum
Postoperative 1. Retention of urine or cystitis
2. Haemorrhage: primary or
secondary
3. Infection
Late 1. Dyspareunia
2. Cervical stenosis-
hematometra
3. Infertility
4. Cervical incompetency
5. Cervical dystocia in labor

12. Reference
• Gynaecology by Ten Teachers 19th Ed
• Dutta-Gynecology
• Bonney Gynaecological Surgery 11E