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\begin{document}

\title{Minimally invasive Fothergill -Manchester operation with connective
tissue conservation}



\author[1]{Peter Petros}%
\author[2]{Ray Hodgson}%
\author[3]{Xiuli Sun}%
\author[4]{Jianliu Wang}%
\affil[1]{University of Western Australia}%
\affil[2]{University of New South Wales}%
\affil[3]{Peking University Peoples hospital}%
\affil[4]{Affiliation not available}%


\vspace{-1em}



  
  \date{May 16, 2024}


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\selectlanguage{english}
\begin{abstract}
Our minimally invasive Fothergill-Manchester technique aims to decrease
blood loss and surgical trauma and to preserve function by1. Vaginal
conservation. 2. Cardinal (CL) and uterosacral (USL) ligaments plicated,
not severed. 3. Direct suture of vagina to cervix without Sturmdorf
sutures after cervical amputation. 4. Use of No2 polyester sutures to
create new collagen to reinforce the plicated ligaments.%
\end{abstract}%



\sloppy


\textbf{TITLE}

\textbf{Minimally invasive Fothergill -Manchester operation with
connective tissue conservation}

\textsuperscript{1}Petros PE* , \textsuperscript{2}Hodgson
R,\textsuperscript{3}Sun X, \textsuperscript{3}Wang JL

\textsuperscript{1}School of Mechanical and Mathematical Engineering,
University of Western Australia, Perth Australia

\textsuperscript{2}University of NSW, Sydney Australia.

\textsuperscript{3} Obstetrics \& Gynecology~Dept. Peking University
People's Hospital~ Beijing 100044 CHINA

*\textbf{Corresponding Author} \textsuperscript{1}Petros
PE,\textsuperscript{1}School of Mechanical and Mathematical Engineering,
University of Western Australia, Stirling Highway, Crawley,Perth
Australia 6009. \textbf{Email} pp@kvinno.com

Tel +61411181731

\textbf{Running title} Minimally invasive Manchester operation

No of words TEXT 1706 Abstract

\textbf{ABSTRACT}

Our minimally invasive Fothergill-Manchester technique aims to decrease
blood loss and surgical trauma and to preserve function by1. Vaginal
conservation. 2. Cardinal (CL) and uterosacral (USL) ligaments plicated,
not severed. 3. Direct suture of vagina to cervix without Sturmdorf
sutures after cervical amputation. 4. Use of No2 polyester sutures to
create new collagen to reinforce the plicated ligaments.

\textbf{INTRODUCTION}

\textbf{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.

\textbf{Anatomy and pathogenesis}

At 10cm dilation of the cervix, both CL and USL may be stretched or torn
because of pressure of the head as it enters the birth canal. In the
menopause, further ligament weakness may occur because of collagen break
down. CL prolapses down onto the lateral part of the cervix, fig3, and
the bladder rotates down like a trapdoor as a cystocele (transverse
defect), fig3.

The same 10cm cervical dilatation may overstretch the attachments of USL
to weaken and elongate them, fig 2, and separate them laterally to form
an enterocele.

It is evident from fig2, that the cardinal ligaments MUST elongate in
parallel with uterosacral ligament elongation. Therefore both CL and USL
must be repaired, and the fascial layer of vagina re-attached, fig3.

\textbf{Identification of a prolapsed cardinal ligament.}

Fig3 shows the classical appearance of vagina prolapsing down lateral to
the cervix and fig4 where hysterectomy has been performed. Two lateral
``dimples'' identify the site of the hysterectomy incision.

\textbf{Proving CL pathogenesis of transverse defect cystocele}

Grasping the displaced CLs with Allis forceps and approximating them
medially on the anterior lip of the cervix restores vaginal anatomy. See
VIDEO.

\textbf{Cervical amputation (if required)}

The length of the cervix is estimated by palpating the USL insertions at
the posterior cervical ring. Two sutures are placed high above the
cervix laterally to tie off the descending uterine arteries. The cervix
is amputated, preferably with cutting diathermy, and the vaginal skin is
directly attached with interrupted 00 vicryl sutures. (see VIDEO).

\textbf{SURGICAL TECHNIQUE USING TRANSVERSE INCISIONS}

VIDEO of transverse incision CL repair https://youtu.be/aJDPOELZZfc

VIDEO transverse incision USL repair
https://www.youtube.com/watch?v=MGLdYHtqxzg

\textbf{Indications for transverse incision} The main indication is
simplicity of the surgery, ideal for women with minimal prolapse. CLs
and USLs are much easier to locate as the transverse incision brings the
surgeon virtually on top of the laterally displaced ligaments. This USL
plication technique, fig5, was used in 1996 to address chronic pelvic
pain in women with apical prolapse, with 70\% cure at 12 months {[}6{]}.
The pain was hypothesized to originate from insufficient support of the
pelvic visceral plexuses by lax USLs {[}6{]}.

\textbf{Transverse incision cardinal ligament (CL) plication.}

All steps in the surgery are performed with the vagina stretched and
under tension. The cervix is grasped with a tenaculum and pulled towards
the surgeon. Under tension, a transverse incision is made 1 cm above the
cervix or hysterectomy scar. The bladder is dissected off the cervix or
vagina (with previous hysterectomy), initially with dissection scissors,
then with finger dissection to expose the anterior cervix and push
ureters away from the field of surgery. With previous surgery, the scar
may be very adherent to bladder. Grasp bladder wall with forceps to
create counter tension to vagina to facilitate entry to the right
dissection plane.

The CL ligaments are located at 9 and 3 o'clock. Tensioning the lateral
ends of the vaginal incision helps locate CLs. A strong band at 3 and 9
o'clock identifies CLs which are approximated to the midline with two
polyester *sutures (fig 3).

*No2 polyester creates a collagen reaction which will help reinforce the
ligament. The collagen1created has a breaking strain of 18,000lbs/sq
inch and may be sufficient to create a longer-term result. Clearly it is
not as collagenopoietic as a 7-10 mm polypropylene tape which can no
longer be used in many countries.

If CLs cannot be accurately located, take a No2 polyester suture 1-1.5cm
inferolaterally on each side, ``S'', fig 3, and approximate. The tissues
taken up are invariably attached to CLs

Re-attachment of musculofascial layer of vagina to the approximated
cardinal ligaments is best done with a purse-string suture 1cm from the
cut edge with 00 vicryl (see VIDEO).

Push the vagina down to the CL suture and tie the purse string deep into
the vagina onto CL Close vaginal skin with 00 Vicryl.

\textbf{Transverse incision uterosacral ligament (USL) plication.}

The cervix is grasped with a tenaculum.

Forceps are placed 5cm apart 3-4 cm below cervix or hysterectomy scar
(fig5) at apex of enterocele, stretched towards the surgeon, and a 5cm
transverse incision is made. Inserting a Sims speculum helps open out
the incision. With major prolapse, USLs are often laterally located.
Stretching vagina facilitates identification, generally at 2 and 10
o'clock.

.

The enterocele is gently dissected off the vagina but not entered. The
USLs are grasped with strong forceps, penetrated and approximated using
a No2 polyester suture, fig5to close the enterocele without opening it.
Attachment of rectovaginal fascia to USLs is made with a purse-string
suture 1cm from the cut vaginal edge (VIDEO) then tied deep into the
already approximated USLs. Vagina is closed with 00 vicryl.

\textbf{If the ligaments cannot be accurately located} , take two
sutures laterally beyond the vaginal incisions and approximate. The
tissues taken up are invariably attached to the

ligaments and the sutures will approximate them.

\textbf{SURGICAL CL/USL REPAIR USING VERTICAL INCISIONS}

VIDEO repair CL/USL with vertical vaginal incisions using No2 polyester
sutures.

Vertical incisions are more familiar for those familiar with the
traditional Manchester operation. The surgical methodology as regards
dissection and ligament repair is identical to that for transverse
incisions. The vertical CL operation repairs a high cystocele
(transverse defect) and reconstructs the CLs of the prolapsed uterus
exactly as does the transverse incision. The cervix is grasped with a
tenaculum. A full thickness vertical incision is made from cervix to 1cm
short of the bladder neck. The bladder is dissected off the vagina and
cervix. CLs are identified and approximated with No2 polyester sutures.

A central defect is higher up, just below bladder neck, fig6. excess
vaginal tissue is not excised, but repaired by the vaginal conservation
technique, fig 7.

\textbf{Is cystoscopy indicated after CL/USL plication to exclude
ureteric kinking?}

Though the technique described has built-in safety as regards kinking
the ureter, it is preferable to perform cystoscopy to check ureters are
working

\textbf{Discussion}

\textbf{Ligaments for structure, vagina for function} The differential
biomechanics of ligaments (structure) and vagina (function) endorse the
intuition of Fothergill in making CL and USL repair key parts of his
operation. Tissue biomechanics explain poor results for prolapse with
vaginal repair only {[}1{]}. Ligaments 300
mg/mm\textsuperscript{2}{[}7{]} are the main structural support of the
uterus while the more elastic vagina 60mg/mm\textsuperscript{2},
transmits the muscle forces to close and open the urethra, and to
stretch the vagina to control the afferent impulses from the urothelial
stretch receptors {[}8{]}.

\textbf{Vaginal conservation} The vagina is an organ\textbf{.} Once its
collagen and elastin are excised, they cannot be regenerated. Rather
than excision, excess vaginal tissue can be easily re-assigned, fig7.
The cut edge of epithelium is brought down onto the fascia below, in
effect, compressing the loose tissue. Within a few weeks the component
collagen and glycosaminoglycans which constitute the structural elements
of the vagina re-order the tension within the vaginal tissue, so by 6
weeks review, vaginal appearance appears normal. Excision and scarring
may fibrose the vagina sufficiently to cause the ``Tethered Vagina
Syndrome'' (TVS) {[}9{]}, which may cause massive urine loss,
characteristically on getting out of bed in the morning. TVS can only be
repaired by a skin graft to the vagina.

\textbf{Minimizing excision of tissues reduces bleeding.} By conserving
vagina, not hiding potential bleeding points on the cervix behind
Sturmdorf sutures, not transecting CL, many potential bleeding points
are avoided.

\textbf{Native ligament repair does not work well after the
menopause}Shkarupa et al. published native ligament repair data for
CL/USL much as described here, in two cohorts, premenopausal and
postmenopausal {[}10{]}. By 18 months, good results for cure of
prolapse, OAB (urge, frequency, nocturia) were obtained at 3,6,12,18
months, Table 1, but only for the premenopausal cohort. A massive
stepwise deterioration in symptoms and prolapse occurred by18 months,
Table1. The authors concluded that the cause for the rapid deterioration
was collagen breakdown in the ligaments {[}10{]}. They recommended
cardinal/USL slings in postmenopausal women.

\textbf{Use of No2 polyester} . The midurethral sling's success in
curing stress urinary incontinence is based on harnessing the
collagenopoietic effect of an implanted polypropylene tape to
structurally reinforce weakened pubourethral ligament {[}11{]}. The
collagen created, collagen I, has a breaking strain of 18,000 lbs / sq
inch{[}11{]}. It follows, not much collagen is required to reinforce a
ligament 0.5-0.7mm in diameter. Our aim in using a thick No2 polyester
suture was to create new collagen to reinforce the native tissue
ligament repair.

\textbf{Conclusions} The minimally invasive repair faithfully follows
the Fothergill principle of ligament repair, suitably modified to
conserve tissue, reduce bleeding and hopefully, to provide longer term
cure.

\textbf{Contributions} Surgery VIDEOS PP RH XS. Planning PP RH XS
Analysing PP RH XS WJL Writing PP RH XS

\textbf{Conflict of interest} NIL for any author.

\textbf{Ethics} Not applicable. These are standard hospital operations
for all authors.

\textbf{Funding} NIL

\textbf{Acknowledgments}

Professor Sekiguchi for the cervical amputation video.

Professor Shkarupa for Table1.

\textbf{References}

\begin{enumerate}
\tightlist
\item
  Glazener CMA, Breeman S, Elders A, Hemming C, Cooper KG, Freeman RM,
  et al. (for the PROSPECT study group) Mesh, graft, or standard repair
  for women having primary transvaginal anterior or posterior
  compartment prolapse surgery: two parallel-group, multicentre,
  randomised, controlled trials (PROSPECT) LANCET 2016 Published Online
  December 20, 2016 http://dx.doi.org/10.1016/ S0140-6736(16)31596-3
\item
  Baroness Cumberlage Report. The Independent Medicines and Medical
  Devices Safety Review Written Evidence Clinicians, Academics and Other
  Individuals -- Pelvic Mesh Published December 2018.
\item
  Donald, A. Journ. Obstet. and Gynaecol. Brit. Emp., March, 1908.
\item
  Fothergill WE. Pathology \& the operative treatment of displacements
  of the pelvic viscera. Journal of Obstets \& Gynaecol of the British
  Empire, 1907) 13:410-419.
\item
  Buchman, M. I. (1953). Blood loss during gynecological operations
  Amer. J. Obstet. Gynec., 65, 53.
\item
  Petros PE. Severe chronic pelvic pain in women may be caused by
  ligamentous laxity in the posterior fornix of the vagina. Aust NZ J
  Obstet Gynaecol. 1996;36(3):351-354.
\item
  Yamada H. Aging rate for the strength of human organs and tissues.
  Strength of Biological Materials, Williams \& Wilkins Co, Balt. (Ed)
  Evans FG. (1970); 272-280.
\item
  Liedl B, Inoue H, Sekiguchi Y, Gold D, Wagenlehner F, Haverfield M,
  Petros P. Update of the Integral Theory and system for management of
  pelvic floor dysfunction in females. Eur J Urol. EURSUP-738.
  http://dx.doi.org/10.1016/j.eursup.2017.01.001
\item
  Williams G Browning A Petros PE The integral theory and its tethered
  vagina syndrome visited: vaginal scarring may cause massive urinary
  incontinence BJU Int 2018 Oct;122(4):532-534. doi:
  10.1111/bju.14218.~Epub 2018 Apr 23.
\item
  Shkarupa D, Zaytseva A, Kubin N, Kovalev G, Shapovalova E. Native
  tissue repair of cardinal/uterosacral ligaments cures overactive
  bladder and prolapse, but only in pre-menopausal women.~Cent European
  J Urol.~2021;74:372--378.
\item
  Petros PE, Development of the midurethral sling for stress urinary
  incontinence, Doctor of Surgery Thesis 1999, University of Western
  Australia.
\end{enumerate}

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.

\emph{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.

\emph{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
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