Le Fort's operation

In Le Fort's operation the anterior and posterior walls of a patient's vagina are bared, and sewn together, so that a central longitudinal partition runs down its centre. This gives her a bipartite vagina which cannot prolapse, and which will also prevent her uterus from prolapsing. Prolapse of her bladder and rectum are also almost impossible. She cannot have sex, but there is still sufficient vaginal drainage to allow her to menstruate. This operation is rarely done in premenopausal women, because they usually want to have sex. Unfortunately, prolapse may recur down one side. This operation may not be popular in your community: she must understand what is to be done.

Fig. 20-11 LE FORT'S OPERATION. A, the cervix pulled downwards with vulsella, and the area of vaginal skin mapped out. B, mucosa being dissected off its anterior surface. C, mucosa being dissected off its posterior surface. D, the cervix inverted, and the raw surfaces being united with mattress sutures. E, the raw surfaces being joined together over and around the cervix. F, the cervix has disapppeared. G, the repair, complete with small channels at either side. Roberts TWD, in Rob C, and Smith R, ''Operative Surgery: Gynaecology and Obstetrics; p. 89. Butterworth, with kind permission.

LE FORT'S OPERATION INDICATIONS. An old postmenopausal woman with procidentia, or advanced prolapse of the second degree, who no longer has sex.

CONTRAINDICATIONS. (1) Premenopausal women. (2) Ulcerations of the vaginal mucosa.

ANAESTHESIA. (1) Saddle block. (2) Ketamine. (3) Local infiltration. (4) Subarachnoid anaesthesia.

METHOD. Put the patient into the lithotomy postion and examine her uterus. If she has any cervical lesions, deal with them[md]it will be the last opportunity you will have to take a Pap smear.

Using careful aseptic precautions, grasp her cervix and draw it out of her vulva with a vulsellum. Mark out an area on her anterior vaginal wall to be excised (A, in Fig. 20-11). Excise a rectangle of mucosa. Do the same on her posterior vaginal wall. Replace her cervix, and use catgut mattress sutures to unite the bare areas and cover her cervix, except for small channels on either side. If the local circulation is good, and there is no infection, the anterior and posterior walls of her vagina will unite.