Halban Culdoplasty
The Halban culdoplasty is a cul-de-sac obliteration technique that uses interrupted sutures placed in a sagittal (anteroposterior) plane from the posterior vaginal wall peritoneum to the anterior rectal wall serosa, progressively closing the pouch of Douglas to prevent or treat enterocele. Its defining feature — and the key distinction from the Moschcowitz procedure — is the sagittal orientation of suture placement, which keeps sutures away from the lateral pelvic sidewall and substantially lowers ureteral injury risk.[1][2]
For the orthogonal concentric variant, see Moschcowitz Procedure. For the apical-elevation alternative performed at vaginal hysterectomy, see McCall Culdoplasty. For sacrocolpopexy, see Sacrocolpopexy.
Historical Background
Attributed to Josef Halban (1870–1937), a Viennese gynecologist who proposed sagittal (front-to-back) cul-de-sac sutures as a safer alternative to Moschcowitz's concentric purse-strings (1912). The reasoning: midline-only suture placement avoids the lateral pelvic sidewall — particularly the ureteral course.[1][2]
Indications
| Setting | Use |
|---|---|
| Treatment of enterocele | Obliteration of a deep cul-de-sac that permits herniation of small bowel or sigmoid[2][3] |
| Adjunct at abdominal sacrocolpopexy | Cul-de-sac obliteration as part of mesh-augmented apical reconstruction[4][5] |
| Prophylaxis at hysterectomy (abdominal or vaginal) | Largely superseded by McCall culdoplasty for vaginal hysterectomy based on Cruikshank 1999 RCT[6] |
| Adjunct at rectopexy for rectal prolapse | Historical use[2] |
Surgical Technique — Abdominal
Performed via laparotomy or laparoscopy with the patient in Trendelenburg position.
- Cul-de-sac exposure. Pack small bowel and sigmoid cephalad. Assess depth — a cul-de-sac extending to or below the posterior vaginal fornix is pathologic.
- First (deepest) suture. Place a permanent or delayed-absorbable suture (2-0 silk, Ethibond, braided polyester) at the deepest point of the cul-de-sac, incorporating in a sagittal (front-to-back) bite:
- Posterior vaginal-wall peritoneum (or vaginal cuff) anteriorly
- Seromuscular layer of the anterior rectal wall (never full thickness) posteriorly
- Critical distinction from Moschcowitz. Sutures do NOT extend laterally to incorporate the uterosacral ligaments or pass near the ureteral course — they remain in the midline sagittal plane, approximating posterior vagina to anterior rectum in a series of anteroposterior bites.
- Serial parallel sagittal sutures. Place 3–5 interrupted sutures in parallel sagittal rows progressing from the deepest point cephalad. Tie sequentially to obliterate the cul-de-sac from deep to superficial.
- Verification. Confirm complete cul-de-sac obliteration; ureteral patency check is recommended despite the lower theoretical risk.
Halban vs Moschcowitz vs McCall
| Feature | Halban | Moschcowitz | McCall |
|---|---|---|---|
| Suture orientation | Sagittal (anteroposterior) | Concentric purse-strings | Transverse / oblique |
| Structures incorporated | Posterior vaginal peritoneum + anterior rectal serosa (midline only) | Posterior vaginal peritoneum + USLs + anterior rectal serosa (circumferential) | USL-cardinal complex + posterior vaginal peritoneum + rectal serosa |
| Ureteral injury risk | Lowest — midline only | Highest — passes near lateral ureteral course | Moderate — incorporates USLs with controlled lateral placement |
| Apical elevation | None | None | Yes — plicates USL-cardinal complex AND elevates posterior apex |
| Ligament plication | None | Brings USLs to midline | Plicates USL-cardinal complex |
| Enterocele prevention at 3 yr | Similar to Moschcowitz (~70%) | 70% | 94% (Cruikshank 1999) |
(The Cruikshank 1999 RCT did not include a Halban arm directly; the Halban is generally considered comparable to Moschcowitz for prevention but with lower complication risk.)[1][6]
Rationale for Sagittal Placement
The fundamental advantage is reduced ureteral injury risk. Ureters course along the lateral pelvic sidewall ~1.5–2 cm lateral to the uterosacral ligaments. Moschcowitz purse-strings must pass through or near the USLs laterally — placing the ureters at risk of kinking, ligation, or obstruction. Halban confines all sutures to the midline sagittal plane, encountering no critical lateral structures.[7][8][1][2]
The trade-off: because the procedure does not incorporate the uterosacral ligaments, it provides no apical elevation and no structural ligament plication — purely a cul-de-sac obliteration technique.[6][2]
Outcomes
Standalone enterocele prophylaxis
No direct RCT comparison vs Moschcowitz or McCall. Based on mechanism (cul-de-sac obliteration without ligament plication or apical elevation), efficacy is generally considered comparable to Moschcowitz (~70% at 3 yr) and inferior to McCall (94% at 3 yr) — McCall's superiority being driven by the additional features of USL-cardinal plication and posterior vaginal apex elevation that Halban lacks.[6][9]
As adjunct to sacrocolpopexy
Effective for preventing postoperative enterocele when combined with abdominal sacrocolpopexy. Sacrocolpopexy + pouch-of-Douglas obliteration + posterior mesh extension showed no recurrence of vault prolapse or enterocele at mean 26 months (Baessler 2001).[5] Choice between Halban and Moschcowitz is largely surgeon preference; Halban offers lower ureteral risk.[4][5]
Advantages and Limitations
| Advantage | Limitation |
|---|---|
| Lowest ureteral injury risk of the cul-de-sac obliteration techniques (sagittal placement)[1][7] | No apical support — does not plicate USLs or elevate the vaginal apex[6][2] |
| Technical simplicity — no requirement to identify and incorporate USLs | Inferior to McCall for enterocele prevention at vaginal hysterectomy[6] |
| Applicable abdominally, laparoscopically, or as a vaginal modification | No ligament plication — does not address underlying USL-cardinal weakness[6][9] |
| Effective cul-de-sac obliteration[2] | Limited comparative data — no RCTs directly comparing Halban to Moschcowitz or McCall[2] |
Complications
| Complication | Rate / note |
|---|---|
| Ureteral injury | Theoretically the lowest risk among cul-de-sac obliteration techniques due to sagittal placement; confirm ureteral patency intraoperatively if any sutures placed laterally[7][8] |
| Rectal injury | If sutures are placed full-thickness rather than seromuscular |
| Small bowel obstruction | Rare; bowel adhesion to suture line, similar to Moschcowitz |
| Enterocele recurrence | Higher than McCall — absent ligament plication and apical elevation[6] |
| Postoperative constipation / altered defecation | 28% in Baessler 2001 series — possibly from rectal-mobilization denervation rather than the culdoplasty itself[5] |
Vaginal Modification
A vaginal Halban-type approach at vaginal hysterectomy or transvaginal enterocele repair:[10][11]
- After enterocele sac identification and excision, visualize peritoneal edges.
- Place interrupted sutures in a sagittal direction approximating posterior vaginal wall fascia to anterior rectal wall fascia.
- Tie sutures to obliterate the cul-de-sac from below.
- Often combined with site-specific fascial defect repair, reapproximating pubocervical and rectovaginal fascia to close the hernial port.
Laparoscopic Adaptation
Readily adaptable to laparoscopic surgery. Sagittal suture placement is technically straightforward laparoscopically; midline orientation avoids lateral dissection near the ureters. Some laparoscopic enterocele repairs labeled "modified Moschcowitz" actually employ a sagittal (Halban-type) suture orientation with running suture from posterior vaginal fascia to anterior rectal wall.[12]
Current Clinical Role
The Halban culdoplasty occupies a niche but relevant role:
- Preferred over Moschcowitz by some surgeons when cul-de-sac obliteration is needed and ureteral safety is the priority.[1][2]
- Adjunct to sacrocolpopexy for cul-de-sac obliteration when sagittal placement is preferred.[4][5]
- Largely supplanted by McCall culdoplasty for enterocele prophylaxis at vaginal hysterectomy — McCall provides apical elevation that Halban lacks.[6][9]
- Not a standalone apical-suspension procedure — when apical support is needed, Halban must be combined with a separate suspension (sacrocolpopexy, sacrospinous fixation, USL suspension).[1][2]
Key Principles
- Halban culdoplasty obliterates the cul-de-sac with sagittal interrupted sutures from posterior vaginal peritoneum to anterior rectal serosa — midline only, no lateral extension.[1][2]
- Lowest ureteral injury risk among cul-de-sac obliteration techniques — defining advantage over Moschcowitz.[7]
- Place 3–5 sagittal interrupted sutures from deep to superficial; incorporate seromuscular rectum (never full thickness) and posterior vaginal peritoneum / fascia.
- No apical elevation — purely cul-de-sac obliteration; combine with a separate apical-suspension procedure when apical support is needed.[6][2]
- Inferior to McCall culdoplasty for enterocele prophylaxis at vaginal hysterectomy; McCall is preferred when apical elevation can be achieved.[6]
- When used as adjunct to sacrocolpopexy, perform cul-de-sac obliteration before peritonization of the mesh.[4][5]
- Counsel about postoperative altered defecation / high-outlet constipation (28% in Baessler series).[5]
References
1. Raz S, Nitti VW, Bregg KJ. Transvaginal repair of enterocele. J Urol. 1993;149(4):724-30. doi:10.1016/s0022-5347(17)36193-1.
2. Holley RL. Enterocele: a review. Obstet Gynecol Surv. 1994;49(4):284-93.
3. Ranney B. Enterocele, vaginal prolapse, pelvic hernia: recognition and treatment. Am J Obstet Gynecol. 1981;140(1):53-61. doi:10.1016/0002-9378(81)90257-x.
4. Winters JC, Cespedes RD, Vanlangendonck R. Abdominal sacral colpopexy and abdominal enterocele repair in the management of vaginal vault prolapse. Urology. 2000;56(6 Suppl 1):55-63. doi:10.1016/s0090-4295(00)00662-2.
5. Baessler K, Schuessler B. Abdominal sacrocolpopexy and anatomy and function of the posterior compartment. Obstet Gynecol. 2001;97(5 Pt 1):678-84. doi:10.1016/s0029-7844(00)01205-9.
6. Cruikshank SH, Kovac SR. Randomized comparison of three surgical methods used at the time of vaginal hysterectomy to prevent posterior enterocele. Am J Obstet Gynecol. 1999;180(4):859-65. doi:10.1016/s0002-9378(99)70656-3.
7. Chan JK, Morrow J, Manetta A. Prevention of ureteral injuries in gynecologic surgery. Am J Obstet Gynecol. 2003;188(5):1273-7. doi:10.1067/mob.2003.269.
8. Symmonds RE. Ureteral injuries associated with gynecologic surgery: prevention and management. Clin Obstet Gynecol. 1976;19(3):623-44. doi:10.1097/00003081-197609000-00012.
9. Given FT. "Posterior culdeplasty": revisited. Am J Obstet Gynecol. 1985;153(2):135-9. doi:10.1016/0002-9378(85)90097-3.
10. Milani R, Manodoro S, Cola A, et al. Transvaginal native-tissue repair of enterocele. Int Urogynecol J. 2018;29(11):1705-1707. doi:10.1007/s00192-018-3686-3.
11. Miklos JR, Kohli N, Lucente V, Saye WB. Site-specific fascial defects in the diagnosis and surgical management of enterocele. Am J Obstet Gynecol. 1998;179(6 Pt 1):1418-22; discussion 1822-3. doi:10.1016/s0002-9378(98)70004-3.
12. Cadeddu JA, Micali S, Moore RG, Kavoussi LR. Laparoscopic repair of enterocele. J Endourol. 1996;10(4):367-9. doi:10.1089/end.1996.10.367.