Moschcowitz Procedure
The Moschcowitz procedure is an abdominal cul-de-sac obliteration technique that uses concentric purse-string sutures placed in the pouch of Douglas to progressively close the pelvic cul-de-sac, preventing or treating enterocele. It was first described by Alexis V. Moschcowitz in 1912 for rectal prolapse — based on his theory that rectal prolapse was a sliding hernia through the pelvic floor with the pouch of Douglas as the hernia sac. Today its dominant role is enterocele prophylaxis as an adjunct to abdominal sacrocolpopexy.[1][2][3][4][5]
For the orthogonal sagittal alternative, see Halban Culdoplasty. For the McCall culdoplasty performed at vaginal hysterectomy, see McCall Culdoplasty. For sacrocolpopexy, see Sacrocolpopexy.
Indications
| Setting | Use |
|---|---|
| Adjunct at abdominal sacrocolpopexy | Most common current use — cul-de-sac obliteration to prevent postoperative enterocele[6][7] |
| Treatment of enterocele | Obliteration of a deep cul-de-sac allowing herniation of small bowel or sigmoid between vagina and rectum[2][4] |
| Prophylaxis at vaginal hysterectomy (vaginal Moschcowitz-type modification) | Largely superseded by McCall culdoplasty based on Cruikshank 1999 RCT[1] |
| Adjunct at abdominal rectopexy for rectal prolapse | Historical; supplanted by ventral mesh rectopexy and other modern techniques[5][8][9] |
| Combined pelvic-floor reconstruction | When sacrocolpopexy is performed with cul-de-sac obliteration and posterior mesh extension[6][7] |
Surgical Technique — Abdominal
Performed via laparotomy or laparoscopically, with the patient in Trendelenburg and bowel packed out of the pelvis.
- Cul-de-sac exposure. Retract small bowel and sigmoid colon cephalad to expose the pouch of Douglas. Assess depth — a cul-de-sac extending to or below the level of the posterior vaginal fornix is pathologic.
- First (deepest) purse-string. Place a permanent or delayed-absorbable suture (2-0 silk, Ethibond, or braided polyester) at the deepest point of the cul-de-sac, incorporating in a circumferential bite:
- Posterior vaginal-wall peritoneum (anteriorly)
- Uterosacral ligaments (laterally)
- Anterior rectal wall seromuscular layer (posteriorly) — never full thickness
- Critical safety landmark — ureters. Each suture must be placed medial to the ureters. The ureters course along the lateral pelvic sidewall ~1.5–2 cm lateral to the uterosacral ligaments — incorporation of the ureter into a purse-string is the most feared complication.[1]
- Tie the first purse-string. Obliterates the deepest portion of the cul-de-sac.
- Serial concentric purse-strings. Place 3–5 progressively larger purse-strings more cephalad, each tied sequentially to close the pouch from deep to superficial. Final suture brings peritoneal surfaces together at the level of the posterior vaginal fornix or vaginal cuff.
- Verification. Confirm complete cul-de-sac obliteration with no residual peritoneal pocket. Confirm ureteral patency with cystoscopy (ureteral efflux) or direct visualization.
Vaginal Moschcowitz-Type Modification
A vaginal adaptation at the time of vaginal hysterectomy:[1]
- After uterus removal, visualize cul-de-sac from below.
- Bring uterosacral-cardinal complex together in the midline.
- Place purse-string or interrupted sutures to close the cul-de-sac and approximate the uterosacral ligaments.
Key distinction from McCall culdoplasty: the Moschcowitz-type vaginal procedure primarily closes the cul-de-sac and brings the ligaments to the midline, whereas McCall additionally plicates the USL-cardinal complex and elevates the posterior vaginal apex — a critical functional difference that drives the McCall outcome advantage.[1]
Laparoscopic Modification
Cadeddu 1996 description of a laparoscopic adaptation:[3]
- Three trocars + transvaginal digital manipulation; reduce the enterocele.
- Obliterate the cul-de-sac by approximating posterior vaginal fascia to the anterior rectal wall with a running suture.
- Small series (n = 3): no operative morbidity, no enterocele recurrence at mean 10.5 mo follow-up.
Comparative Outcomes
Cruikshank & Kovac 1999 — landmark RCT
100 women randomized to Moschcowitz-type vs McCall culdoplasty vs simple peritoneal closure at the time of vaginal hysterectomy. 3-year enterocele prevention:[1]
| Technique | 3-yr enterocele recurrence |
|---|---|
| McCall culdoplasty | 6% (2/32) |
| Moschcowitz | 30% (10/33) |
| Simple peritoneal closure | 39% (13/33) |
McCall was significantly superior to both Moschcowitz and simple closure (p = 0.004) — establishing McCall as the preferred adjunct at vaginal hysterectomy.
Moschcowitz vs Halban — orientation matters
| Moschcowitz | Halban | |
|---|---|---|
| Suture orientation | Concentric (purse-string) | Sagittal (anteroposterior) |
| Lateral suture extension | Reaches near ureteral course | Stays in midline; theoretical lower ureteral risk |
| Apical elevation | None | None |
| Cul-de-sac obliteration | Effective | Effective |
Both obliterate the cul-de-sac but neither provides apical elevation — that distinguishes McCall from both.[1][2]
Role as Adjunct to Sacrocolpopexy
The dominant contemporary use is adjunct cul-de-sac obliteration during abdominal sacrocolpopexy:[6][7]
- After mesh attachment to vaginal vault and sacral promontory, the cul-de-sac is obliterated with Moschcowitz-type purse-strings before peritonization to prevent postoperative enterocele.
- Baessler & Schuessler 2001: sacrocolpopexy with pouch-of-Douglas obliteration and posterior mesh extension was effective for vault prolapse, enterocele, and anterior rectal-wall procidentia — no recurrence of vault prolapse or enterocele at mean 26 months.[7]
- Winters 2000: abdominal sacrocolpopexy should always be accompanied by abdominal enterocele repair and cul-de-sac obliteration.[6]
Complications
| Complication | Rate / note |
|---|---|
| Ureteral injury / kinking | The principal risk unique to Moschcowitz — concentric purse-strings pass near the lateral ureteral course; ureter can be ligated or kinked. Prevention: place sutures medial to USLs; intraoperative cystoscopy after placement[1] |
| Small bowel obstruction | Rare delayed complication — bowel adhesion to or entrapment in the suture line[4] |
| Rectal injury | If sutures are placed too deeply through the rectal wall |
| Bleeding | From uterosacral-ligament vessels |
| High-outlet constipation | 28% in Baessler / Schuessler reported altered defecation with stool stopping higher in the rectosigmoid — possibly from rectal-mobilization denervation[7] |
Outcomes Summary
| Setting | Result |
|---|---|
| Standalone enterocele prophylaxis at vaginal hysterectomy | 70% success at 3 yr — inferior to McCall (94%)[1] |
| Adjunct at abdominal sacrocolpopexy | Highly effective — no enterocele or vault recurrence in mature series[7][6] |
| Primary treatment of rectal prolapse | Largely abandoned — supplanted by ventral mesh rectopexy[8][9] |
Current Status
The Moschcowitz procedure occupies a diminished but still relevant role:
- Largely supplanted by McCall culdoplasty for enterocele prophylaxis at vaginal hysterectomy (Cruikshank 1999).[1]
- Largely supplanted by ventral mesh rectopexy for rectal prolapse.[8][9]
- Still used as an adjunct at abdominal sacrocolpopexy for cul-de-sac obliteration; some surgeons prefer Halban (sagittal) or simple peritoneal closure with mesh extension.[7][6]
- The laparoscopic modification remains feasible for MIS enterocele repair.[3]
- Principal limitation is the risk of ureteral injury inherent to the concentric purse-string design — not shared by Halban.
Key Principles
- The Moschcowitz procedure obliterates the cul-de-sac with concentric purse-strings from deep to superficial — original 1912 design for rectal prolapse, now primarily an enterocele-prophylaxis adjunct at sacrocolpopexy.[1][2]
- Always place sutures medial to the ureters — most critical safety consideration; confirm patency with intraoperative cystoscopy.[1]
- Incorporate seromuscular rectum (never full thickness) and posterior vaginal-wall peritoneum / fascia.
- 3–5 concentric purse-strings, deep-to-superficial.
- McCall culdoplasty is superior to Moschcowitz for enterocele prophylaxis at vaginal hysterectomy (Level 1 evidence: 94% vs 70% prevention at 3 yr).[1]
- Halban (sagittal) is the orientation alternative with lower theoretical ureteral risk.[2]
- When used as adjunct to sacrocolpopexy, perform cul-de-sac obliteration before peritonization of the mesh.[6][7]
- Watch for delayed small bowel obstruction and high-outlet constipation as procedure-specific complications.[4][7]
References
1. 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.
2. 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.
3. 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.
4. Dicke JM. Small bowel obstruction secondary to a prior Moschcowitz procedure. Am J Obstet Gynecol. 1985;152(7 Pt 1):887-8. doi:10.1016/s0002-9378(85)80086-7.
5. Corman ML. Rectal prolapse — surgical techniques. Surg Clin North Am. 1988;68(6):1255-65. doi:10.1016/s0039-6109(16)44685-2.
6. 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.
7. 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.
8. Bordeianou L, Paquette I, Johnson E, et al. Clinical practice guidelines for the treatment of rectal prolapse. Dis Colon Rectum. 2017;60(11):1121-1131. doi:10.1097/DCR.0000000000000889.
9. Wald A, Bharucha AE, Limketkai B, et al. ACG clinical guidelines: management of benign anorectal disorders. Am J Gastroenterol. 2021;116(10):1987-2008. doi:10.14309/ajg.0000000000001507.