Skip to main content

Halban Culdoplasty

The classic Halban culdoplasty is a cul-de-sac obliteration technique using sagittal (anteroposterior) sutures along the pouch of Douglas, approximating the posterior vaginal or peritoneal surface toward anterior rectal or rectosigmoid serosa. Its defining distinction from the Moschcowitz procedure is sagittal rather than concentric purse-string orientation.[2][13] A procedure called modified Halban colpopexy may additionally attach the cuff to uterosacral support.[15]

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​

The technique is attributed to Josef Halban (1870–1937), a Viennese gynecologist who described sagittal (front-to-back) cul-de-sac sutures as an alternative to Moschcowitz's concentric purse-strings (1912). The anatomical reasoning is that midline placement avoids lateral pelvic-sidewall bites near the ureteral course. A lower comparative injury risk has not been established.[13]

Indications​

SettingUse
Treatment of enteroceleObliteration of a deep cul-de-sac that permits herniation of small bowel or sigmoid[2][3]
Adjunct at abdominal or laparoscopic sacrocolpopexyA described combined technique[4][5][14]
Prophylaxis at hysterectomy (abdominal or vaginal)Historical application; the Cruikshank 1999 vaginal-hysterectomy trial favored McCall over vaginal Moschcowitz-type repair and simple closure, but did not test Halban.[6] For stage II uterovaginal prolapse at vaginal hysterectomy, the 2025 ISGE guideline recommends McCall culdoplasty (Grade 1B).[16]
Adjunct at rectopexy for rectal prolapseHistorical use[2]

Surgical Technique — Abdominal​

Performed via laparotomy or laparoscopy with the patient in Trendelenburg position.

  1. Cul-de-sac exposure. Pack small bowel and sigmoid cephalad. Assess the enterocele and cul-de-sac depth in relation to the apical and posterior defects.
  2. First (deepest) suture. Place a permanent or delayed-absorbable suture (historical examples: 2-0 silk or braided polyester) at the deepest point of the cul-de-sac, incorporating 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
  3. Distinction from Moschcowitz. Place successive parallel sagittal sutures side by side between the uterosacral ligaments, approximating posterior vaginal peritoneum to anterior rectal serosa while avoiding lateral pelvic-sidewall bites.[17][15]
  4. Serial parallel sagittal sutures. Place several interrupted sutures in parallel sagittal rows progressing from deep to superficial.[13] The number and material are adjusted to the actual defect and tissues.[13]
  5. Verification. Confirm complete cul-de-sac obliteration and check ureteral patency, despite the lower theoretical risk.

Halban vs Moschcowitz vs McCall​

FeatureHalbanMoschcowitzMcCall
Suture orientationSagittal (anteroposterior)Concentric purse-stringsTransverse / oblique
Structures incorporatedPosterior vaginal/peritoneal surface + anterior rectal or rectosigmoid serosa (midline)Posterior vaginal peritoneum + lateral support/sidewall + anterior rectal serosa (circumferential)USL-cardinal or pararectal support + posterior vaginal cuff/peritoneum; rectal serosa is not a routine McCall fixation target
Ureteral considerationsMidline placement avoids lateral bites; comparative risk unestablishedLateral purse-string bites can kink or incorporate a ureterUSL-cardinal bites require attention to the ureters
Apical elevationNot from isolated classic closure; modified Halban colpopexy can add USL fixationNot from isolated cul-de-sac closureYes; plicates USL-cardinal complex and elevates posterior apex
Ligament plicationNone in classic closure; modified colpopexy can add USL fixationNot a defining step of classic closure; the trial's vaginal Moschcowitz-type variant brought the USL-cardinal complex to midline[6][13]Plicates USL-cardinal complex
Enterocele events at 3 yr in Cruikshank 1999Not studied10/33 (vaginal Moschcowitz-type)2/32[6]

Rationale for Sagittal Placement​

The rationale is to avoid lateral suture placement near the ureters. Ureteral relationships vary with pelvic level, prolapse, and prior surgery; a fixed distance from the uterosacral ligament is not a safe operative landmark. Sagittal placement reduces lateral extension but does not guarantee ureteral protection or establish lower comparative complication rates.[7][8][1][2]

The classic closure alone does not provide a separately established apical suspension. Wu described modified Halban colpopexy with uterosacral-to-cuff fixation and sagittal cul-de-sac closure in 27 women undergoing laparoscopic-assisted vaginal hysterectomy; no vault prolapse was observed at 10–23 months.[13][15] The apical support comes from the added fixation.[13][15]

Outcomes​

Standalone enterocele prophylaxis​

No direct Halban arm was included in the cited randomized comparison.[6][9] The 3-year results support McCall over vaginal Moschcowitz-type repair and peritoneal closure at vaginal hysterectomy.[6][9]

As adjunct to sacrocolpopexy​

Baessler 2001 enrolled 33 women; 31 returned for follow-up at 12–48 months (mean 26) after sacrocolpopexy, pouch-of-Douglas obliteration and posterior mesh extension.[5] No vault or enterocele recurrence was observed among the 31 followed, but 16/28 preoperative rectoceles recurred despite posterior mesh extension.[5] A separate laparoscopic sacrocolpopexy series explicitly describes Halban culdoplasty with sutures in posterior mesh before peritonization.[14]

Advantages and Limitations​

AdvantageLimitation
Sagittal placement avoids lateral purse-string bites[2][13]Classic closure alone provides no apical suspension; a modified colpopexy can add USL fixation[13][15]
Classic sagittal closure does not require USL fixationHalban was not tested against McCall in the cited trial; modified colpopexy may add USL fixation[6][15]
Described abdominally, laparoscopically, and in vaginal modificationsClassic closure does not plicate ligaments; apical weakness requires a separately planned suspension[13][15]
Provides a described method of cul-de-sac obliteration[13]Limited comparative data. No direct Halban-versus-Moschcowitz/McCall trial was identified in the cited evidence[6]

Complications​

ComplicationRate / note
Ureteral injuryAssess ureteral safety according to the entire repair and intraoperative findings[7][8]
Rectal injuryIf sutures are placed full-thickness rather than seromuscular
Small bowel obstructionBowel obstruction is a reported complication of abdominal sacrocolpopexy.[4]
Enterocele recurrenceComparative recurrence versus McCall is not established by the cited trial[6]
Altered defecation at follow-up (high outlet constipation)In Baessler’s combined sacrocolpopexy series, 28% of women described stool stopping higher in the rectosigmoid colon at follow-up (12–48 months, mean 26 months).[5]

Vaginal Modification​

A vaginal enterocele repair may use related sagittal or fascial closure concepts. In the Miklos series, all 17 women also underwent USL vault suspension and 15 had posterior colporrhaphy.[10][11] A descriptive Halban-type sequence is:

  • 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​

A laparoscopic midline closure has been described: in Cadeddu’s three-patient report, a running suture approximated posterior vaginal fascia to the anterior rectal wall, but the authors named the repair modified Moschocowitz. Midline placement avoids lateral pelvic-sidewall bites. One small laparoscopic report (three women, mean follow-up 10.5 months) labeled its repair "modified Moschcowitz" but approximated posterior vaginal fascia to the anterior rectal wall with a running suture, a sagittal (Halban-type) orientation.[12]

Current Clinical Role​

The Halban culdoplasty is used in a limited set of settings:

  • An option when sagittal cul-de-sac closure suits the anatomy.[1][2]
  • It has been described as an adjunct to sacrocolpopexy for cul-de-sac obliteration when sagittal placement is preferred.[14][4]
  • McCall culdoplasty provides apical elevation as well as cul-de-sac closure; Halban culdoplasty itself is not an apical suspension.[6][9]
  • Classic closure is not a standalone apical suspension. When apical support is needed, add an actual suspension (sacrocolpopexy, sacrospinous fixation or USL fixation), and distinguish modified Halban colpopexy, which includes such fixation.[13][15]

Key Principles​

  • Halban culdoplasty obliterates the cul-de-sac with several parallel sagittal interrupted sutures from posterior vaginal peritoneum to anterior rectal serosa, placed side by side between the uterosacral ligaments.[1][2][13][15]
  • Midline orientation avoids lateral bites, but a lower ureteral-injury rate has not been established.[7]
  • Place several sagittal interrupted sutures from deep to superficial; incorporate seromuscular rectum (not full thickness) and posterior vaginal peritoneum or fascia; exact count and material depend on the repair.[13]
  • Classic closure alone does not supply a separately established apical suspension; modified Halban colpopexy can include USL fixation.[13][15]
  • One laparoscopic sacrocolpopexy sequence places Halban sutures in posterior mesh before peritonization.[14]
  • Baessler’s 28% altered-defecation figure came from combined sacrocolpopexy.[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. PMID 8202302

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.

13. Choi KH, Hong JY. Management of pelvic organ prolapse. Korean J Urol. 2014;55(11):693-702. doi:10.4111/kju.2014.55.11.693.

14. Cosson M, Rajabally R, Bogaert E, Querleu D, Crépin G. Laparoscopic sacrocolpopexy, hysterectomy, and Burch colposuspension: feasibility and short-term complications of 77 procedures. JSLS. 2002;6(2):115-119. PMID 12113413

15. Wu MP. Laparoscopic modified Halban colpopexy combined with LAVH in treating uterine prolapse. J Gynecol Surg. 1997;13(4):175-179. doi:10.1089/gyn.1997.13.175.

16. Chrysostomou A, Noé G, Linnamägi A, van Herendael BJ, Djokovic D. "Evidence-based recommendations of the International Society for Gynecologic Endoscopy (ISGE) for the prevention of apical prolapse following vaginal hysterectomy for prolapsed and non-prolapsed uterus." Eur J Obstet Gynecol Reprod Biol. 2025;312:114559. doi:10.1016/j.ejogrb.2025.114559

17. Haylen BT, Maher CF, Barber MD, et al. "An International Urogynecological Association (IUGA)/International Continence Society (ICS) Joint Report on the Terminology for Female Pelvic Organ Prolapse (POP)." Neurourol Urodyn. 2016;35(2):137-168. doi:10.1002/nau.22922