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Moschcowitz Procedure

The Moschcowitz procedure is a cul-de-sac obliteration technique using concentric purse-string sutures in the pouch of Douglas. It was described by Alexis V. Moschcowitz in 1912 for rectal prolapse, based on a sliding-hernia theory. Abdominal and vaginal variants have since been used for enterocele repair or prevention, including historical adjunctive use at sacrocolpopexy.[1][5][6][9]

For the orthogonal sagittal alternative, see Halban Culdoplasty. For the McCall culdoplasty performed at vaginal hysterectomy, see McCall Culdoplasty. For sacrocolpopexy, see Sacrocolpopexy.

Indications​

SettingUse
Adjunct at abdominal sacrocolpopexyReported use for cul-de-sac obliteration to prevent postoperative enterocele[6][7]
Treatment of enteroceleObliteration 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)Historical option; the three-arm trial found 10/33 posterior enteroceles after this method versus 2/32 after McCall at 3 years.[1] For stage II uterovaginal prolapse at vaginal hysterectomy, the 2025 ISGE guideline recommends McCall culdoplasty (Grade 1B).[12]
Adjunct at abdominal rectopexy for rectal prolapseHistorical use; contemporary rectal-prolapse operations are selected from several abdominal and perineal approaches. The ASCRS 2017 recommendations cover rectopexy (suture, with sigmoid resection, mesh and ventral) and perineal operations, and do not include cul-de-sac obliteration[5][8]
Combined pelvic-floor reconstructionWhen 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.

  1. Cul-de-sac exposure. Retract small bowel and sigmoid colon cephalad to expose the pouch of Douglas. Assess actual herniation and apical or posterior support.
  2. First (deepest) purse-string. Place a permanent or delayed-absorbable suture (historical examples: 2-0 silk or braided polyester) at the deepest point of the cul-de-sac. In the classic IUGA/ICS definition, concentric bites include the posterior vaginal wall, pelvic sidewalls, and sigmoid serosa.[14] In a described vaginal Moschcowitz-type modification at hysterectomy, the purse-string takes posterior vaginal-wall peritoneum anteriorly, uterosacral-cardinal ligaments laterally, and anterior rectal serosa posteriorly, without full-thickness bowel bites.[1]
  3. Safety relationship: ureters. Identify the ureteral course for the actual anatomy and keep bites away from it; a fixed distance from the uterosacral ligament is not a safe landmark. Lateral bites can incorporate or kink a ureter. Assess patency according to the entire repair.[9]
  4. Tie the first purse-string. This obliterates the deepest portion of the cul-de-sac.
  5. Serial concentric purse-strings. Place several progressively larger purse-strings more cephalad, each tied sequentially to close the pouch from deep to superficial. Number and extent depend on the defect and tissue. The final suture approximates peritoneal surfaces near the posterior vaginal fornix or cuff.[9]
  6. Verification. Confirm complete cul-de-sac obliteration with no residual peritoneal pocket. Inspect the ureteral course and assess ureteral patency with cystoscopy and bilateral efflux as appropriate to the repair.

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.

Distinction from McCall culdoplasty. In the trial, vaginal Moschcowitz-type closure brought the uterosacral-cardinal complex to midline; McCall plicated the complex and also elevated the redundant posterior vaginal apex.[1]

Bowel safety during sac closure. For a demonstrated enterocele sac, Sussman and colleagues describe placing a circumferential 2-0 purse-string around the sac and extending the stitch into the peritoneal cavity to ligate it. As the proximal purse-string is tightened, they place a finger in the peritoneal cavity, remove the laparotomy sponge, and confirm that bowel is not incorporated before tying the suture. This is the chapter authors' described safety sequence for their repair, without comparative outcome data.[11]

Laparoscopic Modification​

Cadeddu 1996 description of a laparoscopic adaptation:[3]

  • Three trocars with transvaginal digital manipulation; reduce the enterocele.
  • In this modified Moschocowitz repair, a running suture obliterated the cul-de-sac by approximating posterior vaginal fascia to the anterior rectal wall, rather than using classic concentric purse-strings.[3][9]
  • Small series (n = 3), each with an additional pelvic repair: no operative morbidity or identified enterocele recurrence at mean 10.5 months (range 7–15).[3]

Comparative Outcomes​

Cruikshank & Kovac 1999 — landmark RCT​

In this randomized trial, 100 women undergoing vaginal hysterectomy for varied indications were assigned to vaginal Moschcowitz-type closure, McCall culdoplasty, or simple peritoneal closure; pelvic organ prolapse was the primary hysterectomy indication in four.[1] At 3 years, pelvic examination assessed posterior-superior vaginal prolapse among 98 followed women.[1]

Technique at vaginal hysterectomyPosterior enterocele at 3 years
McCall culdoplasty6% (2/32)
Moschcowitz30% (10/33)
Simple peritoneal closure39% (13/33)

McCall had the fewest posterior enteroceles.[1] The published abstract reports an overall three-arm comparison (χ² = 11.27, 2 degrees of freedom, p = 0.004).[1]

Moschcowitz vs Halban — orientation matters​

MoschcowitzHalban
Suture orientationConcentric (purse-string)Sagittal (anteroposterior)
Lateral suture extensionCircumferential bites can reach the lateral ureteral courseWu's modified Halban uses parallel sagittal sutures; comparative ureteral-injury risk is unmeasured[10]
Apical elevationNot from isolated closureNot from isolated classic closure; modified colpopexy can add USL fixation
Cul-de-sac obliterationIntendedIntended

The isolated classic closures are not apical suspensions.[9][10] A reported modified Halban colpopexy adds USL-to-cuff fixation.[9][10]

Role as Adjunct to Sacrocolpopexy​

One described application is adjunct cul-de-sac obliteration during abdominal sacrocolpopexy:[6][7]

  • In one reported abdominal sacrocolpopexy technique, after mesh attachment to the vaginal vault and sacral promontory, the cul-de-sac is obliterated with Moschcowitz-type purse-strings before peritonization as an adjunct intended to prevent postoperative enterocele.[6][9][13]
  • Baessler & Schuessler 2001. In this prospective series, 33 women underwent sacrocolpopexy with pouch-of-Douglas obliteration and posterior mesh extension; 31 returned for follow-up (mean 26 months), with no vault or enterocele recurrence among those followed, but 16/28 preoperative rectoceles recurred and one occurred de novo.[7]
  • Winters 2000. The authors advocated combining abdominal sacrocolpopexy with enterocele repair and cul-de-sac obliteration.[6]

Complications​

ComplicationRate / note
Ureteral injury / kinkingLateral purse-string placement can endanger a ureter. Identify its actual course, avoid compromising bites, and assess patency according to the full repair; no comparative injury rate versus Halban is established[9]
Small bowel obstructionReported delayed after Moschcowitz closure[4]
Rectal injuryIf sutures are placed too deeply through the rectal wall
BleedingFrom uterosacral-ligament vessels
Altered defecation28% reported altered defecation in Baessler / Schuessler’s combined sacrocolpopexy series; 31 of 33 women returned for follow-up at 12–48 months. The authors considered possible denervation during rectal mobilization.[7]

Outcomes Summary​

SettingResult
Standalone enterocele prophylaxis at vaginal hysterectomy10/33 posterior enteroceles after vaginal Moschcowitz-type repair versus 2/32 after McCall at 3 years in the cited trial[1]
Adjunct at abdominal sacrocolpopexyNo enterocele or vault recurrence among 31 of 33 women who returned for follow-up at 12–48 months (mean 26) in a small combined-operation series; independent closure benefit unestablished[7][6]
Primary treatment of rectal prolapseHistorical sliding-hernia operation; modern operation selection includes several abdominal and perineal approaches[5][8]

Current Status​

Current status of the Moschcowitz procedure:

  • The studied vaginal Moschcowitz-type prophylaxis produced more posterior enteroceles than McCall at 3 years.[1]
  • The original rectal-prolapse role is historical; contemporary rectal-prolapse repair offers several approaches.[5][8]
  • Cited series describe adjunctive Moschcowitz closure at sacrocolpopexy without testing whether closure is necessary or specifying a standard technique.[7][6]
  • A laparoscopic modified Moschcowitz repair was reported in three women, with no identified enterocele recurrence at 7–15 months.[3]
  • Circumferential placement warrants ureteral attention; sagittal Halban placement avoids lateral bites, but comparative injury rates have not been established.

Key Principles​

  • The Moschcowitz procedure obliterates the cul-de-sac with concentric purse-strings from deep to superficial; its original rectal-prolapse design and later enterocele applications are distinct.[5][9]
  • Protect the ureters by identifying their actual course and avoiding compromising bites; assess patency when indicated by the full repair.[9]
  • Incorporate seromuscular rectum (never full thickness) and posterior vaginal-wall peritoneum or fascia.
  • Use several concentric purse-strings deep-to-superficial; no fixed suture count is established by the cited source.[9]
  • The cited randomized trial favored McCall over vaginal Moschcowitz-type repair at vaginal hysterectomy (2/32 versus 10/33 posterior enteroceles at 3 years).[1]
  • Halban (sagittal) closure is the orientation alternative that avoids lateral bites; a lower ureteral-injury rate has not been measured.[9]
  • In historical combined sacrocolpopexy descriptions, cul-de-sac closure can occur before mesh peritonization.[6][7]
  • Delayed small bowel obstruction was reported after Moschcowitz closure in one case report; its frequency is unknown.[4]

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. 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.

10. 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.

11. Sussman RD, Brown ET, Dmochowski RR. Enterocele Repair. In: Smith JA Jr, Dmochowski RR, Thomas JC, Preminger GM, eds. Hinman's Atlas of Urologic Surgery. 5th ed. Elsevier; 2025:700-705.

12. 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

13. Dash KK, Dasgupta A, Pal A, et al. "Comparison of transvaginal sacrospinous ligament fixation with abdominal sacrocolpopexy in treatment of post-hysterectomy vault prolapse-a prospective randomized study." Int J Reprod Contracept Obstet Gynecol. 2022;11(1):177-182. doi:10.18203/2320-1770.ijrcog20215099

14. 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