DOI: 10.1111/tog.
12724 2021;23:148–53
The Obstetrician & Gynaecologist
http://onlinetog.org
Manchester repair (‘Fothergill’s
operation’) revisited
a b
Dhanuson Dharmasena MRCOG, Clive Spence-Jones
Wai Yoong MD FRCOG*d
a
ST6 Trainee in Obstetrics and Gynaecology, North Middlesex University Hospital, Sterling Way, London N18 1QX, UK
b
Consultant Obstetrician and Urogynaecologist, Whittington Hospital, Magdala Ave, London N19 5NF, UK
c
Urogynaecology Subspecialist, Whittington Hospital, Magdala Ave, London N19 5NF, UK
d
Consultant Obstetrician and Gynaecologist, North Middlesex University Hospital, Sterling Way, London N18 1QX, UK
*Correspondence: Wai Yoong. Email: waiyoong@nhs.net
Accepted on 4 June 2020. Published online 17 March 2021.
Please cite this paper as: Dharmasena D, Spence-Jones C, Khasriya R, Yoong W. Manchester repair (‘Fothergill’s operation’) revisited. The Obstetrician &
Gynaecologist 2021;23:148–53. https://doi.org/10.1111/tog.12724
Introduction
Anatomical uterine prolapse affects 14% of postmenopausal
women,1 and an estimated 175 000 apical compartment
surgeries are performed annually in the USA.2 In England,
approximately 29 000 prolapse repairs were performed
between 2010 and 2011, at a cost of £60 million. With an
aging female population, this number will probably increase.3
Furthermore, 1 in 10 women will need at least one surgical
procedure, with the rate of recurrence being as high as 19%.4
While vaginal hysterectomy (VH) remains the best known
and most practised procedure worldwide for uterovaginal
prolapse,5–7 there is a demand for minimally invasive and
robotic surgery, and many patients now prefer uterus-
preserving procedures.8 Reasons for this include the desire to
maintain future fertility, a belief that the uterus affects sexual
function or sense of identity and surgical concerns about
vaginal hysterectomy. Several recent studies have shown that
uterus-sparing techniques lead to shorter hospital stay and
less morbidity than VH.9,10 The landscape of surgery in
urogynaecology has changed dramatically over the last
decade,5 with the use of mesh for prolapse and
incontinence surgery coming under much scrutiny by NHS
England. Members of the public are currently more mesh
averse owing to the high media profile raised by
complications and litigation cases. Clinicians must therefore
be able to advise patients about alternative non-mesh
options. This may lead to a revival of historic techniques,
such as Manchester repair, which utilises autologous tissue.
The British Society of Urogynaecologists (BSUG) and
National Institute for Health and Care Excellence (NICE)
have recently developed a decision aid, which includes the
Manchester repair as a choice.11
148
Tips and techniques
Articles in the Tips and techniques
section are personal views from
experts in their field on how to
carry out procedures in obstetrics
and gynaecology.
c
FRCS FRCOG, Rajvinder Khasriya PhD MRCOG,
The Manchester repair was first described in 1908 by
Professor Donald, from Manchester,12 and later modified by
his colleague Professor Fothergill13, from the same city. The
Manchester repair involves excision of the elongated cervix
and approximation of the cardinal ligaments anterior to the
cervix to elevate and retract it so that the uterus is both
anteverted and supported.
Originally designed for women with second and third-degree
uterine descent, the Manchester repair has a short operating time,
is associated with low morbidity and has the possibility of day
case discharge.14,15 The procedure had become ‘unfashionable’
for some years, but recent studies by Tolstrup and co-authors
have shown it to be superior to VH.10,11 The alternatives to this
procedure include sacrospinous hysteropexy, mesh or suture
hysteropexy and hysterectomy with vault suspension; these are
beyond the remit of this article and are not covered here. The
authors have included an edited video of the procedure, which is
provided as online supporting information (Video S1).
Indications
The indication for Manchester repair includes patients:
 with cervical elongation
 with second and third-degree uterine prolapse who wish to
retain their uterus/reproductive function.
It may also be a safe option for patients who are mesh averse,
or for those who have considerable adhesions from previous
pelvic surgery because the peritoneal cavity is not breached.
Decision aids provided by NICE and BSUG16 can help the
patient to decide which surgical approach they prefer, in
conjunction with discussions after a urogynaecology
multidisciplinary team (MDT) meeting. Contraindications
are listed in Box 1. Patients must be made aware of possible
ª 2021 Royal College of Obstetricians and Gynaecologists

Box 1. Contraindications of uterine-preserving surgery
 Abnormal or postmenopausal bleeding
 Endometrial pathology
 History of recent or current cervical dysplasia
 Tamoxifen therapy
 Hereditary nonpolyposis colonic cancer (40–50% lifetime risk of
endometrial cancer)
 Familial cancer BRAC1 and BRAC2 (increased ovarian cancer risk and
theoretical risk of fallopian tube and serous endometrial cancer)
 Unable to comply with routine gynaecology surveillance and follow-
up
Box 2. Complications of Manchester repair
 Haemorrhage
 Bladder/bowel injury
 Infection (urinary tract infection)
 Cervical stenosis (leading to haematometra/pyometra)
 Cervical incompetence (leading to preterm labour/miscarriage)
 Dyspareunia
Box 3. Simplified steps of Manchester repair
1. Cervical dilatation and endometrial biopsy
2. Circumferential cervical incision
3. Securing cardinal complex
4. Amputation of the cervix
5. Insertion of Sturmdorf suture, plication of cardinal ligament
followed by Fothergill suture
Anterior and posterior colporrhaphy if required
perioperative complications (see Box 2), such as haemorrhage
and injury to the bladder or rectum, and urinary tract or
localised infection. Late complications include cervical stenosis
(leading to haematometra), dyspareunia, cervical
incompetence and dystocia. Clinicians must also emphasise
that Manchester repair is not suitable for women who have yet
to complete their family; data for pregnancy outcomes
following this procedure are limited to small case series17-20
and prophylactic cervical cerclage may be required to support
future pregnancy.21
Patient position and anaesthesia
As with similar vaginal procedures, the patient should be
placed in the lithotomy position, with buttocks just
overhanging the edge of the operating table. A self-
retaining vaginal retractor such as the Lone Star retractor
(Cooper Surgical Inc., Trumbull, USA) is often useful to
maximise exposure to the surgical field. The procedure can
be carried out under general or regional anaesthesia.
ª 2021 Royal College of Obstetricians and Gynaecologists
Dharmasena et al.
Procedure
Intravenous antibiotics (for example, co-amoxiclav 1.2 g) at
induction are usually administered and an indwelling Foley
catheter may be inserted, depending on surgeon’s preference.
The steps of this procedure are summarised in Box 3. The
anterior and posterior lips of the cervix are grasped with
Vulsellum tissue forceps and a uterine sound used to assess the
cavity length. The cervical os is then dilated using a Hegar
dilator (up to H8) to facilitate subsequent uterine drainage and
help prevent cervical stenosis following the procedure. A
secondary advantage of dilating the cervical canal is to facilitate
the passage of the needle at the time of the Sturmdorf and
Fothergill sutures. It is also prudent to perform an endometrial
curettage to obtain an endometrial sample.
The vaginal skin is infiltrated with 20 ml of bupivacaine
0.5% (w/v) and adrenaline 1: 200 000 to effect vasoconstriction
and to create a plane of dissection.
A circumferential incision is made around the cervix and
the bladder carefully mobilised (Figure 1) to prevent
inadvertent injury during subsequent cervical amputation.
Ensure that the anterior incision is deep enough to expose the
cervix. The elongated cervix can be further skeletonised and
cleared of pericervical tissue by blunt dissection using the
surgeon’s index finger (wrapped with a gauze swab) to push
gently in the direction of the bladder (Figure 2). When
skeletonising the cervix, it is important to stop at the
uterovesical fold and not to breach the peritoneal cavity.
Unnecessary dissection beyond this level increases the risk of
bleeding and of inadvertently entering the myometrium.
Posteriorly, the cervical incision is continued and the vaginal
skin and rectum are similarly freed using sharp and blunt
dissection (Figure 3). An assistant can facilitate this step by
applying traction to the posterior cervical lip in an
upwards direction.
To display the field of surgery, assistants should use
Langdon lateral wall retractors to create good exposure. The
uterosacral–cardinal ligament complex can be palpated as a
narrow band of dense tissue traversing the lateral side of the
cervix. The cardinal ligament and the descending branch of
the uterine artery are secured bilaterally with a 1-0 absorbable
polyfilament polyglactin 910 (1-0 Vicryl; Ethicon, Somerville,
NJ, USA) suture (Figure 4). The cervix is now amputated
from the uterus using a scalpel or cutting point diathermy
(40W) (Figure 5). The authors suggest mobilising vaginal
skin anterior to the point at which the cervix is amputated so
that the cardinal ligament can later be easily reattached as
part of the Fothergill suture.
A Sturmdorf suture (using 1-0 Vicryl; Ethicon) is used to
re-epithelise the posterior portion of the excised cervix while
leaving the cervical canal open, thus ensuring adequate
drainage. The suture passes from the posterior vaginal skin
on one side to the inner aspect of the cervical canal. The
149
 Manchester repair
Figure 1. Anterior cervical incision made at the level of the vaginal
rugae.
needle is then driven to secure the mid-portion of the
posterior vaginal wall and then passes back to the cervical
canal and posterior vaginal skin on the contralateral
side (Figure 6).
The cut ends of cardinal ligaments are brought across the
anterior surface of the cervix remnant and sutured using an
interrupted 0-0 delayed absorbable monofilament polydioxan
suture (0-0 PDS; Ethicon); this has the effect of supporting
and anteverting the uterus. The Fothergill suture (Figure 7)
allows the vaginal skin to cover the anterior portion of the
Figure 2. The anterior cervical incision must be sufficiently deep, and blunt dissection is used to mobilise the bladder.
150
amputated cervix and also approximates the incised cardinal
complex to help suspend the uterus.
The pubocervical fascia is dissected off the vaginal mucosa
and later plicated in the midline using interrupted 2-0
delayed absorbable monofilament polydioxone sutures (2-0
PDS; Ethicon). The redundant portion of the vaginal mucosa
is excised and the margins are reconstructed using 2-0
absorbable polyfilament polyglactin 901 sutures (2-0 Vicryl,
Ethicon). If other compartment defects are noted during the
procedure, these can be corrected concurrently.
With enhanced recovery techniques, the Manchester repair
is suitable as a day case, in which case the indwelling catheter
is removed at the end of surgery and no vaginal pack is left
in place.
Discussion
The current tendency for patients to prefer non-mesh
surgical options for pelvic organ prolapse (POP) has led
clinicians to revisit historic repair techniques using native
tissue, such as Manchester repair. The 2016 systematic review
by Tolstrup and colleagues9 compared the efficacy of
Manchester repair with VH for the treatment of POP.
Although the data were predominantly retrospective and
unmatched, the authors assessed the outcomes of nine
studies of Manchester repair versus VH (cumulative total:
2674 Manchester repair versus 3671 VH cases). They noted
that symptomatic POP recurrence was higher after VH (9%–
13%) compared with the former procedure (3%–10%).
Furthermore, there were no statistical differences in sexual
function, quality of life or urinary dysfunction between the
two procedures, with the Manchester repair group having less
need for blood transfusion (3% versus 6%). In their 2018
ª 2021 Royal College of Obstetricians and Gynaecologists

Figure 3. Applying upward traction to the posterior cervical lip, a similar incision is made on the posterior vaginal skin.
(a)
Figure 4. Securing (a) the right and (b) the left cardinal complexes.
cohort control study of Manchester repair (n = 295) versus
VH (n = 295) cases matched for age and preoperative POP
stages, Tolstrup and co-authors10 also confirmed that the rate
of recurrent or de novo POP in any compartment was higher
following VH (18.3% versus 7.8%; 95% CI 1.3–4.8), which
was also associated with more perioperative complications
(2.7% versus 0%; p = 0.007) and postoperative
intraperitoneal bleeding (2% versus 0%; p = 0.03)
compared with Manchester repair. There is therefore some
level II evidence (Canadian Task Force Levels of Evidence) to
indicate that outcomes following Manchester repair may be
superior to VH and that this less invasive procedure should
be preferable to VH if there are no other indications
for hysterectomy.
ª 2021 Royal College of Obstetricians and Gynaecologists
Dharmasena et al.
(b)
The inherent risk of developing future uterine pathology
following Manchester repair can be mitigated by performing
a routine preoperative ultrasound scan or endometrial biopsy
at the time of surgery. A retrospective Turkish study followed
204 premenopausal women over a median follow-up time of
five years after Manchester repair and reported no cases of
endometrial neoplasm.15 Similarly, Engelbredt, Glavind and
Kjaerdgaard22 published a case series of 299 women who
underwent Manchester repair and reported no evidence of
cervical or uterine malignancies after a mean follow-up of
7.8 years. Arguably, the rate of preinvasive cervical neoplasia
would be lower than in the baseline population because the
squamocolumnar junction would probably have been
surgically removed during the Manchester procedure. By
151
 Manchester repair
Figure 5. The skeletonised cervix (left) is amputated from the uterus.
Figure 6. Sturmdorf suture to re-epithelise the posterior portion of
the excised cervix. Figure created by Dhanuson Dharmasena.
Figure 7. Fothergill suture to plicate the cardinal complex and
approximate anterior vaginal skin. Figure created by Dhanuson
Dharmasena.
contrast, the rate of endometrial cancer/hyperplasia is
unaffected because the uterine corpus is not involved in the
procedure. Any postmenopausal bleeding after Manchester
repair would warrant an urgent gynaecological referral,
although post-procedure cervical stenosis means this may
be missed in occult cases.
Being a uterine-sparing option, Manchester repair patients
can potentially conceive afterwards, but there are risks during
the pregnancy. There are, in fact, very few published data on
fertility rates and pregnancy outcomes following the procedure
152
because most case series and systemic reviews relate to
postmenopausal women. A 1951 case series of seven women
of child-bearing age (range: 23–37 years at time of surgery) who
underwent Manchester repair revealed reduced fertility and
increased rates of pregnancy loss, as well as intrapartum
complications.17 In 1970, Tipton and Atkins18 reported two
successful births in five women planning pregnancy after the
procedure, but did not specify outcomes or mode of delivery.
Rouzi et al. (2009)19 published a series of seven women (mean
age 32.4  5.2 years) with prolapse who underwent
Manchester repair because they wanted to conceive. Of the
seven, two became pregnant (28.6%) and had vaginal births
with episiotomy, but no further details were provided as to why
the remaining five failed to conceive. More recently, Jasonni,
Matonti and Alfieri (2017)20 described four women who
conceived following Manchester repair (age range 33–
37 years), culminating in two vaginal births at 35 and 36
weeks of gestation and two caesarean sections at 35–37 weeks of
gestation. More contemporary data on conception, which
could be comparable, was published by Kim and co-authors,21
who reported 10 pregnancies in 36 patients following vaginal
radical trachelectomies (RT) for early stage uterine cervical
carcinoma. They concluded that preterm labour and preterm
prelabour rupture of membranes (PPROM) were serious
complications and, despite prophylactic insertion of cerclage at
the time of RT using nylon suture, only six of the 10 women
delivered after 24 weeks of gestation. Thus, Manchester repair
is more suitable for women who have completed their family. If
future pregnancy is contemplated, patients should be
counselled about the risk of preterm labour, PPROM and the
need for elective cervical cerclage.
Although Manchester repair has declined in popularity over
the last half a century, this minimally invasive procedure is
relatively safe, with a shallow learning curve and good surgical
outcomes. The current pause in mesh-associated procedures
ª 2021 Royal College of Obstetricians and Gynaecologists

and the increase in patient preference for uterine-preserving
surgery means that this operation should be offered as an
option in appropriately selected patients. Despite this,
Manchester repair is not included in Urogynaecology and
Vaginal Surgery Advanced Training Skills Modules, or even in
the subspecialty training curriculum.
Given the paucity of long-term data on Manchester repair,
it is crucial that surgeons intending to perform this
procedure upload their surgical data onto the online BSUG
Audit database so that clinicians can reflect on surgical
outcomes and improve patient care.
Disclosure of interests
WY is an Associate Editor of The Obstetrician &
Gynaecologist. He was excluded from editorial discussions
regarding the paper and had no involvement in the decision
to publish. The other authors have no conflicts of interest.
Contribution to authorship
DD performed the literature search, edited the video and
wrote the article. RK co-wrote the article. CSJ and WY
initiated the project, performed the procedures and co-wrote
the manuscript.
Supporting Information
Additional supporting information may be found in the
online version of this article at http://wileyonlinelibrary.
com/journal/tog
Video S1. A demonstration of the Manchester repair.
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