What is the Vaginal Vault
The vaginal vault is the uppermost portion of the vagina, specifically the top 2.5 cm measured posteriorly from the apex (highest point) of the posterior vaginal wall. 1
Anatomical Structure
The vaginal vault corresponds to Level I of the vaginal anatomy and comprises four distinct components 1:
- Anterior fornix: The area through which the cervix protrudes (or where it is removed during hysterectomy) 1
- Posterior fornix: The posterior-most recess 1
- Two lateral fornices: The side recesses 1
Ligamentous Support System
Before hysterectomy, the vault receives structural support from 1:
- Uterosacral ligaments (USL): Provide posterior support to the cervix and upper vagina 1
- Cardinal ligaments (CL): Provide lateral support 1
- Cardinal-uterosacral ligament complex: The distal segments of these ligaments fuse together, forming a combined support structure approximately 2-3 cm in length 1
Post-Hysterectomy Changes
After hysterectomy, the support architecture changes significantly 1:
- The anterior fornix retains some residual USL support 1
- The posterior fornix loses its ligamentous support entirely, making it particularly vulnerable to prolapse 1
- The vaginal vault becomes the "vaginal cuff" or "cuff scar" 2
Clinical Significance
The vaginal vault is clinically important because 3, 4:
- Vaginal vault prolapse represents descent of the apex of the vagina after hysterectomy 2
- It is a common complication following vaginal hysterectomy, negatively impacting quality of life through associated urinary, anorectal, and sexual dysfunction 4
- Adequate suspension of the vaginal apex during hysterectomy using shortened cardinal and uterosacral ligaments draws the proximal vagina over the levator plate, providing support for the distal vagina 3
Common Pitfall
The most critical error is failing to provide adequate vault support during hysterectomy, as preexisting pelvic floor defects prior to hysterectomy represent the single most important risk factor for subsequent vault prolapse 4. Proper surgical technique at the time of hysterectomy, such as McCall's culdoplasty under direct visualization, has been shown to be superior in preventing this complication 4.