A variety of operations now exists for the treatment of vaginal vault prolapse and the reestablishment of apical support—from abdominal sacral colpopexy and abdominal uterus sacral suspensions, to sacrospinous vaginal vault suspensions, sacrospinous hysteropexies, and iliococcygeal vaginal vault suspensions.
All options have been described in the literature as being effective operations with minimal complications and varying degrees of success, but the optimal approach for vaginal vault prolapse remains a subject of debate. Unfortunately, many surgeons are not comfortable with vaginal surgery, despite the safety, speed, and effectiveness that sacrospinous vaginal vault suspension and its modifications can provide in experienced hands.
Sacrospinous vaginal vault suspension was originally described by Dr. Paul Zweifel in Germany in 1892. It was “rediscovered” in 1951 by Dr. I.A. Amreich in Austria, modified by Dr. J. Sederl, and then studied and described extensively in 1968 by fellow Austrian Dr. K. Richter.
The operation received more attention when Dr. C.L. Randall and Dr. D.H. Nichols reported on it (Obstet. Gynecol. 1971;38:327–32). Since then, the posterior approach to sacrospinous vaginal vault suspension that was described by Dr. Nichols has been modified, and an alternative approach through the anterior compartment of the vagina has been developed and described. Several newer devices, in the meantime, have offered improved safety and simplicity.
The Original Posterior Approach
The posterior approach to sacrospinous vaginal vault suspension involves a posterior vaginal incision, perforation of the rectal pillars, and blunt dissection of the pararectal space anterior to the ligament.
In the original posterior approach described by Dr. Nichols, two Allis clamps are placed at the level of the hymenal ring, approximately 1 cm from the midline, and a dilute vasopressin solution can be used to infiltrate underneath the posterior vaginal wall to within 1 cm of the apex of the vagina. The scalpel is used to make a transverse incision between the Allis clamps, and then the Metzenbaum scissors are used to dissect underneath the vaginal epithelium in the midline, vertically to within 1 cm of the apex of the vagina.
The Metzenbaum scissors can be used to spread beneath the vaginal epithelium and smooth muscle to free the underlying endopelvic connective tissue from its attachments on the undersurface of the vaginal epithelium and smooth muscle. (See photo.) The scissors can then be used to make a vertical incision in the posterior vaginal wall to about 1–2 cm away from the vaginal apex.
Placement of Allis clamps—or self-restraining retractor hooks—on the incised edges of the vaginal epithelium and smooth muscle can allow for exposure and resection of the endopelvic connective tissue from the undersurface of the vaginal epithelium and smooth muscle laterally to the level of the rectal pillars. This may be facilitated by countertraction from your assistant, using tissue forceps on the endopelvic connective tissue.
Once this dissection is complete, the ischial spine on the patient's right side may be palpated, and—with either sharp dissection with the tips of the Metzenbaum scissors or blunt dissection with the operator's right index finger—the endopelvic connective tissue can be swept from anterior-lateral to medial of the ischial spine across the coccygeus muscle to remove the fatty tissue that overlies the ischial spine and the sacrospinous ligament.
The entire coccygeus muscle with its anterior sacrospinous ligament should be palpated, and the rectum and pararectal attachments mobilized bluntly with the index finger from lateral to medial. This is a relatively blood-free plane, and such a maneuver is possible with minimal bleeding so long as the affecting finger remains anterior to the ischial spine and sacrospinous ligament.
A short Breisky-Navratil retractor can then be placed at the 10 o'clock position, resting on the ischial spine. By maintaining your right index finger against the ischial spine, you can then insert a long Breisky-Navratil retractor directly opposing the short retractor over the ventral surface of your finger, against the ischial spine with its posterior edge just anterior to the coccygeus muscle.
Sweeping this long retractor counterclockwise immediately across the coccygeus muscle, keeping its posterior blade in contact with the muscle throughout, will mobilize the rectal and pararectal fat medially and expose the coccygeus muscle and sacrospinous ligament. This retractor should be held at approximately the 2 o'clock position, creating a 60- to 90-degree angle with the other Breisky-Navratil retractor. (The exact angle will depend on the angle of the pubic arch.)
At this point, the right-angle Haney retractor can be placed at approximately the 7 o'clock position over the coccygeus muscle and then, with posterior traction, withdrawn distally until it pops down in front of the coccygeus muscle, exposing this muscle and sacrospinous ligament.