Sacrospinous Vaginal Vault Suspension: Variations on a Theme

This approach, the thinking goes, allows for a wider width of the vaginal apex in the posthysterectomy patient, as well as good lateral support.

Often, a bilateral sacrospinous ligament suspension may be augmented by bilateral paravaginal defect repairs performed through the vagina, with or without the use of an adjuvant graft. The dissection for placement of these sutures is identical to the ipsilateral dissection for sacrospinous vaginal vault suspension, just described, on the patient's right side; it also can be performed on the patient's left side, with care taken to mobilize the rectum medially (which is often a more challenging task on the patient's left side).

Bilateral suspension to the sacrospinous ligament has not, however, been compared directly to unilateral sacrospinous vaginal vault suspension. Sometimes, when scarring exists in the midline from prior vaginal hysterectomy, or when an enterocele repair has been performed, there may be indentation in the midline of the vaginal vault, creating a somewhat Y-shaped vagina.

In a report published in 1997, Dr. J.F. Pohl and Dr. J.L. Frattarelli concluded that bilateral suspension is feasible in many patients, but that it requires significant intraoperative judgment both as to its feasibility and as to the width of the vaginal cuff that will allow a bilateral suspension without tension (Am. J. Obstet. Gynecol. 1997;177:1356–61).

In our practice, we tend to prefer right-sided vaginal vault suspensions in which we utilize either an anterior approach or a posterior approach, with a left-sided iliococcygeus vaginal vault suspension. This requires less dissection and less risk of bleeding, as the sutures are placed lateral to the ischial spine.

It also creates a vagina with further cephalad elevation of the right vaginal apex than the left vaginal apex, as well as an ample apical width.

Anterior sacrospinous suspension is an approach that we have pursued and described in order to address possible shortcomings or limitations of the conventional posterior approach—chiefly, recurrence of anterior vaginal wall prolapse and a deep posterior angle and narrowing of the upper one-third of the vaginal vault.

Whereas posterior suspension uses a posterior vaginal incision and pararectal dissection, anterior suspension uses an anterior vaginal incision, perforation into the right retropubic space, and dissection of the ipsilateral paravaginal space from the level of the bladder neck to the ischial spine, to create a wide space to accommodate the vaginal vault.

In our experience—Dr. Harvey A. Winkler, Dr. Janet E. Tomeszko, and I first reported on the technique in 2000—the anterior approach appears to reduce postoperative proximal vaginal narrowing and lateral deviation of the upper vagina by avoiding passage through the rectal pillars (Obstet. Gynecol. 2000;95:612–5).

The technique involves opening the anterior vaginal wall and separating the endopelvic connective tissue on the patient's right from the pubic ramus at the level of the bladder neck to the ischial spine, exposing the paravesical and pararectal space. The sacrospinous ligament is identified and isolated through this space.

Two permanent sutures are placed approximately 2 cm apart through the ligament, anchored with pulley stitches underneath the vaginal epithelium and smooth muscle, and tied down to the ligament.

An Evolution in Instrumentation

The Deschamps ligature carrier is the device originally used for applying sutures through the coccygeus muscle and sacrospinous ligament. However, because the ligature carrier is delivered posterior-laterally to anterior-medially, there always has been concern about potential damage to the pudendal artery, vein, and nerve.

With the advent of newer devices that deliver the suture in a limited arc from the anterior to posterior direction, the risk of damage to the pudendal complex has been significantly minimized and the need for extensive dissection is often unnecessary. The newer devices have thus improved not only the safety of the procedure but also its simplicity, and they have reduced the operative time required.

The first of these devices described for applying sutures in a defined arc from anterior to posterior was the Miya hook, described by Dr. F. Miyazaki.

Another new device, the Capio device, is a push-and-catch suture delivery system that allows the suture to be delivered over a defined arc into a catch device. The Capio device has enabled placement of sacrospinous sutures through palpation and without direct visualization of the ligament. This further limits the need for dissection of the perirectal space, potentially improving safety and reducing blood loss.

Other authors have described using the Schutt device, which also delivers a suture from anterior to posterior in a defined arc to improve the safety and speed of the procedure.

Evolving Research