Master Class

Sacrospinous Ligament Suspension, With and Without Mesh


 

The sacrospinous ligament suspension technique was first described by Karl Richter in 1968 and later introduced into the United States by David H. Nichols and Clyde L. Randall in 1971. It has been and continues to be an effective technique for apical suspension via the vaginal route, and is a valuable addition to the surgical armamentarium of the gynecologic surgeon.

In the 1990s, the procedure was done less frequently because of the popularity of uterosacral ligament suspension. Recently, however, sacrospinous ligament suspension has regained popularity for various reasons. The uterosacral ligament technique, for one, requires peritoneal entry, and the ligament is often of variable strength and also can sometimes be difficult to identify.

In addition, new tools and variations in technique, such as use of the Capio needle driver, have made sacrospinous ligament suspension easier and safer. Finally, the popularity of vaginal mesh procedures has created renewed interest in sacrospinous suspension as a direct visualization attachment technique for apical mesh, compared with trocar/needle-based techniques, which involve blind passage and possible injury to the bowel and bladder.

With proper technique, the procedure is safe, effective, and durable and has few complications related to future sexual function. Long-term success rates have been excellent in properly selected patients.

Indications

Various techniques of apical suspension are available to the gynecologic surgeon. Sacrospinous suspension is indicated in patients with adequate vaginal length who desire a vaginal procedure. An office-based exam should be performed to assess vaginal length and location/severity of prolapse.

Oftentimes, the procedure can be performed using the traditional technique with attachment of the vaginal mucosa or with mesh augmentation using the sacrospinous sutures as the apical mesh attachment points. In my practice, the procedure is contraindicated in patients with a short vagina, chronic pelvic pain, or any history of sciatica.

Prior to Surgery

Vaginal exam prior to initial dissection is helpful in ensuring that the vagina is of adequate length to reach the sacrospinous ligament. Marking of the vaginal apex for placement of suspension sutures sites also is helpful. The vagina is reapproximated to either or both sacrospinous ligaments using an Allis clamp, which is then adjusted in order to maximize vaginal length and reapproximation to the corresponding ligament. The location of the Allis clamp is then tagged with a full thickness marking suture.

Surgical Dissection

The procedure begins with entry into the sacrospinous space. Traditionally, this dissection has been described through a posterior vaginal mucosal incision associated with rectocele repair. A midline incision is made from the perineal body to the vaginal apex. The vaginal mucosa is then dissected off the underlying rectovaginal septum distally and any enterocele proximally. In the upper third of the vagina, lateral dissection is extended in the pararectal space until areolar tissue is encountered. Blunt dissection is then performed toward the ischial spine in a back-and-forth manner.

The relevant anatomy including the ischial spine, the sacrospinous ligament, the coccygeus muscle, and the lateral side wall with White's line, is identified (Fig. A). An identical dissection is performed on the contralateral side.

An anterior approach to sacrospinous suspension was described by Peter K. Sands et al. in 2000. This is especially helpful if the patient has only anterior and apical defects without the need for rectocele dissection or is undergoing an anterior mesh augmentation procedure. The anterior vaginal wall is opened, and the endopelvic connective tissue is separated 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 defect.

Perhaps the easiest method of entering the sacrospinous space is through a midcompartment approach just lateral to the enterocele. This is often described with isolated apical/enterocele defects. The vaginal mucosa over the apex/enterocele is incised in the midline. The edges of the incision are grasped using Allis clamps, and lateral dissection is performed between the vaginal mucosa and enterocele sac until loose areolar tissue is noted. Blunt finger dissection in a back-and-forth motion is performed to the ischial spine.

An identical procedure is then performed on the contralateral side. Such midcompartment dissection is associated with very little bleeding and quick access to the sacrospinous space.

Suture Placement

A variety of tools and techniques have been described to place the sacrospinous suspension sutures. Traditionally, suture placement has been described using a standard needle holder, Miya hook, Des-Champs ligature, Shutt punch, or Nichols-Veronikis ligature carrier. Each device is loaded with the suture/needle.

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