Sacrospinous Ligament Suspension, With and Without Mesh

Vaginal retractors (I prefer the Breisky-Navratril retractors) are used to gain exposure to the sacrospinous space until the ligament is visualized. The suture is placed around the sacrospinous ligament approximately two fingerbreadths medial to the ischial spine, with care given to avoid injury to the pudendal neurovascular bundle (Fig. B).

A permanent suture (Ethibond or Gore-Tex) is used for a pulley stitch attachment, while a delayed absorbable suture such as polydioxanone (PDS) is used for a full thickness vaginal attachment. A second suture may be placed just slightly medial to the first at the surgeon's discretion. Bilateral sacrospinous sutures also could be placed. Bilateral suspension sutures are especially useful when considering mesh augmentation of the anterior and/or posterior segment.

More recently, traditional devices have been replaced with the Capio needle driver. This is a disposable multiuse suture retrieval device which makes sacrospinous ligament suspension significantly easier, faster, and safer. The device has a medium caliber shaft with a plunger for suture application. The end has a hook which allows push-catch retrieval of a small needle-based suture. Various permanent and delayed absorbable sutures are available. Under direct finger guidance, the device is used to hook the sacrospinous ligament at the appropriate location. Depression of the plunger passes the needle through the ligament, and the needle is then retrieved by fins on the other side. Removal of the device completes placement of the suture.

One of the true benefits of the Capio needle driver is the ability to perform suture placement under direct finger guidance without the need for visualization using retractors – a benefit that minimizes the extent of dissection and the time involved. In my opinion, this device has revolutionized sacrospinous suspension by allowing more physicians to perform the procedure safely and effectively.

The next evolution in sacrospinous suspension will include anchor-based single-point attachment – an approach that has recently become available and may supplant traditional suture placement, which can potentially strangulate tissue and result in postoperative pain. Additional clinical experience is required before this technique can be supported, but initial results are encouraging, especially with respect to postoperative sacrospinous pain.

Completion of Procedure

Once the suture(s) are in place, a rectal exam is recommended to exclude unintentional rectal injury or suture placement. Once confirmed, tie-down of the sutures can be completed. In cases of simple sacrospinous suspension, the suture is taken through the vagina at the apex marked prior to initial incision. Two techniques are available for this.

The traditional pulley technique with permanent suture is taken through full thickness vagina excluding the epithelium, and then tied down prior to closure of the mucosal incision, thereby burying the knot under the mucosa. This sometimes can be technically confusing and difficult, and may reduce the strength of vaginal attachment. The benefit of this technique is use of a permanent suspension suture.

An alternative technique utilizes delayed absorbable suture and involves both arms of the suture being taken through the full thickness vaginal mucosa at the apex (Fig. C, D). The mucosal incision is then closed followed by suture(s) tie-down (Fig. E, F)F I prefer this technique as it is technically easier and allows full thickness attachment of the vagina. More importantly, it gives the surgeon easy access to the suspension sutures if the sutures need to be removed in the postoperative period in cases of persistent postoperative pain.

Regardless of technique, it is important to tie down the suture securely, but not tightly, as strangulation of the sacrospinous tissue may increase the chances of postoperative pain.

I prefer bilateral sacrospinous suspension sutures with only one attachment on each side in order to minimize deviation of the vagina to one side as well as to maximize support. A single suture on each side also removes any confusion over which suture may be involved in uncommon intraoperative complications such as rectal penetration or ureteral kinking.

If mesh/graft augmentation is being performed, the bilateral sacrospinous suspension sutures are taken through the apical lateral extensions of the trapezoid-shaped mesh and tied down. Although permanent suture can be used for this technique, I would recommend the use of delayed absorbable suture; permanent suture can sometimes strangulate the sacrospinous ligament with contraction of the mesh/graft over time.

After initial tie-down, these suspension sutures then can be taken through the vaginal apex as described above for further apical support. The distal ends of the mesh are then attached to the pubocervical fascia lateral to the bladder neck or the perineal body, depending on whether the procedure involves anterior or posterior mesh placement, respectively.