The sacrospinous fixation is likely the most popular vaginal approach to vaginal vault suspension in the United States (US). Initially described in Germany and popularized in the US during the 1980s, this procedure has a high degree of effectiveness and longevity in restoring vaginal vault support. The vaginal apex is attached to the sacrospinous ligaments with permanent or delayed absorbable sutures. The procedure can be performed via a posterior vaginal dissection or anterior paravaginal dissection, and unilaterally or bilaterally. The main drawback of this procedure is the well-recognized recurrence of anterior vaginal wall defects. Because of the downward deviation of the vaginal axis, the anterior vaginal wall is more subject to transmission of intraabdominal pressure and creation of a significant cystocele. In our experience, the resultant cys-tocele typically does not extend beyond the vaginal introi-tus and is typically not symptomatic. In addition, when a bladder neck suspension procedure or mid-urethral sling is performed concomitantly, there is a well-recognized risk of postoperative voiding dysfunction.
Over the past few years, the number of sacrospinous fixations performed at our center has decreased with the advent of new vaginal vault suspension techniques and technology. When we perform a sacrospinous fixation, we will use a posterior vaginal dissection. The patient is placed in high stirrups and the vaginal apices are marked with marking sutures. This will help identify both apices because our preference is for a bilateral sacrospinous fixation as a means of normalizing vaginal support. If the procedure is performed unilaterally, we believe there is a higher risk of cystocele or opposite-side enterocele development. We have found that most patients can undergo a bilateral procedure without difficulties.
Once the posterior vaginal wall has been infiltrated with a hemostatic agent, a vertical incision is made from the introitus to an area approximately 2 cm below the vaginal apex. The rectum and connective tissue are then dissected off of the vaginal mucosa bilaterally to the level of the lateral vaginal sulcus, and the pararectal space is entered.
The dissection is followed bluntly to the ischial spine. This is typically a fairly straightforward dissection. The loose connective tissue overlying the ischial spine and sacrospinous ligaments are then digitally cleared and the ligament is very clearly identified. We then place two CV-2 Gore-Tex sutures through each vaginal apex. Because we use Gore-Tex suture, we avoid full-thickness penetration of the vaginal mucosa with the suture material. If a woman's vaginal mucosa is significantly atrophic, we will use a small (2 x 3 cm) piece of Prolene mesh along the underside of either apex to enhance vaginal support. We then place each Gore-Tex suture through the mid portion of the ipsilateral sacrospinous ligament with a Miya hook. Other instruments are available for this purpose, but we have found the Miya hook to be quite acceptable and have not modified our instrument of choice. Once the sutures have all been placed, the upper half of the vaginal mucosal incision is closed. The Gore-Tex sutures are then to be tied, elevating the vaginal apex. Care must be taken to maintain appropriate vaginal symmetry when tying the sutures. Additional reconstructive surgical procedures can then be performed. Because these patients typically have a posterior enterocele as well, we will reattach any endopelvic fascia that has separated from the vaginal apex to the vaginal apex with permanent sutures to restore posterior wall fascial integrity.
Care must be taken in passing the hook through the sacrospinous ligaments. It is important to pass the hook through the ligament and not behind it, to avoid any damage to pudendal, sciatic, or other vascular or nerve structures. In addition, the sutures should be placed at least a finger breadth medial to the ischial spine.
In our series of 89 patients, our success rates have been quite positive.3 Recurrence of vaginal vault prolapse has been identified in only 2.2% of patients. When this occurs, it is typically because of the de novo occurrence of an apical midline enterocoele between the two sites of sacrospinous ligament suspension sutures. The placement of a submucosal reinforcing piece of mesh has not been demonstrated to enhance our outcomes. In addition, our reoperative rate for any recurrent prolapse was 4.5%, and cystocele development rate was 14.6%.
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