Sacrospinous Ligament Fixation
Table of contents
Operative Note
_ indicates a section that needs to be reviewed or completed.
I (or a fellow) will do the operative notes for procedures that I perform (and you assist). These notes are included here so that you can read about the procedure before we get to the OR - allowing you to familiarize yourself with both the steps of the procedure and nuances/dogma of my technique compared to another surgeon’s that you may have seen in the past. As you read the note, consider the instruments and anatomy. Consider how we maximize exposure and where the high risk portions of the procedure lie. Bonus points if you can customize the risk to the patients and their anatomy/history.
Posterior Approach
After informed consent was obtained, the patient was taken to the operating room where she was placed in the dorsal supine position. She then underwent uncomplicated induction of general anesthesia. She was repositioned in the dorsal lithotomy position with her legs in yellow fin stirrups. She was prepared and draped in a normal sterile fashion. A surgical timeout was performed and a Foley catheter was inserted into the bladder.
Examination of the vagina revealed the location of the new vaginal apex. This was tagged with a single stitch of 2-0 vicryl.
Attention was then turned to the posterior vaginal wall. A full thickness, vertical incision was made in the midline of the vagina after injecting with a dilute solution of epinephrine in normal saline (1:800,000). Dissection was then carried out sharply and bluntly through the rectovaginal septum and pararectal space until the ischial spine was palpated. The ischial spine on the patient’s right was localized and the sacrospinous ligament was cleaned.
The Capio needle driver was used with a MONODEK suture and the suture was placed through the ligament approximately 1.5cm medial to the ischial spine. This suture was used as a leader to pull two sutures of 0 PDS through the same location in the ligament. These were then passed through the new apex of the vagina.
The vaginal incision was closed in the midline using 0 Vicryl suture in a running fashion. The PDS sutures were then tied securing the vaginal apex to the right sacrospinous ligament.
Attention was then turned to the posterior repair following the injection in the perineal body and posterior vaginal wall with 1:800,000 dilute epinephrine solution. An inverted triangular incision was made along the perineal body and carried up to the posterior vaginal wall. The vaginal epithelium was dissected off the underlying endopelvic connective tissue in the midline using the Metzenbaum scissors. The excess vaginal epithelium was excised. The epithelium and underlying tissue was plicated in the midline using an 0 Vicryl. We then dissected out laterally to reach the fascia of the levator muscles at the level of the hymen. This was plicated in the midline using 0 Vicryl in an interrupted fashion. We then reapproximated the perineal body using a 0 Vicryl in an interrupted fashion. The perineal skin was then reapproximated using a 3-0 Vicryl in a running subcuticular fashion.
Sponge, lap, and needle counts were correct x2. The patient tolerated the procedure well, was taken to the recovery room in stable condition.
Anterior Approach
After informed consent was obtained, the patient was taken to the operating room where she was placed in the dorsal supine position. She then underwent uncomplicated induction of general anesthesia. She was repositioned in the dorsal lithotomy position with her legs in yellow fin stirrups. She was prepared and draped in a normal sterile fashion. A surgical timeout was performed and a Foley catheter was inserted into the bladder.
Examination of the vagina revealed the location of the new vaginal apex. This was tagged with a single stitch of 2-0 vicryl.
Attention was then turned to the anterior vaginal wall. A full thickness, vertical incision was made in the midline of the vagina after injecting with a dilute solution of epinephrine in normal saline (1:800,000). Dissection was then carried out sharply and bluntly through the paravesical space until the ischial spine was palpated. The ischial spine on the patient’s right was localized and the sacrospinous ligament was cleaned.
The Capio needle driver was used with a MONODEK suture and the suture was placed through the ligament approximately 1.5cm medial to the ischial spine. This suture was used as a leader to pull two sutures of 0 PDS through the same location in the ligament. These were then passed through the new apex of the vagina. These sutures were tagged and attention was turned to the anterior vaginal repair.
The epithelium of the anterior vaginal wall was then dissected off the underlying muscularis laterally and anteriorly to the level of the inferior pubic rami bilaterally. The muscularis was then gathered toward the midline using a series of 2-0 vicryl interrupted stitches. This reduced the anterior prolapse. The excess epithelim was then trimmed and the incision was closed with a running stitch of 2-0 vicryl.
The PDS sutures were then tied securing the vaginal apex to the right sacrospinous ligament thus restoring vaginal length and suspending the apex.
Attention was then turned to the posterior repair following the injection in the perineal body and posterior vaginal wall with 1:800,000 dilute epinephrine solution. An inverted triangular incision was made along the perineal body and carried up to the posterior vaginal wall. The vaginal epithelium was dissected off the underlying endopelvic connective tissue in the midline using the Metzenbaum scissors. The excess vaginal epithelium was excised. The epithelium and underlying tissue was plicated in the midline using an 0 Vicryl. We then dissected out laterally to reach the fascia of the levator muscles at the level of the hymen. This was plicated in the midline using 0 Vicryl in an interrupted fashion. We then reapproximated the perineal body using a 0 Vicryl in an interrupted fashion. The perineal skin was then reapproximated using a 3-0 Vicryl in a running subcuticular fashion.
Sponge, lap, and needle counts were correct x2. The patient tolerated the procedure well, was taken to the recovery room in stable condition.
Postoperative Considerations
| Follow Up | 6 Weeks |
| Voiding Requirements | Passive Voiding Trial, PVR < 150mL |
| Opioids | AS NEEDED: Oxycodone 5mg PO Q6H #10 |
| Pain Control | SCHEDULED: 1g acetaminophen and 600mg ibuprofen Q6H x 4 days, ALTERNATE |
| Precautions | Urinary tract infection, Urinary retention, Bleeding, Avoid constipation |
| Restrictions | Pelvic Rest x 6 weeks, Resume other activity slowly and as tolerated |
Patients undergoing SSLF will often feel buttock pain/discomfort for a few weeks to a few months. It should improve with time. Patients with radicular buttock/leg pain immediately postop require a return to the OR for revision. Do you recall which nerve(s) travel deep to the sacrospinous ligament?
As with any prolapse surgery, efforts to avoid constipation are critical (both for pain control and durability of the procedure). Perioperative counseling should address this. I typically recommend patients take 17g MiraLAX daily and decrease the dose as needed to avoid diarrhea. Addition of docusate is often appreciated by patients.
Patient Education
Preop
Postop
Implants & Devices
Case Preparation
Start Here
- Walters and Karram Chapter 21, pp.334-339
- Sacrospinous Fixation Video
- NOTE: This is the way Dr. Stewart was trained. He has since made slight modifications, but the basic principles and teaching points are the same.