36 GYNECOLOGY OCTOBER 2010 • OB.GYN. NEWS MASTER CLASS Treating Advanced Pelvic Prolapse t is estimated that 50% of minimally invasive abdominal techniques, many physi- prolapse and urinary incontinence. He is director of the parous women have cians continue to prefer a vaginal route to correct division of urogynecology at Brigham and Women’s Ievidence of loss of pelvic advanced pelvic organ prolapse. They cite the fact that Hospital and assistant professor of obstetrics and gyne- support. a vaginal approach is associated with reduced hospi- cology at Harvard Medical School, both in Boston. ■ Today, women with ad- talization, less postoperative pain, a faster return to vanced pelvic organ prolapse normal activity, and a superior cosmetic result. DR. MILLER is clinical associate professor at the University have a number of surgical op- Over the past 40 years, one of the most popular of Chicago and the University of Illinois at Chicago, CHARLES E. tions. In a 1997 study by Olsen procedures in the vaginal surgeon’s armamentarium immediate past president of the AAGL (www.aagl.org), MILLER, M.D. et al., the authors included 13 has been the sacrospinous ligament suspension. More and vice president of the International Society for different procedures to treat recently, the procedure has been described with mesh Gynecologic Endoscopy. He is a reproductive advanced pelvic organ prolapse (Obstet. Gynecol. placement as well. endocrinologist in private practice in Schaumburg, Ill., 1997;89:501-6). Since the date of that article, many We have asked an expert on this surgical technique, and Naperville, Ill.; the director of minimally invasive more procedures – laparoscopic, robot-assisted, and Dr. Neeraj Kohli, to write this Gynecologic Surgery gynecologic surgery at Lutheran General Hospital in vaginal – have been described and utilized to treat Master Class. Dr. Kohli is a leader in the field of mini- Park Ridge, Ill.; and the medical editor of this column. advanced organ prolapse. Even with the ability to use mally invasive pelvic surgery and the treatment of pelvic Dr. Miller said he had no disclosures. Sacrospinous Ligament Suspension, With and Without Mesh he sacrospinous ligament suspension sacrospinous sutures as the apical mesh the endopelvic connective tissue is sepa- used to gain exposure to the Ttechnique was first described by Karl attachment points. In my practice, the rated from the pubic ramus at the level sacrospinous space until the ligament is Richter in 1968 and later introduced into procedure is contraindicated in patients of the bladder neck to the ischial spine, visualized. The suture is placed around the United States by David H. Nichols with a short vagina, chronic pelvic pain, exposing the paravesical and pararectal the sacrospinous ligament approximate- and Clyde L. Randall in 1971. It has been or any history of sciatica. space. The sacrospinous ligament is iden- ly two fingerbreadths medial to the and continues to be an effective technique tified and isolated through this defect. ischial spine, with care given to avoid for apical suspension via the vaginal Prior to Surgery Perhaps the easiest method of enter- injury to the pudendal neurovascular route, and is a valuable addition to the Vaginal exam prior to initial dissection is ing the sacrospinous space is through a bundle (Fig. B). surgical armamentarium of helpful in ensuring that the midcompartment approach just lateral A permanent suture (Ethibond or the gynecologic surgeon. vagina is of adequate length to the enterocele. This is often described Gore-Tex) is used for a pulley stitch In the 1990s, the proce- to reach the sacrospinous with isolated apical/enterocele defects. attachment, while a delayed absorbable dure was done less frequent- ligament. Marking of the The vaginal mucosa over the apex/en- suture such as polydioxanone (PDS) is ly because of the popularity vaginal apex for placement terocele is incised in the midline. The used for a full thickness vaginal attach- of uterosacral ligament sus- of suspension sutures sites edges of the incision are grasped using ment. A second suture may be placed pension. Recently, however, also is helpful. The vagina is Allis clamps, and lateral dissection is per- just slightly medial to the first at the sacrospinous ligament sus- reapproximated to either or formed between the vaginal mucosa and surgeon’s discretion. Bilateral pension has regained popu- both sacrospinous ligaments enterocele sac until loose areolar tissue sacrospinous sutures also could be larity for various reasons. using an Allis clamp, which is noted. Blunt finger dissection in a placed. Bilateral suspension sutures are The uterosacral ligament is then adjusted in order to back-and-forth motion is performed to especially useful when considering mesh technique, for one, requires NEERAJ maximize vaginal length and the ischial spine. augmentation of the anterior and/or peritoneal entry, and the lig- KOHLI, M.D. reapproximation to the cor- An identical procedure is then per- posterior segment. ament is often of variable responding ligament. The formed on the contralateral side. Such More recently, traditional devices have strength and also can sometimes be location of the Allis clamp is then tagged midcompartment dissection is associated Continued on following page difficult to identify. with a full thickness marking suture. with very little In addition, new tools and variations in bleeding and technique, such as use of the Capio Surgical Dissection quick access to needle driver, have made sacrospinous The procedure begins with entry into the sacrospinous , 2006) ligament suspension easier and safer. the sacrospinous space. Traditionally, this space. CIENCES Finally, the popularity of vaginal mesh dissection has been described through a Right S procedures has created renewed interest posterior vaginal mucosal incision asso- Suture coccygeus-sacrospinous Briesky- ligament complex Navratil EALTH in sacrospinous suspension as a direct ciated with rectocele repair. A midline Placement (C-SSL) retractors H visualization attachment technique for incision is made from the perineal body A variety of tools apical mesh, compared with trocar/nee- to the vaginal apex. The vaginal mucosa and techniques LSEVIER dle-based techniques, which involve is then dissected off the underlying have been de- :E blind passage and possible injury to the rectovaginal septum distally and any scribed to place bowel and bladder. enterocele proximally. In the upper third the sacrospinous HILADELPHIA With proper technique, the procedure is of the vagina, lateral dissection is suspension su- (P safe, effective, and durable and has few extended in the pararectal space until tures. Traditional- Medial retraction ly, suture place- URGERY complications related to future sexual areolar tissue is encountered. Blunt Suture hook function. Long-term success rates have dissection is then performed toward the ment has been of rectum S been excellent in properly selected patients. ischial spine in a back-and-forth manner. described using a The relevant anatomy including the standard needle A YNECOLOGIC Indications ischial spine, the sacrospinous ligament, holder, Miya Miya hook G Various techniques of apical suspension the coccygeus muscle, and the lateral hook, Des- Notched speculum are available to the gynecologic surgeon. side wall with White’s line, is identified Champs ligature, Sacrospinous suspension is indicated in (Fig. A). An identical dissection is Shutt punch, or NATOMY AND patients with adequate vaginal length performed on the contralateral side. Nichols-Veronikis A who desire a vaginal procedure. An An anterior approach to sacrospinous ligature carrier. ELVIC office-based exam should be performed suspension was described by Peter K. Each device is P to assess vaginal length and Sands et al. in 2000. This is especially loaded with the B TLAS OF location/severity of prolapse. helpful if the patient has only anterior suture/needle. A Oftentimes, the procedure can be per- and apical defects without the need for Vaginal retrac- A. Here Briesky-Navratil retractors are used to retract the formed using the traditional technique rectocele dissection or is undergoing an tors (I prefer the rectum medially and the bladder superiorly. B. Here is the with attachment of the vaginal mucosa anterior mesh augmentation procedure. Breisky-Navratril technique of passage of a Miya hook through the ligament. or with mesh augmentation using the The anterior vaginal wall is opened, and retractors) are Inset is the technique of retrieval of the suture. OCTOBER 2010 • WWW.OBGYNNEWS.COM GYNECOLOGY 37 Continued from previous page tant to tie down the suture securely, but In addition, it’s important to assess the with bleeding if there is any injury to the not tightly, as strangulation of the tissue bridge spanning the sacrospinous pudendal neurovascular bundle or its as- been replaced with the Capio needle sacrospinous tissue may increase the ligaments to make sure this is not too sociated branches. driver. This is a disposable multiuse su- chances of postoperative pain. tight. A tight bridge may cause signifi- Oftentimes, tie-down of the suspen- ture retrieval device which makes I prefer bilateral sacrospinous suspen- cant postoperative pain as well as sion suture will control the bleeder. If sacrospinous ligament suspension sion sutures with only one attachment defecatory dysfunction by partially there is persistent and uncontrollable significantly easier, faster, and safer. The on each side in order to minimize devi- obstructing the rectosigmoid. When bleeding, it is best not to be overly device has a medium caliber shaft with ation of the vagina to one side as well as using a mesh, this bridge can be mini- aggressive with hemostatic sutures or a plunger for suture application. The to maximize support. A single suture on mized by cutting the apical transverse surgical clips, as these may result in in- end has a hook which allows push-catch each side also removes any confusion distance to at least 10 cm. creasing injury to the pudendal neuro- retrieval of a small needle-based suture. over which suture may be involved in Cystoscopy with IV indigo carmine is vascular bundle.