Sacrospinous Ligament Vault Suspension

Fig. 8.1

Voiding cystogram confirming presence of moderate cystocele (a) and incomplete emptying (b)

The patient and the family desired a native tissue repair option for her prolapse from which she would recover quickly. She elected to undergo a sacrospinous ligament vault suspension (SSLS) with an anterior and posterior colporrhaphy.

Surgical Indications

Sacrospinous ligament vault suspension is a technique to correct post-hysterectomy vaginal vault prolapse. This technique can be slightly modified in order to perform a sacrospinous hysteropexy as a uterine-sparing technique. This technique should be considered in patients who wish to avoid synthetic material for their vault suspension. SSLS consists of an extraperitoneal approach, which is an advantage in patients with multiple previous abdominal surgeries. The pararectal space is usually not violated during abdominal surgeries making this extraperitoneal technique a safe approach in this situation to avoid bowel adhesions and injury. Secondary to the risk of dyspareunia and deviation of the axis of the vagina that follows this procedure, the best patients to consider for this technique are older patients who are minimally or non-sexually active who desire to keep a functional vagina.

One needs to verify the patient’s vaginal length before consenting the patient for such repair. Vaginal length of approximately 8 cm or more is usually required to ensure that the new apex will reach the sacrospinous ligament without tension to offer adequate support and minimize the risk of failure.

Preoperative Discussion

During the discussion with the patient before surgery, the expected recovery is explained. Minimal to moderate pain is usually experienced requiring some pain relief medication. Patients can expect vaginal bleeding that can last up to 4 weeks after surgery. Patients should limit or avoid exercise, physical activity, heavy lifting and intercourse for 4–6 weeks after surgery. The risks and complications are discussed with patients, including risk of bleeding, infection, pain and buttock pain, organ injury, de novo incontinence and dyspareunia. The reported long term success rate and risk of needing additional procedures are also discussed.

The risk of hemorrhage requiring transfusion has been estimated to be around 0–3 %. Severe bleeding, if it occurs, is usually secondary to hemorrhage from the inferior gluteal vessels, hypogastric venous plexus, or internal pudendal vessels. Controlling this type of bleeding can be difficult. If severe bleeding occurs, it can usually be controlled by packing the vagina and holding pressure for sufficient time (at least 5 min if there is significant bleeding). If this does not control the bleeding, ligation with sutures should be performed. This is a difficult area to approach abdominally and bleeding should be controlled vaginally [1–3].

Perforation of the bladder, rectum and small bowel occur in 0.5–1.7 % [2, 4]. Cystoscopy should be performed to assess the integrity of the bladder. Rectal examination should be done during the operation to identify possible rectal injury that can occur while entering the right pararectal space. Unilateral right-sided SSLS is preferred in order to avoid the recto-sigmoid junction on the left side. Hydrodissection of the right pararectal space prior to its dissection also makes the dissection of the vaginal wall off the rectum easier. Rectal injuries can usually be repaired primarily transvaginally in two or three layers.

One of the most feared complications of this surgery is the occurrence of buttock pain. Approximately 6–14 % of patients will experience moderate-to-severe buttock pain on the side of the SSL fixation. In most patients, this will resolve within 6 weeks after surgery. Reassurance and anti-inflammatory medication are usually sufficient to resolve this type of pain. Because of the proximity of the sciatic and pudendal nerve to the SSL, these nerves can be injured during suture placement. This has been rarely reported. If the patient is experiencing severe and prolonged pain, it should raise the suspicion of potential pudendal nerve entrapment. Removal of the offending sutures should not be delayed and this should offer complete relief almost immediately [2, 3, 5].

Sexual dysfunction and dyspareunia has been reported in up to 3–13 % of patients, but it is unclear if this is secondary to the change in vaginal orientation or other factors. Vaginal stenosis can occur if too much anterior or posterior vaginal wall is trimmed at the time of the anterior or posterior colporrhaphy [5].

As with any prolapse repair surgery, de novo stress urinary incontinence can occur after this surgery, especially if no anti-incontinence procedure was performed concomitantly. The presence of occult stress incontinence should be tested preoperatively with either a stress test with reduction of the prolapse in the office or with a formal urodynamic study with and without vaginal packing.

The reported long term success rate of this surgery is approximately of 75–80 %. The highest incidence of recurrence is usually located along the anterior vaginal wall. Approximately 20 % of patients will have some anterior vaginal wall descent within a year of surgery, but most patients are asymptomatic. Only 5 % of patients will be symptomatic enough to require a repeat surgery to treat the recurrent prolapse. This compromise of the anterior vaginal wall results from the posterior deviation of the vaginal axis compared to its natural position after SSLS.

Surgical Technique (Refer to Video 7.1 Lateral Paravaginal Repair, Colporrhaphy, and Sacrospinous Ligament Vaginal Vault Suspension (De E))

After administration of general anesthesia, patient is positioned in dorsal lithotomy position. A surgical headlamp and a lone-star retractor can be highly beneficial for this procedure. The vaginal vault prolapse is examined to identify the sacrospinous ligament (SSL) and the location of the new apex. The SSL is a firm, somewhat fixed structure that can be identified on pelvic examination between the ischial spine and the lateral border of the sacrum and coccyx. It has a length of 7–8 cm. The SSL lies within the coccygeus muscle. Therefore, the fibromuscular coccygeus muscle and SSL are basically the same structure.

The new apex is positioned on the posterior vaginal wall slightly to the right side of the midline and as close to the vaginal apex as possible. Using an Allis clamp, the new apex is grasped. Verification is made to ensure that the vaginal wall will reach the SSL without tension and that it will touch the SSL without space in between. The intended apex is tagged with an interrupted suture for later identification. The unilateral SSL is usually preferred compared to bilateral suspension. The patient’s right side is the most common side for unilateral SSLS because it is easier for right-handed surgeons and the rectosigmoid junction is avoided on the left side. After the suspension, the vaginal length should be approximately 10 cm.

Decision can be made intraoperatively with the apex reduced manually in the new position as to whether an anterior repair and/or a posterior repair will be necessary. Patients should be consented for possible anterior and posterior repair because it is often difficult to identify the extent of the anterior and posterior defect preoperatively. If an anterior colporrhaphy is warranted, it should be performed prior to suspending the vault. Considering that the axis of the vagina will be more posterior than the “anatomic” position, one should err on the side of performing an anterior colporrhaphy with the SSLS to provide stronger anterior support. Once the anterior colporrhaphy is completed, the anterior vaginal wall incision is closed with a continuous running suture.

The attention is then drawn to the posterior vaginal wall for the SSLS. The posterior vaginal wall is infiltrated with a solution of lidocaine with epinephrine for hydrodissection and hemostasis. A midline incision is made from the introitus toward the apex as for a usual posterior colporrhaphy, ending the posterior incision 3–4 cm distal to the vaginal apex (Fig. 8.2). In cases where a posterior colporrhaphy is required, the vaginal wall is dissected off the rectovaginal fascia on both sides down to the lateral sulcus. For patients with no posterior compartment prolapse or very small rectocele that is reduced when the new vaginal apex reaches the SSL, a posterior colporrhaphy is not required to complete this procedure. In this situation, only the right posterior vaginal wall is dissected sharply and bluntly toward the lateral sulcus.