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Pelvic Floor Reconstruction - Vault Suspension
Pelvic Floor Reconstruction - Vault Suspension
Sacrospinous ligament fixation is a vault suspension procedure. It is intended to correct pelvic prolapse that results from inadequate support of the vaginal apex.
Case Presented by:
Edward Stanford, M.D., F.A.C.O.G.
St. Mary’s/Good Samaritan
Centralia, IL
Overview
Normal vaginal wall support – which maintains both proper uterine and vaginal vault position - may be compromised by damage occurring at childbirth. Repeated stress on the cardinal/uterosacral ligament caused by chronic coughing disorders or repetitive heavy lifting may also weaken support and result in prolapse. Other etiologies of the condition include connective tissue abnormalities, iatrogenic pudendal neuropathy, or anatomic distortion from pelvic reconstructive procedures that have geometrically altered the angles of the vagina.
It is uncommon to encounter a patient who has prolapse affecting only an isolated area or organ of the pelvis, such as isolated anterior vaginal prolapse (cystocele), posterior vaginal prolapse (rectocele), or vaginal apex prolapse (enterocele). Therefore, it is important to fully evaluate the patient’s symptoms and address them in relation to her existing prolapse. Many patients present with multiple levels of prolapse and associated symptomatology such as urinary incontinence, fecal incontinence, pelvic pressure, pelvic pain, back pain, constipation, sexual dysfunction, urinary retention, or other forms of voiding dysfunction.
Sacrospinous ligament fixation is a technique that secures the upper vaginal vault to the sacrospinous ligament, effectively restoring support to the vaginal wall and correcting prolapse. As a transvaginal procedure, sacrospinous ligament fixation mitigates the morbidity associated with abdominal repair techniques. Historically, however, a transvaginal approach required extensive dissection of the pararectal space down to the sacrospinous ligament and overlying coccygeous muscle. Large retractors were needed to improve visualization and needle drivers were used to place the sutures.
A less invasive alternative would combine the advantages of a transvaginal approach with a reduced need for dissection and retraction.
The Capio® Suture Capturing device has been developed to facilitate the pelvic floor surgeon’s efforts to perform a number of procedures transvaginally despite the access limitations imposed by this approach. The use of the Capio Suture Capturing device permits a less invasive transvaginal sacrospinous ligament fixation at the time of vaginal hysterectomy, during repair of posthysterectomy vaginal vault prolapse and / or posterior colporrhaphy. Importantly, the device is designed to allow the surgeon to perform the fixation with minimal finger dissection of the pararectal space without the need for large retractors. With experience, operative times may be decreased. Further, this approach may decrease postoperative pain and shorten recovery times, facilitating a rapid return to work and normal activities.
Preparation for Suture Placement
The vaginal apex was held with clamps and dissection
was made gently downward with Metzenbaum scissors into the rectovaginal space (Figure 1).
Using the index finger, the loose tissue of the pararectal space was gently divided with blunt dissection. The ischial spine, sacrospinous ligament and coccygeus muscle were palpated to accurately identify the suture site.
The dissection finger was moved along the lower edge of the sacrospinous ligament to identify the caudal portion. The ideal site for suture placement is 2cm medial to the ischial spine into the mid-portion of the sacrospinous ligament
(Figure 2).
Suturing Technique
After identifying the suture placement site on the sacrospinous ligament, the Capio® device was loaded with a double-armed “0” braided polyester nonabsorbable suture and grasped at the handle.
The dissection finger was positioned immediately adjacent to the suture placement site on the sacrospinous ligament (Figure 3).
The distal tip of the Capio device was then gently placed alongside the finger at the suture placement site on the ligament. The device was oriented to allow the suture to be thrown in a posterior direction through the ligament. Once proper positioning of the device was confirmed, the dissection finger was placed over the curved portion of the distal tip (Figure 4).
Slight downward pressure was used to stabilize the tip at the suture placement site. The shaft of the device was then shifted upward, creating an angle of 30-45° between the needle catch and the ligament (Figure 5).
Formation of this angle is advised to allow the needle to complete its full throw through the ligament and into the needle catch without interference from any loose tissue in the area.
Continuous pressure was applied to the driver button of the Capio® device with the thumb, driving the suture through full thickness of the ligament at the suture placement site. Once needle capture was complete, the driver button was released and the free hand was used to pull back on the button. This technique is recommended to help ensure that the needle carrier is fully retracted into the head of the device prior to withdrawal.
The device was then withdrawn, pulling the suture through the ligament and out of the vagina (Figure 6).
After throwing the suture through the sacrospinous ligament, the
Capio® device was reloaded with one arm of the suture to prepare to throw through the vaginal wall.
The head of the device was carefully positioned at the upper portion of the vaginal apex. The device was deployed, automatically throwing and retrieving the suture through the vaginal apex in a single step. The device was withdrawn from the vagina, reloaded with the other arm of the suture, repositioned at the vaginal apex, and a second throw was placed through the vaginal wall (Figure 7).
If preferred, vaginal wall suture placement can be accomplished using a free needle. For this approach, the small needle tips from the Capio device suture should be removed after the suture is thrown through the ligament. A free needle can then be used to place the suture through the vaginal wall.
After suture placement, both suture arms are held with clamps.
The vaginal cuff mucosa was closed with absorbable suture. As the sacrospinous ligament fixation suture was tied, the vaginal apex descended to the sacrospinous ligament. Suture position was secured by throwing six to eight knots, effectively supporting the upper vagina (Figure 8).
Conclusion
Sacrospinous ligament fixation is a procedure with a proven record of long term success in the treatment of pelvic prolapse. The Capio® device is designed to improve this less invasive transvaginal approach by reducing the amount of dissection required, patient morbidity and operative time.
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