Sacrospinous Ligament Suspension
The sacrospinous ligament suspension fixation (SSLF) procedure is a less invasive and moderately successful operation for vaginal vault prolapse. Drs. Moore and Miklos have performed this procedure in the past; however, they think that in its traditional form (see below for description) it has a very limited role in vault suspension surgery with the newer, less invasive vaginal approaches available today, such as the Elevate procedure. It is a procedure that is completed vaginally at the same time as other vaginal repairs in certain patients. Traditionally, the vaginal vault is attached to the ligament by one or two sutures on one side. The literature has shown that this is not a very anatomical repair (pulling the top of the vagina off to one side - see Fig. 8 below). Drs. Moore and Miklos also feel that it is not a very secure repair because the only thing that is sutured to the ligament is vaginal skin and they feel failures occur because the suspension sutures pull out of the vaginal skin. Additionally, traditional use of a suture carrier, such as the Maya hook or the newer Capio suture hook, risks damage to the pudendal nerve/vessel complex that can result in nerve injury, pain, or severe bleeding.
Drs. Moore and Miklos’ Early Modification of the SSLF
In the late 1990s and early 2000s, in some patients that would not be candidates for abdominal surgery or were felt to be better candidates for a vaginal approach under epidural anesthesia, Drs. Moore and Miklos did utilize the patient's sacrospinous ligaments to complete a vaginal vault suspension. However, they modified the procedure by utilizing both ligaments in the suspension (bilateral SSLF) and incorporated a graft into the suspension which they felt strengthened the suspension significantly. The apex of the dermal graft they placed during their posterior repair or during an anterior repair was attached to the top of the vagina (all the way across the entire width of the vagina). Sutures were then placed through the sacrospinous ligaments (see below) and then through the top of the graft at each corner. The sutures were then tied down which "elevates" the vagina up very nicely without deviating it to either side. This modification that Drs. Miklos and Moore were doing actually set the groundwork for some of the recent less invasive procedures such as the newer Elevate procedure below.
The sacrospinous ligament technique is described below. Images are from Technique Spotlight Suture Placement, Vol. 3, by Boston Scientific featuring the use of the Capio (TM) Suture Capturing Device. The procedure is completed vaginally.
Sacrospinous Ligament Fig 3
Sacrospinous Ligament Fig 4
Sacrospinous Ligament Fig 5
acrospinous Ligament Fig 6
Drs. Miklos and Moore did see good results with this procedure in the past with the bilateral sacrospinous ligament suspension incorporating a graft placed either along the posterior or anterior wall; however, they did not utilize it on a regular basis secondary to the risk of nerve or vessel damage with the older techniques (such as the Capio device) that placed a suture around the ligament or “hooked” the ligament which can cause nerve impingement or compression. They felt it was a procedure that should only be completed by experienced advanced pelvic surgeons. Risks include bleeding or hematoma in the pararectal or retropubic space (depending on posterior or anterior approach), injury or irritation to the pudendal nerve (buttock or leg pain), rejection or infection of graft material used. With the newer, less invasive methods now available such as the Elevate procedure, Drs. Miklos and Moore do not perform this older, more invasive repair. Dr Moore has been one of the key leaders in the world in helping to develop and study the newer Elevate procedures which utilizes a soft mesh graft placed under the bladder (to repair cystocele) or over the rectum (to repair rectocele) and in either case attaches the top of the graft to the sacrospinous ligaments via a very minimally invasive self-fixating tip into the ligament. Initial results have been very promising. For more information on the Elevate procedure please click here.