Richter's sacrospinous ligament fixation of the prolapsed vaginal vault

The description of the Richter's sacrospinous ligament fixation of the prolapsed vaginal vault covers all aspects of the surgical procedure used for the management of vaginal vault prolapse following hysterectomy. Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: posterior colpotomy, opening of fossae, exposure, sutures, checking the hemostasis, myorrhaphy, suspension of vaginal floor, end of procedure, complications. Consequently, this operating technique is well standardized for the management of this condition.

Browse the WORLD
Virtual University
English ▼

Richter's   sacrospinous   ligament   fixation   of   the   prolapsed   vaginal   vault

Authors
M Cosson, B Occelli, D Querleu
Abstract
The description of the Richter's sacrospinous ligament fixation of the prolapsed vaginal vault covers all aspects of the surgical procedure used for the management of vaginal vault prolapse following hysterectomy.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: posterior colpotomy, opening of fossae, exposure, sutures, checking the hemostasis, myorrhaphy, suspension of vaginal floor, end of procedure, complications.
Consequently, this operating technique is well standardized for the management of this condition.
Media type
Publication
2002-03
Popular
Favorites
Favorites Media
Audio
en fr


E-publication
WeBSurg.com, Mar 2002;2(03).
URL: http://www.websurg.com/doi-ot02en251.htm

Richter's   sacrospinous   ligament   fixation   of   the   prolapsed   vaginal   vault

1. Introduction
The fixation of the vaginal vault to the sacrotuberal ligament (“vaginae fixura sacrotuberalis vaginalis”) was described in 1951. This technique has been modified by the choice to use the sacrospinous ligament (Richter, 1968). It involves opening the pararectal space, identifying the ischial spine and placing 3 sutures through the sacrospinous ligament. These sutures are then anchored to the posterior surface of the vaginal wall, and the floor of the vagina is drawn over the sacrospinous ligament.
This technique was initially indicated for vaginal vault prolapse following hysterectomy (Richter and Albrich, 1981; Richter and Dargent, 1986). The technique is now used for prolapse operated on transvaginally.
2. Anatomy
• Sacrospinous ligament
The sacrospinous ligament, or anterior sacrosciatic ligament, courses posteriorly and medially and inserts into the last 2 sacral vertebrae and the first 2 coccygeal vertebrae. It resembles a fibrous triangle with a lateral apex. Its anterior surface faces the pelvic peritoneum, and its posterior surface faces the inferior border and the anterior surface of the coccygeus muscle to which it is joined so intimately that there is no dissection space between these 2 muscular and fibrous structures. It is limited caudally by the ileococcygeus muscle and cranially by the piriformis muscle.
1. Sacrospinous ligament
2. Coccygeus muscle
3. Ileococcygeus muscle
4. Piriformis muscle
• Anatomical relationships
Knowledge of the relationships of the posterior surface of the sacrospinous ligament is essential. These relationships may lead to intraoperative complications secondary to suture.
- the internal pudendal vessels wrap around the ligament at its origin (ischial spine);
- the roots of the sciatic plexus converge obliquely towards the subpyramidal canal that is limited superiorly by the pyramidal muscle and inferiorly by the sacrospinous ligament itself.
1. Needle passage
3. Indications
Indications
Indications include vaginal vault prolapse after previous hysterectomy and prolapses operated on transvaginally.

Contraindications
In addition to contraindications to anesthesia, the technique is contraindicated if transvaginal access is difficult (osteoarthritis, hip prosthesis).
4. Operating room
• Patient
- pubis and vulva shaved the evening before surgery;
- shower with betadine surgical scrub the evening before and on the morning of surgery;
- general or local-regional anesthesia;
- lithotomy position with thighs drawn back over abdomen and legs as straight as possible;
- urinary catheter (optional);
- betadine applied by compress to the vulva and perineal and subpubic areas up to the umbilicus and down to the upper thighs;
- sterile drapes used: beneath the buttocks, 2 sterile boots, large suprapubic drape, 2 small perineal drapes excluding the anus.
• Team
1. The surgeon is positioned between the patient’s legs, facing her vulva.
2. The first assistant is to the right of the surgeon, below the patient’s left leg.
3. The second assistant is to the left of the surgeon, below the patient’s right leg.
4. The scrub nurse with the instrument table stands behind and to the right of the surgeon, or in the position of the first assistant.
• Equipment
The equipment on the instrument table is to the surgeon’s right.
1. Instrument table
5. Instrumentation
• Specific instruments
1. Eight Allis (atraumatic vaginal) clamps
2. Narrow Breisky retractor (bayonet-shaped retractor)
3. Wide Breisky retractor
4. Two medium-width Breisky retractors
5. Mangiagalli retractors
• Non-specific instruments
- four toothed (Péan) clamps;
- Kocher clamp;
- two grasping forceps with wide jaws (Jean-Louis Faure) for ball-shaped sponges,
- two long needle holders;
- medium-length needle holder;
- straight scissors;
- suture scissors;
- surgical knife;
- electrosurgical knife (optional);
- toothed dissection forceps;
- blunt dissection forceps;
- four cups;
- suction cannula (optional);
- Bingoléa grasping forceps.
1. Péan clamp
2. Kocher clamp
3. Bingoléa grasping forceps
• Disposable instruments
- prostate dressing;
- radiopaque sponges;
- radiopaque ball-shaped sponge;
- sterile gloves;
- sterile fingercots;
- two No. 23 surgical knife blades;
- xylocaine 1% with epinephrine combined with an equal amount of saline;
- syringe with IM needle.
Ligatures:
- for the sacrospinous ligament suspension: non-absorbable Filapeau 1 type (dec 4) 1/2c 35 mm monofilament suture or non-absorbable Mersuture 1 type (dec 4) 1/2c 35 mm braided suture;
- for myorrhaphy of the levator ani muscles (optional): absorbable PDS II 1 type (dec 4) 1/2c braided suture;
- for the vaginal suture: delayed absorbable Vicryl 1 type (dec 4) 1/2c 35 mm braided suture.
1. Prostate dressing
2. Radiopaque sponges
3. Radiopaque ball-shaped sponges
• Variation
Chromium-plated catgut suture was used in the past. Currently, there are 2 possibilities:
- non-absorbable, non-transfixing suture at the level of the vagina, to approximate the vagina without attaching it to the sacrospinal ligament. We have chosen this method;
- use of a delayed absorbable suture that transfixes the vagina and attaches it to the sacrospinal ligament. This variation is based on the development of fibrosis.
6. Major principles
The procedure involves anchoring the vaginal vault to the sacrospinous ligament:
- bilaterally, but this is often excessive;
- or unilaterally, with a risk of pelvic static disequilibrium.
Two operative strategies may be used:
- during treatment for a prolapse after a previous hysterectomy with elytrocele or rectocele;
- during treatment for a total prolapsus, after previous colpohysterectomy and colporrhaphy.
We always perform myorrhaphy of the levator ani muscles with Richter’s sacrospinous ligament suspension because it completes the posterior step of the procedure and recreates the physiologic angle of the vagina.
7. Posterior colpotomy
• Localization
Two mid-sized Breisky retractors are positioned on either side of the posterior vaginal wall. Three Kocher clamps are then placed on the midline of the posterior vaginal wall, between the vaginal floor and the vestibule.
1. The first Kocher clamp is positioned on the vaginal vault (old or recent hysterectomy scar, posterior to the cervix if the uterus is preserved).
2. The second Kocher clamp is placed 1 or 2 cm above the superior angle of the vulva.
3. The third Kocher clamp is placed on the midline between the first 2 clamps, at an equal distance from both.
• Vaginal wall infiltration
60 mL of diluted epinephine solution is administered by infiltration to the posterior vaginal wall and the pararectal fossae (optional step). This infiltration serves 2 purposes: hydrodissection that facilitates dissection of planes and hemostasis for a bloodless procedure. In case of an anesthesia-related contraindication, it is possible to use only saline in the infiltration for the purpose of hydrodissection.
• Vaginal incision
An incision is made with the surgical knife on the posterior vaginal midline, between the Kocher clamps.
This incision is begun at the level of the vaginal floor (vaginal hysterectomy scar or point of closure of the previous colphorrhaphy) and ends 1 to 2 cm above the superior angle of the vulva.
• Placing Allis clamps
Eight Allis clamps are placed on the edges of the vaginal incision between the 3 Kocher clamps. The Kocher clamp that is situated in the middle of the posterior colpotomy is removed. The posterior vaginal incision is completed.
The 2 Breisky retractors are removed, as well as the 2 remaining Kocher clamps.
8. Opening/fossae
• Recto-vaginal dissection
Using the 8 Allis clamps, the 2 assistants exert a star-shaped traction. The rectum is grasped with the blunt dissecting forceps. A divergent traction is exerted relative to one of the pararectal fossae. The tented fibers are incised with the surgical knife. This is repeated on the opposite side.
The infiltration makes it possible to visualize a minimum-risk rectal zone during the dissection.
The recto-vaginal dissection is completed with the index finger, using gentle, lateral, back and forth movements, remaining in contact with the levator ani muscles. This step prepares the levator ani muscles for the myorrhaphy. The dissection must be done sufficiently to the rectum and should enable visualization or palpation of the levator ani muscles. In case of doubt, the integrity of the rectum can be checked during the dissection by digital examination, using a sterile fingercot. Digital examination of the rectum is systematically performed at the end of the recto-vaginal dissection.
• Opening the fossa
The left pararectal fossa is incised first. The right pararectal fossa may be chosen instead (sacrospinous ligament is better perceived, and dissection seems to be easier).
The pararectal fossa is opened after introducing the index finger in a 2 o’clock position on the upper part of the colpotomy incision, using lateral sweeping movements down to the rectum.
The Mangiagalli retractor is then placed in the pararectal fossa in a posterior position. A wide or mid-width Breisky retractor is positioned against the lateral pelvic wall. The narrow or mid-width Breisky retractor is inserted against the first Breisky retractor, pushing the rectum back towards the midline; the retractors are pulled in opposite directions by the 2 assistants (one in a 10 o’clock position and the other in a 4 o’clock position), opening the pararectal fossa.
The retraction should be effective but gentle, because it can cause a small tear in the lower part of the rectum. It is important to adequately dissect the rectum, notably on the lower midline, before introducing the retractors, and to systematically conduct a digital examination of the rectum. The Allis clamps are progressively removed as the retractors are introduced.
1. Mangiagalli retractor
2. Breisky retractor in 4 o’clock position
3. Breisky retractor in 10 o’clock position
• Rectal reflection
A plane between the mesorectum and the levator ani muscles is exposed at the tip of the retractor placed against the pelvic wall. This plane is opened 2 cm with dissection scissors.
A ball-shaped sponge is inserted into this opening with a Jean-Louis Faure grasping forceps. The opening of the plane is extended by gently moving this sponge laterally and back and forth against the levator ani muscles. At the same time, the mesorectum is reflected towards the midline with a blunt dissecting grasping forceps.
1. Mesorectum reflected towards midline
9. Exposure
• Exposure
The prostate dressing is packed into the 10 cm space created in the previous step along the wide or mid-width Breisky retractor pressed against the pelvic wall. The narrow or mid-width median Breisky retractor is removed. It is reintroduced between the dressing and the wide retractor pressed against the pelvic wall, making it possible to retract the rectum and mesorectum toward the midline, and to visualize the posterior lateral pelvic wall.
The large retractor must be positioned for visualizing the sacrospinous ligament posterior to the ileococcygeus muscle that partially covers it (we suggest bringing the tips of the retractor together and carefully pushing it in to flatten the levator ani muscle; it should then be progressively opened and removed until the sacrospinous ligament is revealed). A ball-shaped sponge can also help the surgeon to expose the sacrospinous ligament.
The Mangiagalli retractor is then repositioned between the 2 retractors in a 7 o’clock position, enabling a maximal opening of the pararectal fossa and an excellent view of the sacrospinous ligament. If the space created by the 2 Breisky retractors is not wide enough for the Mangiagalli retractor, however, this part of the step may be omitted.
1. Mangiagalli retractor in 7 o’clock position
2. Sacrospinous ligament
• Warning
The surgeon must avoid palpating the ischial spine in order to view it (this can be dangerous). In addition, the lateral retractor pressed against the pelvic wall is sometimes pushed in too far by the assistant. This can damage the internal pudendal neuro-vascular pedicle located just behind the ischial spine. The lateral retractor must be progressively removed following the levator ani muscle until the sacrospinous ligament is revealed.
10. Sutures
• Placing the sutures
A long needle holder threaded with non-absorbable suture is used. The curve of the needle is positioned perpendicular to the large axis of the needle holder. The needle is passed perpendicularly into the ligament, 2 cm medial to the ischial spine (to prevent vascular and nerve complications to the internal pudendal). A back and forth movement is used, with a clockwise rotation of the wrist. Often the needle comes out at the posterior part of the ileococcygeus muscle, which reinforces the hold.
This needle is grasped by the second needle holder while completing the clockwise rotation. The suture is kept in place with the needle on the Péan clamp.
A second suture is placed on the ligament (medial or lateral to the first suture, taking care to respect the 2 cm security zone around the ischial spine). This is facilitated by the traction created by the first suture. The second suture is held along with its needle on the Péan clamp.
• Variation
An “Endostitch” grasping forceps may be used to pass the suture through the sacrospinous ligament without exposing the ligament with the retractors, but under direct palpation of the ligament with a finger.
The surgeon uses the absorbable suture and transfixes the vagina to tie the sacrospinous ligament fixation sutures at the end of the procedure with an intravaginal knot.
It is possible to perform only one sacrospinous ligament fixation suture. We use 2 sutures to increase solidity and to avoid having to repeat the entire process if a suture breaks when the sutures are tightened at the end of the procedure.
11. Checking the hemostasis
• Checking the hemostasis
The Mangiagalli retractor is removed. The median narrow or mid-width Breisky retractor is then progressively removed, as well as the dressing, using a toothed dissection retractor to control the hemostasis of the mesorectum. The lateral wide or mid-width Breisky retractor is then removed. The 8 Allis clamps are repositioned on the edges of the vaginal incision.
After removing the retractors, the integrity of the rectum must be checked by digital examination. It is particularly important to check for injury to the lateral inferior portion of the rectum linked to the tension between the 2 Breisky retractors. This risk is increased if the dissection of the lower part of the rectum was not sufficient.
• In case of bleeding
If bleeding occurs, direct pressure should be exerted on the pararectal fossa with a dressing for several minutes. The bleeding can usually be stopped in this way.
Hemostatic clips are used. When bleeding occurs behind the sacrospinous ligament, due to the depth and narrowness of the space, the use of a stitch threaded on a Bingolea grasping forceps is very difficult.
If the hemostasis fails, the area must be packed until an arterial embolization can be completed.
12. Myorrhaphy
Myorrhaphy of the levator ani muscles is optional. When it is performed, the 2 sacrospinous ligament fixation sutures are lifted upwards to avoid catching them in the sutures used for the myorrhaphy.
For the myorrhaphy suture of the levator ani muscles, the Allis clamps must be taut and spread out. With a finger, the surgeon pushes back the rectum medially to protect it, while the other hand pierces the levator ani muscle with a rotational movement of the needle holder. The needle is picked up by a second needle holder held by one of the assistants.
One or two absorbable sutures are performed for the myorrhaphy of the levator muscles. They should not be tight. They are held on a Kocher clamp.
It is necessary to always check that the myorrhaphy sutures do not transfix the vagina, in which case the surgeon must remove and redo the suture. The integrity of the rectum is checked by digital examination.
13. Suspension/vaginal floor
• Vaginal floor landmarks
The 2 sacrospinous ligament fixation sutures held in the grasping forceps are lowered. They are joined to the levator ani myorrhaphy suture that is also held in a grasping forceps.
A Kocher clamp is repositioned on the median vaginal floor, 1 cm above the superior angle of the posterior colpotomy.
A trial reintegration of the vagina towards the sacrospinous ligament is then carried out using the Allis clamps, which are held together by the surgeon. This is done to place the vaginal strips on which the sacrospinous ligament fixation sutures are attached at the correct height.
• Vaginal fixation
The surgeon begins the vaginal running suture for closure of the posterior colpotomy with absorbable No. 1 suture (vicryl). This is placed below the Kocher clamp situated on the vaginal vault that is removed just before beginning the suture. The running suture is held upwards in a grasping forceps used as a landmark.
Two strips, 3 cm long and 1 cm wide, are fashioned with scissors on either side of the vaginal border held by the Allis clamps, approximately 2 cm from the vaginal floor. These strips remain attached to their base on the vaginal border. While they are being created, the strips are held by the toothed grasping forceps. They are then de-epithelialized by gently scraping their vaginal surface with the surgical knife, to prevent mucoceles.
Each strip is threaded through with one of the sacrospinous ligament fixation sutures, which are put back on the Péan clamp.
• Variation
Strips are created to increase the solidity of the sacrospinous ligament fixation, as the vaginal hold with a wide base of implantation is more solid than a hold on the thickness of each vaginal edge. In addition, this gesture is easily reproducible.
In a classical vaginal fixation, surgeons fix the 2 sacrospinous ligament fixation sutures on the thickness of each vaginal edge, keeping in mind that the vaginal hold must not be transfixing when nonabsorbable suture is used. Other surgeons use absorbable suture and transfix the vagina to join it to the sacrospinous ligament when the sutures are tightened. The solidity of this process is based on postoperative fibrosis formation.
14. End of procedure
• Closure
The posterior colpotomy is closed in a classic manner. The levator ani muscles of the myorrhaphy are also closed.
The surgeon takes hold of the vaginal running suture of the posterior colpotomy, threading the base of the 2 vaginal strips that are then buried below the running suture and left free. The Allis clamps are progressively removed as the vaginal running suture progresses.
• Tips
To make sure that the edges of the colpotomy coincide correctly, the 2 parts of the vaginal border are fixed with suture and maintained in the midline by a toothed grasping forceps before tightening each stitch of the vaginal running suture.
The tightening of the sacrospinous ligament fixation sutures is performed one suture at a time, 5 cm from the superior angle of the vulva, resulting in the reintegration of the posterior vagina towards the back of the pelvic cavity. The sutures should be cut and tied as soon as they are tightened. The sutures of the myorrhaphy of the levator ani muscles are then tightened.
The surgeon finishes the vaginal running suture by burying the knot of the running suture above the superior angle of the vulva. There may be a small vaginal dog-ear before complete closure of the running suture. The vaginal resection should not be performed until this step, and it must be done sparingly.
The surgeon finishes the procedure by counting the sponges and checking the hemostasis at the level of the vaginal suture. Vaginal packing may be left for 24 hours with a Foley catheter.
15. Complications
• Vascular injury
Considered the most serious complication by surgeons, vascular injuries usually involve the hypogastric venous plexus or the internal pudendal vein, although the perirectal veins, sacral veins or internal pudendal artery may also be damaged. Serious vascular accidents are rare. They may be avoided if the surgeon respects the limits of the dissection (Barksdale, 1998).
• Rectal bladder injuries
These are rare and usually not serious (Sze and Karram, 1997).
• Specific pain
Transient pain is reported with a mean severity rating of 3 (Sze and Karram, 1997). Gluteal pain (42%) and pudendal pain (30%) are most common. Sciatic pain (14%) or vaginal pain leading to dyspareunia (14%) is also observed. Persistent pain including pudendal neuropathies is observed in 1% of cases.
16. Reference
Barksdale PA, Elkins TE, Sanders CK, Jaramillo FE, Gasser RF. An anatomic approach to pelvic
hemorrhage during sacrospinous ligament fixation of the vaginal vault. Obstet Gynecol 1998;91:715-8.
Richter K, Dargent D. La spino-fixation (vaginae fixatio sacro spinalis) dans le traitement des prolapsus du
dôme vaginal après hystérectomie. J Gynecol Obstet Biol Reprod 1986;15:1081-8.
Richter K, Albrich W. Long-term results following fixation of the vagina on the sacrospinal ligament by the
vaginal route (vaginaefixatio sacrospinalis vaginalis). Am J Obstet Gynecol 1981;141:811-6.
Richter K. Die chirurgische Anatomie der Vaginaefixatio sacrospinalis vaginalis. Ein Beitrag zur operativen
Behandlung des Scheidenblindsackprolapses. Geburtshilfe Frauenheilkd 1968;28:321-7.
Sze EH, Karram MM. Transvaginal repair of vault prolapse: a review. Obstet Gynecol 1997;89:466-75.