Richter's sacrospinous ligament fixation

  • Abstract
    Step-by-step description of sacrospinous colposuspension (Richter's operation). Opening of rectovaginal space vaginally, identification of the sacrospinous ligament on the left, placement of the sutures, creating vaginal flaps and closure of the vagina.
  • 00'11" Posterior colpectomy
    The patient is placed in a standard high lithotomy position. Richter’s suspension of the vaginal floor by sacrospinous ligament fixation is an effective weapon in the arsenal for the treatment of vaginal floor prolapse. It can be performed alone for prolapse vaginal vault or as in this case in combination with a prior anterior repair. The procedure begins with placement of Kocher clamps and infiltration of the posterior vaginal wall and pararectal spaces. It continues with an incision on the vaginal midline followed by the placement of Allis clamps before performing rectovaginal dissection and opening of the pararectal fossa.
  • 01'04" Opening of pararectal fossae
    Using the 8 Allis clamps, the 2 assistants exert a star-shaped traction. The rectum is grasped with a blunt dissecting forceps. A divergent traction is exerted relative to one of the pararectal fossae. The left pararectal fossa is incised first. The right pararectal fossa may be chosen instead. The sacrospinous ligament is better visualized and dissection seems to be easier on the left. The pararectal fossa is opened after introducing the index finger in a 2 o’clock position in the upper part of the colpotomy incision using lateral sweeping movements down to the rectum. In our experience, we prefer to perform the dissection of the sacrospinous ligament unilaterally with a wide opening of the pararectal fossa. A sponge is used to retract the rectum and 3 retractors provide the remaining exposure before beginning the dissection of the sacrospinous ligament.
  • 02'06" Exposure of small sacrosciatic ligament
    The dressing is packed into the 10cm space created in the previous step along the wide or mid-width retractor pressed against the pelvic wall. The narrow or mid retractor is removed. Two non-absorbable sutures are placed in the ligament using a back and forth movement away from the ischial spine. The curve of the needle is positioned perpendicular to the large axis of the needle holder. The needle is passed perpendicular into the ligament 2cm 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 ligament. Hemostasis and integrity of the rectum are checked.
  • 02'51" Myorrhaphy of levator ani muscles
    We systematically combine Richter’s suspension with the myorrhaphy at the levator ani muscles using a figure of eight stitch with a good bite retracting the rectum with a finger to protect it. Myorrhaphy of the levator ani muscles is optional. We just perform the 2 sacrospinous ligament fixation sutures are lifted upwards to avoid catching them in the sutures used for the myorrhaphy. For the myorrhaphy suture at the levator ani muscles, the Allis clamps must be taut and spread out. With the 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. Two more absorbable sutures are performed for the myorrhaphy of the levator ani muscles.
  • 03'31" Creation of vaginal strips
    The vaginal closure is begun after identifying the location of the new vaginal floor by simulating the result of the suspension. Two vaginal strips are positioned facing this vaginal floor and threaded through with the sacrospinous ligament fixation sutures. 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 the grasping forceps. A Kocher clamp is repositioned on the median vaginal floor 1cm above the superior angle of the posterior colpotomy.
  • 04'30" Knot-tying and closure
    The closure is pursued without tightening the suspensions. They will be tightened only at the superior angle of the vulva after burying the vaginal strips. Now that the strips are buried, we can continue our suture line in a locked fashion anterior to posterior. At this point, the sutures can be tightened because the strips are completely buried. The lifting of the vaginal floor is now quite good. The myorrhaphy sutures are tied and the vaginal closure is completed after counting the sponges checking the rectal integrity by digital examination again checking the hemostasis.
  • Related medias
    Step-by-step description of sacrospinous colposuspension (Richter's operation). Opening of rectovaginal space vaginally, identification of the sacrospinous ligament on the left, placement of the sutures, creating vaginal flaps and closure of the vagina.