A. Here Briesky-Navratil retractors are used to retract the rectum medially and the bladder superiorly. B. Here is the technique of passage of a Miya hook through the ligament. Inset is the technique of retrieval of the suture.
Source Atlas of Pelvic Anatomy and Gynecologic Surgery (Philadelphia: Elsevier Health Sciences, 2006)
C. Here two sutures have been passed through the complex. D. Technique of fixing the vaginal apex to the coccygeus-sacrospinous ligament complex (C-SSL). If a pulley stitch is performed, then permanent sutures should be used. If the sutures are passed through the vaginal epithelium and tied in the vaginal lumen, then delayed absorbable sutures should be used. E. The vagina is closed prior to tying the suspension sutures. F. Tied sacrospinous sutures.
Source Atlas of Pelvic Anatomy and Gynecologic Surgery (Philadelphia: Elsevier Health Sciences, 2006)
Treating Advanced Pelvic Prolapse
It is estimated that 50% of parous women have evidence of loss of pelvic support.
Today, women with advanced pelvic organ prolapse have a number of surgical options. In a 1997 study by Olsen et al., the authors included 13 different procedures to treat advanced pelvic organ prolapse (Obstet. Gynecol. 1997;89:501-6). Since the date of that article, many more procedures – laparoscopic, robot-assisted, and vaginal – have been described and utilized to treat advanced organ prolapse. Even with the ability to use minimally invasive abdominal techniques, many physicians continue to prefer a vaginal route to correct advanced pelvic organ prolapse. They cite the fact that a vaginal approach is associated with reduced hospitalization, less postoperative pain, a faster return to normal activity, and a superior cosmetic result.
Over the past 40 years, one of the most popular procedures in the vaginal surgeon's armamentarium has been the sacrospinous ligament suspension. More recently, the procedure has been described with mesh placement as well.
We have asked an expert on this surgical technique, Dr. Neeraj Kohli, to write this Gynecologic Surgery Master Class. Dr. Kohli is a leader in the field of minimally invasive pelvic surgery and the treatment of pelvic prolapse and urinary incontinence. He is director of the division of urogynecology at Brigham and Women's Hospital and assistant professor of obstetrics and gynecology at Harvard Medical School, both in Boston.