Laparoscopic Procedure >>
Laparoscopic and Minimally Invasive Procedures Continued
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 it has a very limited role in vault suspension surgery with the newer less invasive vaginal approaches available today, such as the Apogee procedure.. It is a procedure that is completed vaginally at the same time of 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 anatomic repair (pulling the top of the vagina off to one side, see Fig. 8 below). Dr. 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.
Drs. Moore and Miklos Modification of the SSLF
In some patients that may not be candidates for abdominal surgery or are felt to be better candidates for a vaginal approach under epidural anesthesia, Dr. Moore and Miklos will utilize the patients sacrospinous ligaments to complete a vaginal vault suspension. However, they have modified the procedure by utilizing both ligaments in the suspension (bilateral SSLF) and they incorporate a graft into the suspension which they feel strengthens the suspension significantly. The apex of the dermal graft that they place during their posterior repair or during an anterior repair is attached to the top of the vagina (all the way across the entire width of the vagina). Sutures are then placed through the sacropinous ligaments (see below) and then through the top of the graft at each corner. The sutures are then tied down which elevates the vagina up very nicely without deviating it to either side.
Technique
The sacrospinous ligament technique is described below. Images are from Technique Spotlight Suture Placement, Vol 3 by Boston Scientific featuring the use of the CapioTM Suture Capturing Device. The procedure is completed vaginally.
Results/Complications
Drs. Miklos and Moore have seen very good results in the past and rare complications with the bilateral sacrospinous ligament suspension incorporating agraft placed either along the posterior or anterior wall. This however is a procedure that should only be completed by experienced advanced pelvic surgeons. Our patients are pleased with their vaginal vault support with minimal vaginal length compromise. The procedure can be completed vaginally under epidural anesthesia. 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. They may decide to utilize this approach in a patient that is not a candidate for laparoscopic sacralcolpopexy and needs a vault suspension. Secondary to some of the newer procedures available today that are less invasive, they do not use this procedure as much as in the past and reserve it for very select patients.
Atlanta Urogynecology Associates Experience
Drs. Moore and Miklos offer their patients the most advanced techniques in pelvic reconstructive surgery. The anterior approach to the sacrospinous ligament is a relatively new but well described and proven procedure for vault prolapse. They have worked with world leaders in reconstructive pelvic surgery to develop modifications of this procedure as well as the posterior approach to improve cure rates and to complete a more anatomic result for their patients. However, no one surgery is the answer to all patients and that is why that they tailor every patient’s repair to their individual needs.
Drs Miklos and Moore are well versed in all of the above procedures and are considered experts in the field of minimally invasive vault suspension surgery and therefore can offer their patients all of these advanced procedures to be completed in a time efficient but also safe manner.
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