Welcome, my name is Ty Erikson and today we'll be reviewing an edited video of a bilateral sacrospinous ligament fixation using native tissue and a novel suture device for permanent suture fixation into the sacrospinous ligament. The device itself has a head which we will be placing the suture cap as demonstrated here. The suture cartridge cap is placed into the head, make sure that it is flush, I generally do this by placing my finger along the distal portion of the head, rolling it back, put gray to gray so that the cap is actually placed on the post of the device. Here you can see that there is a scooping mechanism by which the needle itself grabs the cap. The dissection in the posterior compartment is the same dissection that would be used for any other native tissue procedure. As you can see, I typically go approximately one-third to one-half of the epithelium is dissected and then undermine below up to the apex of the vagina. In this case, we're out and out laterally to the patient's left side exposing the sacrospinous ligament. Metzenbaum scissors are used directly over the spine to open up a space that we can clean the tissue completely off the ligament itself. The delivery device shaft has a malleable portion that allows the device head to flex approximately 15 degrees. Introduce the head with your index finger directly to the sacrospinous ligament to prevent tissue being captured. The delivery knot device should then be engaged in the lateral position so that the wings are parallel to the ground. The index finger should be placed on the neck and gentle pulling of the lever until a click is heard will confirm that the needle has been inserted into the cap. Perform the same procedure on the contralateral side and what we identify on the patient's right is the sacrospinous ligament. We are using a seven-degree endoscope for visualization into the perivaginal space. As visualized here, the head is placed under tension against the sacrospinous ligament. The index finger will be pushing on the neck as here demonstrated and then we fire the needle into the cap. Once we have captured the sacrospinous ligament, we gently will withdraw the device and you can see that the ligament maintains its integrity as the device and the suture is brought out through the operative field. This picture in a picture demonstrates pulling with tension on the suture to verify that we have obtained a good bite into the sacrospinous ligament. Embedded in the suture cartridge, a taper needle is found attached to the opposite end of the permanent suture. A long ellis clamp is used to grab the apex of the vagina at the utero sacral ligament. This will be used to provide support to the apex by using the needle and placing a double helical throw through the utero sacral ligament to provide a durable support at the vaginal apex. We are demonstrating this on the patient's right, but during the procedure we performed this bilaterally so that we had bilateral apical support. It is important as you tightened the suture lifting the apex of the vagina to prevent deviation either to the right or to the left using a bilateral sacrospinous fixation. By maintaining alignment of the vaginal apex and not deviating it, we decrease the potential future risk of an anterior compartment defect. Finally, closure of the incision in the posterior wall is performed using vicral absorbable suture and a classic running lock. After that is done, vaginal packing is placed and the patient is transferred to the recovery room.

Ty Erikson

sacrospinous ligament fixation

native tissue

suture device

surgical procedure