The objectives of this video are to understand the pararectal anatomy, including important structures that are in close proximity to the sacrospinous ligament. In addition, it is important to understand the various surgical approaches and outcomes to sacrospinous ligament fixation. The sacrospinous ligament was first described for use in the repair of vaginal vault prolapse in Europe in 1958. In the United States, Nichols and Randall popularized this surgical technique and first published its use in 1971. Since its introduction in the United States, variations to the surgical technique and new instruments to assist in suture placement have continued to make the sacrospinous ligament an important structure for reconstructive pelvic surgery. The sacrospinous ligament is a cord-like structure lying within the substance of the coccygeus muscle. It is often referred to as the coccygeus sacrospinous ligament. Originating at the ischial spine, the sacrospinous ligament can be traced posteriorly and medially until it attaches to the sacrum. The sacrospinous ligament is approximately 5 cm in length. In close proximity to the sacrospinous ligament, several vascular structures are encountered. The hypogastric venous plexus, which is located superior to the sacrospinous ligament, may be encountered during dissection of the pararectal space. In addition, the inferior gluteal artery, a branch off the hypogastric artery, is found superior to the sacrospinous ligament. Coursing beneath the ischial spine are the pudendal artery and vein. The nerves that the surgeon must be aware of when approaching the sacrospinous ligament include the pudendal nerve and the sciatic nerve. In one anatomic study, the distance from the ischial spine to the sciatic nerve was found to be 2.5 cm, while the distance to the pudendal nerve was 0.5 cm. The pudendal nerve exits the pelvis via the greater sciatic foramen, runs behind the lateral third of the sacrospinous ligament, underneath the ischial spine, before turning to re-enter the pelvis through the lesser sciatic foramen, then exiting the pelvis through Alcox canal. We will now discuss the various surgical approaches to the sacrospinous ligament. The posterior approach is the most common way to access the sacrospinous ligament. Entry into the pararectal space is performed by blunt dissection through the fibroarollar tissue of the rectal pillar and mobilizing the rectum medially. The surgeon must take great care during this dissection to avoid disrupting the hypogastric venous plexus superiorly while ensuring that the rectum is adequately retracted medially. The sacrospinous ligament is identified by palpation utilizing dorsal and medial movements of fingers from the ischial spine towards the sacrum. Further blunt dissection can be performed to remove remaining tissue overlying the sacrospinous ligament. Once completed, a rectal exam can be performed to ensure no inadvertent injury has occurred. The next technique that can be utilized is the anterior approach. Anterior access to the sacrospinous ligament was first described by Winkler to Metzko and Sand in 2000. The bladder and peritoneum are mobilized superiorly four to six centimeters away from the vaginal cuff to provide adequate space to mobilize the left apex of the vagina to the right sacrospinous ligament. Subsequently, the paravesical space is entered by separating the endopelvic connective tissue from its insertion just beneath the pubic rami. The anterior endopelvic connective tissue is freed from its lateral attachments from the bladder neck down to the ischial spine. Similar to the posterior approach, dissection of the pararectal space is performed in order to access the sacrospinous ligament. After the adequate dissection, proper exposure is crucial for successful placement of sutures on the sacrospinous ligament. Strategies for obtaining excellent exposure include the following techniques. One technique, described by Randall and Nichols, uses Breisky-Navratil retractors for direct visualization and subsequent passage of sutures through the ligament. A second technique uses a two-handed approach with deflection of the rectum with the medial hand and placement of suture with the lateral hand. Ideal suture placement avoids the adjacent neurovascular structures while providing a strong point of fixation for suspending the apex. Sutures should be anchored to the sacrospinous ligament one to two finger breaths medial to the ischial spine. Care should be made to avoid the rectum which borders the sacrospinous ligament medially. Superficial placement of the sutures into the sacrospinous ligament will help to avoid deeper structures. We recommend No. 0 Delayed Absorbable Sutures for Sacrospinous Ligament Fixation. Several instruments for suture placement have been described in the literature. These include direct placement with a needle driver, Deschamps Ligature Carrier with Nerve Hook, Miyazaki Hook Ligature Carrier, Nichols-Veronikis Ligature Carrier, and the CAPIO device. A surgeon should utilize the instrument he or she is most comfortable with. Our preference is the CAPIO device. The CAPIO device utilizes the two-handed technique to deflect the rectum with the medial hand and placement of suture with the lateral hand. Special double needle sutures are designed to be used with the CAPIO device. After anchoring the sutures to the new apex, a coporaphy is completed and the skin incision is closed using standard technique. The apex is then suspended by sequentially tying down the sacrospinous ligament sutures. Anatomic success of the apical compartment has been reported to be between 85-100% with a mean follow-up of 12-73.6 months. Recurrent prolapse is most often seen in the anterior wall following a sacrospinous ligament. Rates of 6-26.7% have been reported in several studies. One theory suggests that the deviation of the vagina posteriorly after sacrospinous ligament fixation may result in loss of support to the anterior vaginal wall. Sexual function appears to be good following sacrospinous ligament fixation. In one large series by Perezo et al., the rate of dyspareunia was 14% with only half of them representing de novo cases. Risk factors for de novo dyspareunia and sexual dysfunction after sacrospinous ligament fixation appear to be related to vaginal narrowing or concomitant anterior coporaphy. Although infrequent, complications can occur with performing sacrospinous ligament fixation. Complications include vascular injury resulting in hemorrhage that can occur during dissection of the perirectal space. Buttock pain occurs in 10-15% of patients and often resolves by 6 postoperative weeks. Because of the close proximity of the sciatic nerve to the sacrospinous ligament, the potential for nerve injury is also present. Vaginal injury can occur during dissection of the perirectal space as well as during mobilization of tissue of the sacrospinous ligament. Development of stress urinary incontinence may occur postoperatively and is probably secondary to straightening of the vesicourethral junction after restoration of vaginal support. Finally, vaginal stenosis from performing an aggressive anterior or posterior coporaphy may occur and can lead to postoperative dyspareunia. In conclusion, access to the sacrospinous ligament provide the surgeon an important point of fixation for reconstructive pelvic surgery. Although generally a safe procedure, the surgeon must understand the anatomy of the perirectal space in order to avoid intraoperative neurovascular injury.

pararectal anatomy

surgical approaches

sacrospinous ligament fixation

reconstructive pelvic surgery

vaginal vault prolapse repair