Over the years, we have had excellent success with the Michigan 4-Wall Sacrospinous Ligament Suspension, even in complex cases. This video will illustrate techniques we have developed to ensure excellent outcomes in a variety of situations. There are several features of the Michigan 4-Wall that differ from the traditional Sacrospinous Ligament Suspension. The 4-Wall technique allows the surgeon to excise excess vaginal length, includes the anterior, posterior, and lateral walls in the suspension, avoids contralateral wall descent, eliminates the need for a bilateral suspension, and uses absorbable suture to attach the vaginal cuff to the ligament for direct healing. To review the 4-Wall technique, a diamond-shaped incision is made and retroperitoneal dissection performed along the posterior wall down to the sacrospinous ligament. Two passes are made through the ligament with a loop suture that is then cut. The sutures are then placed through the full thickness vaginal wall in a manner that closes the incision and suspends all four walls. Once tied down, you can see the excellent suspension result. The appropriate vaginal length is critical for the operation's success. For the suspension to have the best outcome, it is important that each of the walls reaches the ligament with an appropriate amount of tension. A vagina that is too long will leave laxity and potential prolapse, and one that is too short will not reach the ligament. With careful attention to technique, we have had success rates equivalent to mesh sacroculpapexy. The secret to success is to tailor each repair to the unique situation of that woman's prolapse. This video will review some specific strategies to address unique issues and optimize outcomes. Choosing the right suspension points is key to achieving optimal support with the Michigan four wall. This case shows a large post-hysterectomy enterocele with a short anterior wall. You can see the hysterectomy scar, and on examination, the posterior wall is longer than the anterior wall. Alice clamps are placed and checked to ensure those points reach the sacrospinous ligament. With an appropriately placed posterior alice, you can see the perineal body lift. The lateral alice clamps are placed in a diamond configuration and checked to make sure all four suspension points reach the ligament and resolve the prolapse. In this case, the patient had a vault prolapse without excess vaginal length to excise. Alice clamps are placed horizontally posterior to the hysterectomy scar and checked to ensure these points reach the ligament and resolve the prolapse. You can see that if an excision was performed, the vagina would not reach the ligament. A horizontal incision is made with a T extension to allow room to dissect to the ligament. Retroperitoneal dissection is performed along the posterior wall to the sacrospinous ligament. The T extension is then closed with a running vicral suture. The sutures that were passed through the sacrospinous ligament are now passed through the full thickness vaginal wall, leftmost sutures to left anterior and posterior walls, and rightmost sutures to right anterior and posterior walls, and tied down sequentially. At the completion of the suspension, you can see the closed vaginal incision and excellent apical support. At this point, one can then proceed with peroneoraphy. With a large vault prolapse, vaginal excision is important to restore normal vaginal length and caliber. In this case, we have a very large vault prolapse, and you can see that excision is necessary. With the initial diamond placement, there is still some wall laxity, indicating the need to adjust our suspension points to resolve the laxity. A larger diamond excision is then planned and marked that restores normal vaginal length and resolves the prolapse, and the width of the vagina will be corrected with the anterior and posterior repair noted by the markings on the anterior and posterior walls. At the completion of the suspension and anterior and posterior repairs, a normal vaginal length and width has been restored. In this case, there is a fascial defect in the central portion with healthy tissue more lateral. Alice clamps are placed such that this abnormal tissue will be excised. When checked to the ligament, we found that the Alice clamp on the patient's left will not reach the ligament, and we will need to close a portion of this incision to make it smaller and reach the ligament. The abnormal tissue is excised. The corner on the patient's left side is then closed, making the diamond smaller and ensuring enough vaginal length to reach the sacrospinous ligament. At the completion of the suspension, the apex reaches the ligament, all walls are well supported, and the abnormal tissue has been excised. A sacrospinous ligament suspension is an excellent suspension for a patient desiring uterine sparing surgery. After an anterior repair, an Alice clamp is placed posterior to the cervix and checked against the sacrospinous ligament to ensure that a suspension at this point will resolve the prolapse. A horizontal incision is made to avoid excising vaginal length, and retroperitoneal dissection is performed. Here you can see the Deschamps suture carrier in the sacrospinous ligament. One looped suture has been placed, cut, and held, and this is the second looped suture being placed. The suture loop is retrieved, cut, and held, and the suture ends are placed through the vaginal wall. The sutures are tied down and cut, and with the combination of the anterior repair and suspension, the patient has an excellent surgical outcome with her uterus remaining in situ. The four-wall sacrospinous ligament suspension can also be performed at the time of hysterectomy. With a Leahy thyroid clamp on the cervix, an Alice clamp is placed where the anterior colpotomy will be made, and this point is checked against the ligament. The posterior Alice is placed at a point that will reach the ligament and ensure a proper posterior wall length. You can also see that the cervix is elongated. If you choose a posterior colpotomy point closer to the cervix, you can see that you will want to trim some of the posterior vaginal wall. The anterior and posterior points are checked against the ligament, and a colpotomy is made that includes these points. In this case, we have a large uterine prolapse that requires restoration of normal vaginal length with a diamond colpotomy. These suspension points are chosen and checked against the sacrospinous ligament. A diamond-shaped colpotomy is made. At this point, the hysterectomy has been completed. We have our suspension sutures placed through the ligament and held. The anterior repair is done. The cardinal and utero sacral sutures are held on either side, and the peritoneum has been closed. The sutures are then placed through the vaginal wall and tied down to the ligament. These sutures serve both as the vaginal cuff closure and the suspension. At the end, you can see that all vaginal walls are supported with the same amount of tension. This patient had prior anterior and posterior vaginal mesh and presented with apical prolapse. Suspension points were chosen, taking care to not encounter the mesh, but still ensuring resolution of the prolapse. Since this patient did not require vaginal excision to restore normal length, a transverse incision is made. Retroperitoneal dissection is performed to the sacrospinous ligament. Sutures are passed through the ligament and then, in standard fashion, passed through the vaginal wall and tied down to the ligament. After the suspension, normal apical support has been restored, and you can see that the anterior and posterior walls remain supported by the previously placed mesh. Typically, with the Michigan four-wall technique, we do the anterior repair prior to tying up the suspension. However, in this case, it was noted after the suspension was completed that an anterior repair was needed. In cases like this, an elliptical anterior repair is a good strategy to ensure a successful outcome. An ellipse is marked out and incised sharply, and the vaginal epithelium is sharply dissected off. The vaginal wall is then closed with a running or interrupted delayed absorbable suture. At the end, we see that the anterior laxity has been resolved and the patient has excellent support. We hope you have enjoyed this video of secrets to success for complex cases using the Michigan four-wall sacrospinous ligament suspension.

Michigan 4-Wall Sacrospinous Ligament Suspension

techniques and strategies

complex cases

vaginal length

absorbable sutures