This video will demonstrate a 4-point sacrospinous ligament suspension utilizing porcine urinary bladder extracellular matrix and polyether ether ketone anchors for the correction of pelvic organ prolapse. Examination under anesthesia is performed. An anterior vaginal wall defect is noted. Apical prolapse with point C at minus 2. A large posterior anterocele is identified, and there is detachment of the distal posterior vaginal septum from the perineal body. The anterior dissection is started with a full thickness dissection of the anterior vaginal epithelium. The sacrospinous ligaments are palpated after blunt and sharp dissection is performed. The anterior approach was first described by Winkler in 2000. The apical prolapse is again appreciated. The posterior dissection is started, the anterocele sac is clearly identified. The traditional posterior approach to the sacrospinous ligament is then started, the initial spines are palpated, and a sweeping motion is then undertaken to identify the sacrospinous ligament. This is also demonstrated in this cartoon. Sweeping motions are limited as the anchor placement requires very little dissection. High ether ketone anchors are then prepared, and placement is shown here into the left sacrospinous ligament from the posterior approach. The anchor is placed in a perpendicular motion to the floor into the sacrospinous ligament, and a distinct pop can be identified when the anchor is deployed into the ligament. Pull-out force within the porcine rectus fascia has been demonstrated to be greater than 39 newton. This is placement into the right posterior sacrospinous ligament, and again, there is minimal dissection and no visualization required for proper placement. Anchors are also deployed into the sacrospinous ligament from the anterior approach on both the right and left sides. The stylet is then manually bent at approximately 4 to 5 centimeters in order to provide placement of an anchor at the distal arcus tendineus for distal anterior vaginal wall support. The sheath of the stylet is not utilized during this portion of the procedure. The apical sutures of the final closure of 0 vicral are placed at this time in order to facilitate closure, as the apex can be very difficult to reach once the suspension is completed. The cervical sutures are placed. This is a permanent monofilament suture, but a long-delayed absorbable suture can also be utilized. These are the anterior cervical sutures being placed, posterior sutures being placed, and a true four-point fixation is performed. The fixation is performed as a flush fixation to either the right or left side, and a slight bridge to the contralateral side as to not spread the apex of the vagina. The pulley sutures are then deployed, and the apex is brought to the level of the ischial The porcine graft is then cut to form. This is the anterior graft with a four-point fixation. These are the initial proximal anterior sutures being placed. The distal anterior sutures will also be placed to provide a four-point fixation of the anterior graft. The proximal portion is slid into place along the same sutures that were utilized for the sacrospinous ligament suspension. The anterior vaginal wall is then closed with the traditional anterior coporaphy sutures being placed, and then closure of the anterior vaginal wall with a running, imbricating suture. The posterior graft is then prepared, and again this demonstrates the suturing of the proximal posterior portion of the graft. A Breisky retractor is utilized to protect the bowel from being caught in the pulley sutures which place the graft at the level of the ischial spine. The distal posterior graft is then attached to the posterior aspect of the perineal body after perineoplasty is performed. A delayed absorbable suture is utilized for this part of the closure, and the posterior closure is completed with interrupted sutures and a running suture of the vaginal epithelium. Again a delayed absorbable suture is utilized here. The perineal body is then closed with a running suture of 2-0, delayed absorbable suture, completing the perineoplasty. Adequate vaginal length is clearly identified utilizing the Breisky retractor, and the cervix can be visualized at approximately minus 10. The same surgical set technique can be utilized in cases of massive vaginal vault prolapse as demonstrated in this 33-year-old, G5, P5. There's marked excoriation of the vagina. The anterior and posterior dissections are carried out in a similar fashion with significant trimming necessary of the vaginal epithelium. Here all four points of fixation are demonstrated, as well as the distal anterior sutures identified at 12 o'clock. Adequate vaginal length and support has been restored. A combination of peak anchors with tactile fixation and porcine urinary bladder extracellular matrix may represent an important pivot point in the augmented repairs of pelvic organ prolapse. Long-term follow-up of these repairs is necessary to ensure safety, efficacy, and adequate sexual function.

surgical procedure

pelvic organ prolapse

4-point sacrospinous ligament suspension technique

porcine urinary bladder extracellular matrix

polyether ether ketone anchors