Welcome, I'm Susan Barr and I'm the moderator for today's webinar on sacrospinous ligament fixation. Before we begin, I'd like to share that we will take questions at the end of the webinar but you can submit them anytime by typing them into the question box on the left-hand side of the event window, in the lower left-hand side there. Today's webinar is titled, The Sacrospinous Ligament Fixation, Classical Apical Support with a Great Future and it's presented by Dr. Kent Burke. Dr. Burke is the Director of Female Pelvic Medicine and Reconstructive Surgery at his alma mater, the University of Missouri School of Medicine in Kansas City. He completed his specialty training in obstetrics and gynecology at the University of Texas Southwestern Parkland Memorial Hospital and spent the next 23 years in private practice with the last five being dedicated to female pelvic reconstruction. Following his board certification in FPMRS, Dr. Burke accepted his current position in order to take an active role in teaching surgical skills and pelvic reconstruction for future generations of gynecologic surgeons. Dr. Burke feels strongly that pelvic reconstructive surgeons should be experts in vaginal, laparoscopic and robotic approaches to pelvic reconstruction in order to best serve individual patient needs. With that, I will let Dr. Burke begin. Thanks, Susan and welcome everyone. I was hoping to keep this somewhat informal and interactive and so I was hoping to utilize a poll everywhere, hopefully you're familiar with it. There should be a link to the Poll Everywhere website and web link to this particular presentation. You can also use your phone with texting, which is a convenient way to do it as well. None of the questions are very difficult. It's just more to kind of stimulate a back and forth conversation. If everyone can see the first slide here. I was going to say, if anybody's looking on their screen in that lower left hand corner, there's a resources tab they can pop up and there's a link if they want to use their computer to answer your questions. Additionally, if you can use the text or information at the top of the screen. There we go. Somebody has answered. This is Alex. I will try not to respond. They have a 30 second delay from what they hear so it might take a second for that to come through. Excellent. As we go through, I will have a couple of other questions. Obviously the first one was wondering if you went to AUGS. Looks like we are 50-50 there at this point in time. We will go ahead and get started. This is my opening slide. The introduction kind of went through things. I have been, actually, I have exclusively used the sacrospinous ligament or almost exclusively for vaginal support surgery of the apex since I got out of training. I feel that I went from the early 90s until now improving and continuing to develop a process of using the sacrospinous ligament to support the apex of the vagina over that period of time. It certainly is something that has a long learning curve to it. It is, I think, difficult to get excellent results if you don't have a lot of experience. You can get excellent results if you don't take some of the key ingredients and don't have to reinvent the wheel. My hope is that I can pass along some of those pearls and tips and let you know how I feel like I get a better result from the sacrospinous ligament support of the apex. I want to know how everybody thinks as far as outcome compares using a sacrocopopexy to doing a sacrospinous ligament fixation. So, my opinion is I feel that the sacrospinous ligament offers nearly as good of an outcome as the sacrocopopexy and that's if used in conjunction. We'll get into some of the detailed data as we get further on as far as outcomes are concerned, but used as a tool in the pelvic reconstruction done vaginally, I think it responds favorably to a sacrocopopexy. In isolation, perhaps not as well. So, a historical perspective. The first description of using the sacrotuberous ligament was first done in the late 1800s. At that time, however, the approach was very minimal, very difficult, and as we can understand, the sacrotuberous ligament would be higher in the pelvis and behind the sacrospinous ligament and was not really well thought of. Most of the procedures back in that time were done as obliterative procedures because of the increased morbidity and mortality. Aseptic techniques and modern antibiotics dramatically changed that and it was in the mid-1950s to 1960s that more reconstructive procedures began. The current sacrospinous ligament, as we utilize it now, was originally brought to popularity in Europe by Richter and Albright and by Randall and Nichols here in the United States. Their initial presentation of the procedure was in 1971 and it became somewhat of a mainstream procedure at that time. The original technique involved approaching from the posterior aspect through a posterior repair incision and it extended out through the perirectal space, piercing the rectal pillar on the right and attaching the vagina to the ligament. Two polyglycolic sutures were placed and they were placing those sutures one and a half to two fingerbreadths medial to the ischial spine. We'll come back to this placement area later on as far as one of the refinements that's occurred. They attached that to the underside of the posterior vaginal wall with its apical support and a posterior coporaphy was completed. So if we look at the anatomical relationships that occur right around the sacrospinous ligament, these are going to be the areas of concern as well as success leading to a good sacrospinous ligament suspension. As we know that just posterior to the sacrospinous ligament and coccygeal complex, the gluteus maximus muscle and the ischial rectal fossa are there. The pudendal vessels lie just behind the spine and the pudendal nerves, the pudendal nerve just medial to that. The sciatic nerves lies above and behind the sacrospinous ligament and there's a tremendous amount of blood supply as you move more medial along the sacrospinous ligament towards the sacrum. Both perirectal and anterior paravaginal dissections have both been used to assess this and there's extensive literature describing both techniques. So again, here's an example of the sacrospinous ligament. You can see it arising from the ischial spine, traversing along to the coccyx and sacrum and it's fan-shaped and is about 5.5 centimeters in length or 55 millimeters. It is contiguous with the coccygeal muscle with the ligament being the more superior and more anterior portion of that complex. So the first question is, what distance would we place our sutures when performing a SSLF in the sacrospinous ligament? How far away from the ischial spine? Well, the original description has us placing them about 1.5 to 2 centimeters across. However, when we do some cadaver research and look into where the structures of concern are, we find that perhaps that we need to modify our technique some. So if we look along this ligament, we know that the pudendal vessels are fairly well protected and hidden behind the spinous process. If we move 1 centimeter or 1 finger breadth medial to the spine and go deep to the ligament itself, we are immediately in contact with the pudendal nerve. That's, of course, where we do a pudendal nerve block, which many of us have performed in obstetrical cases. And so we want to be probably more medial than that. As we move on down the ligament, we get closer to the sciatic nerve and incorporating the sciatic nerve, which is immediately superior and cephalad from the ligament. If we were to incorporate the sciatic nerve, we could incorporate some nerve damage. That actually has been looked at with cadaver studies, and they looked at 24 cadavers. And this was done out of Louisiana State, where they took the 24 cadavers. And one of the interesting parts of this study is they actually looked at these specimens and they did an obstetrical conjugate. In other words, they evaluated the size of the pelvis and divided them into the largest pelvis and the smallest pelvis based on measurement of the obstetrical conjugate. Of course, everybody knows the obstetrical conjugate is measured by putting your fingers into the vagina, the tip of your fingers on the sacral promontory, and measuring the distance along the sacral promontory to the inferior aspect of the pubic symphysis. When they did that, they found that they could divide the pelvises into the smallest, the largest, based on that size of the pelvis. If you look at the length of the ischial spine to the sacrum, there's a variation between the largest to the smallest in the mean in the length of the ligament. However, the pudendal complex and the sciatic nerve distances were somewhat consistent along those, meaning that the longer supraspinous ligaments, the extra length was towards the coccyx rather than out towards the spine, and the areas of danger or the structures that we want to avoid were pretty consistent in their location compared to the ischial spine. So we should continue to use the ischial spine as our measuring point or our reference point when we place our sutures. Again, when we looked at those structures, they were located between .9 and 3.3 centimeters medial to the ischial spine. They were located behind the ligamentous complex, and the suggestion from this study was that we should perhaps be moving our suture location to three centimeters or more medial from the spine in order to avoid the pudendal and the sciatic structures. Anybody who's done this, what have you been using to anchor items into the sacrospinous ligament? Type in an answer and it should pop up on our screen. Dr. Bard, do we have any questions that have popped up so far? Not just yet. Okay. Dr. Bard, what do you use to, do you use a Capio or do you use another device? Traditionally, I would use the Mya hook because I believe I rescued one out of our, whatever the OR calls the recycling bin when I started. In some instances, if it's a primary apical defect, I'll usually do the more traditional repair. If it's kind of icing on the cake where I feel like it's primarily anterior and posterior, then sometimes I will use a minimally invasive suture device like a Capio. Yeah. I have adopted to the Capio. I used the Mya hook for a long period of time. I think the Mya hook, the Capio have the advantage of placing the suture from anatomically anterior to posterior along the ligament. In other words, as the patient's lying in lithotomy, from top down through the ligament. One of the keys to placing these sutures is to make sure that we don't go behind the ligament. And I feel like my Capio device really helps keep me from going behind the ligament as it fires back towards itself rather than extending out. Other people I know have used the endostitch device, the laparoscopic endostitch device, which the students strike me as a very good thing to be just kind of firing a sharp needle up inside there. I kind of wanted to have a little more control over it than that device would give me. Have you seen that used or anything else used? I have not seen that one used, but we did have a question pop up wanting to know kind of how you approach teaching these. Yeah, so the dissection part, as I go out through the dissection, I actually will, I use a posterior approach. So as we get further on in, we'll talk about the anterior versus posterior approach. But as I develop this, I try to identify the ligament and I tend to do the first side dissection, let the resident or fellow feel the dissection after I've performed it so they understand what the ligament should feel like and the spine feels like prior to doing their first dissection on the opposite side. I'm a big believer in blunt dissection. I guess I like to use the Capio because I don't have to put a full-size retractor in. I don't expose to visual, visually expose the ligament anymore. I feel like doing so just for teaching puts the patient at a disadvantage compared to a more minimally invasive approach to getting to the ligament. So I'm teaching it to be done as a minimally invasive blind insertion into the ligament. I will have the, I can kind of see the Capio device on the outside of the patient and understand whether I think it looks like it's in the right spot. And after it's deployed, I will check to see if it's where it needs to be. I usually give the learning physician a couple of tries at getting it in the right spot before, I feel like, before I take over. The nice thing about the Capio is it can be, the stitch can be removed and reloaded and tried again without causing any harm to the patient. It looks like most people are using a Capio as well here. The original DeChamps ligature carrier is shown in the upper right of this screen. Dr. Delancey is a big advocate of just using a retractor's full visualization of the ligament and placing sutures directly with a needle driver into the ligament. And that, I've done that. I don't know if anyone else has, but that is a very difficult approach. Getting the needle correctly through the ligament is a difficult thing and I would think very difficult to teach to someone without a lot of experience suturing high up inside the vagina. The Capio, I think, is probably the most popular method of delivering sutures to the ligament at this point in time. Next question would be permanent sutures or delayed sutures or a combination thereof. I'm wanting to know whether people think they use a permanent suture or should just use delayed absorbable sutures only or some combination of the two. So as people weigh in, I use permanent sutures almost exclusively for my apical support. And I do that because I have the ability to come through a posterior approach. If I were taking an anterior approach, my partner here in Kansas City takes an anterior approach. He uses a combination of permanent and absorbable sutures. And I think that would probably be my choice as well at that point. But at this point, I'm still using only permanent sutures. I have some issues with the permanent suture being exposed into the vagina postoperatively. But it's something that almost always can be taken care of surgically. I mean, sorry, taken care of in the office without needing additional surgery in order to remove the sutures. So the next is the approach. We take an anterior approach. So an anterior approach to the ligament. You dissect in the parabasical space down posterior towards the sacrospinous ligament. You can also come through the peritoneum after a hysterectomy and open up after going through the peritoneal cavity, open the retroperitoneum a second time and approach the ligament in that fashion. Or you can come through a posterior approach through the periorectal pillar and approach it in the periorectal space in order to get to the ligament. And all three have been described. And actually, studies that have been done comparing these three different approaches show good outcomes from all three approaches. So I think it is a preference of surgeon and perhaps even a technique that could be tailored to the difficulties of the patient's having. I have particular reasons for why I prefer a posterior approach, and I'll explain that as we get further along. So which way do most people approach things on their approach to the sacrospinous ligament? That's interesting. I kind of expected there would be some anterior or transperitoneal purists out there that only approach from the top. But apparently everybody does take a posterior approach at least some of the time. That's interesting. That's encouraging. So even though we say it's an anterior or posterior approach, I do like this image because it does demonstrate that we actually are coming at the ischial spine and the spinous process from an anterior angle, regardless of whether we enter through the rectovaginal periorectal space or the perivesical space, the angle of which is the only difference is the angle of which we come into that space. But both are coming down from an anterior to posterior because the ischial spine and the sacrospinous ligament is located superior to the anal triangle and not directly behind the urogenital triangle, which is where our vaginal and our surgical incisions are for either approach. So this is the way we go about making an anterior sacrospinous ligament suspension. We identify the mucosa and vagina overlying the ischial spines and sacrospinous ligaments bilaterally, and they're identified for future reference. An anterior incision is made from the vaginal cuff up to the base of the bladder. We identify the ligament three centimeters from the ischial spine, which is two finger breaths, and we put a stitch into the ligament, bringing it out medially. The sutures are then attached to the vagina. If we're attaching absorbable sutures, they can go full thickness through the vaginal wall. Non-absorbable sutures need to be placed in the vagina without traversing the mucosa, as we don't want to have an obvious and create a for sure exposure of suture into the vagina. If an anterior repair or a paravaginal repair is performed, we perform it before tightening the sutures. We also repair an interseal or rectoseal, and then we tight our sutures down after the remaining of the defects have been performed. The idea here is that with Delancey's levels of support, we're looking to secure. The goal is to fix level one support with this procedure. If the patient has additional level two support that needs to be performed, or she needs to have either anterior or posterior, we need to perform those procedures prior to securing the apex, or securing the apex will put too much tension on our tissues that we're trying to repair in the middle section, in the level two support area. So we have to make sure that we're fixing those at the same time. The last thing we want to do then is then return the apex up into the vagina, and then we can finish closing our mucosal incisions. This is an illustration of what we end up with. One of the things with a unilateral and superior sacrospinous ligament fixation is the vagina comes down, and because the left and right portion of the vaginal apex is brought to the same ligament on one side, you can see that the top of the vagina, the apex of the vagina, deviates to one side, but it also tends to narrow some at the top of the vagina. And those are, I think, issues that we can perhaps improve on with a different technique. But that's the way it was originally described. A posterior approach, we do a similar procedure. We identify with two Alice clamps, and what I call, and it was described in a couple of articles, and what I refer to as the new apex. Now I want to identify the area of the vagina posteriorly that corresponds with the sacrospinous ligament, and I'm doing a bilateral sacrospinous, but it could also be done just unilateral. And I want to identify that area of the vagina that when brought back up, corrects the excess level two defect posteriorly as well. In other words, I want to eliminate, for the most part, all of the prolapse along the posterior vaginal wall and the apex when I attach the vagina up to the sacrospinous ligament. I don't want it to be on tension. I don't want it to be overly taut, and I don't want to have the sutures banjo-stringed or having a gap between the tissue and the ligament. But I do want it to be brought up and correcting most of the posterior defect at the same time. I then make a triangular incision, just like a posterior repair, and incise the vagina along the midline. Dissect out into the right and left pararectal space, penetrating the rectal pillars and palpating the ligament. I put two sutures, and in my case, two non-absorbable sutures into the ligament. I bring those back and attach them to the vagina just below the vaginal cuff along the posterior vaginal wall. I take care to make my posterior incision stop so that it doesn't go up and between my two sutures if I'm doing it bilaterally. I want to make sure that if there's tension from one side to the other along the posterior vagina, that my incision doesn't cross that area between those two so that if any tension's there, it's not pulling my incision apart. So my incision is stopping just prior to I get to those areas that I've identified that will be approximated to the sacrospinous ligament. So Dr. Burke, you have a question here that asks if you would change your approach if your patient had a primarily anterior vaginal defect. So I don't. What I do though is, and so let's assume that she has a hysterectomy, is having a concurrent hysterectomy, and if she has a concurrent hysterectomy, once I've identified how much I've got my Alice clamps on the vagina, I'm taking them back. It's supporting the upper part of the vagina and the posterior wall of the vagina well. I then can then say, okay, that's what needs to be done posteriorly. Now I can then assess how much anterior repair or paravaginal repair needs to be performed in order to take care of any additional anterior prolapse. And what I found is that there's actually a limited amount of anterior repair needs to be performed. Even though I haven't taken the vaginal cuff, either the old cuff or the new cuff, I'm a little bit along the posterior wall from that point. And even without having gone out and gotten a cuff, I can tell that I don't have to do a tremendous amount of anterior repair in order to get adequate support of the anterior vagina. Some of that is because I'm doing it bilaterally. By spreading the vagina across and making the vaginal apex a wider structure by doing it bilaterally, I've actually created a situation where there's less anterior repair that needs to be done. And I used to do unilateral exclusively. When I was doing unilateral repairs, I found that a lot more anterior repair needed to be done in order to adequately support the anterior vagina. And in that situation, I started to realize that the vagina was getting more narrow than I would like. So I ran into a situation of causing narrowing of the vagina caliber because I was having to take out more anterior vagina and doing more paravaginal or anterior repair in order to get the vagina well enough supported. Once I switched and started doing bilateral, I found that I needed to do very little anterior repair in order to get adequate support anteriorly. So again, you can either use permanent or absorbable sutures. I am softening to the idea of using absorbable sutures in this situation. And I'm getting that somewhat from the experience we're now having with sacrocopalpexy and using absorbable sutures in order to secure the mesh to the vagina. And since that has been doing so well, I'm questioning whether we need to be using permanent sutures exclusively. I may be going to a one permanent and one absorbable suture type of approach going forward. The literature certainly supports those doing just as well as far as long-term outcomes in sacrospinous ligament support. So as I finish my approach, typically because I've pulled the vagina up to where I wanted it to go, I have very little posterior repair that needs to be done. So many times I'm just simply closing the full thickness vagina that I opened in order to reach the peri-rectal space and the ligament. So it's usually just a simple closure of that area. One of the things that I think is very important is actually is making sure that we bring the perineal body back together. So bringing the pubis, the lobus cavernosus muscles and the transverse perineal muscle and rebuilding the perineum is an important aspect of this procedure and adds that necessary support to the structures that we've just done. So that's kind of filling in the gap and getting the lancy level 3 supports also taken care of posteriorly. Obviously anteriorly for level 3, if they need a TBT or a mid-urethral sling, we would be performing that as well. So when we do the sutures, we actually will then be tying the sutures down in order to secure them. This is showing two permanent sutures like I had previously described in my technique. Both of which are tied to the outside of the vagina so that we can avoid having sutures show up in the vaginal cavity itself. I use a pulley stitch in order to get those sutures to pull down and that simply is putting after we have our stitch through the ligament, I put two throws into the vagina at the predetermined location that I had marked with an Alice and those sutures crisscross and I want to have them at differing angles so that I'm incorporating as many of the fibrous, I'm crossing as many fibrous aspects of the vaginal tissue as possible in order to get it to hold well. And by putting two throws through the vagina, the suture will only pull through the ligament. So as I tighten that stitch down, the vagina will be pulled back without suture moving through the vagina. And what I have found is that the vagina, if the suture is kind of pulling through the vagina, particularly if you have a braided suture, the braid as it's on tension like that pulling on the vagina, it will actually just cut through the tissue like a saw. And so you end up weakening the tissue you're trying to use to support. So a pulley stitch is a very important part of it. It's really just putting two throws into the vagina and then that creates a situation where all of the slack has to come out the other side through the ligament, which is a much stronger structure. In addition, when doing these sutures, I take a tremendous amount of care to make sure that my sutures don't get crisscrossed. So as I'm pulling these sutures, I'm very careful to make sure that the stitch goes down through the ligament, up through the vagina, and that I'm not getting any twists or turns in my sutures down in that space. My experience is, and this has been in the past, if we get some crossing, either crossing one suture onto the other or crossing the two halves of the same suture, as we start to tie down, it's such a long tensioned knot that's being placed that I think the tensioning of the sutures running past each other in that manner cause it to weaken significantly. I tell the residents that they push past each other and they actually just will melt each other because the braided suture will just pop without any resistance at all if we do it that way. So I'm very careful to make sure that I get those sutures, keep them all straight so that they don't get crossed over one another. Certainly doing it bilaterally, the last thing you certainly do not want to have happen is your sutures on the left to get intertwined with the sutures on the right because once that's happened, you can't adequately tie one side down. The one permanent suture and one absorbable suture technique is shown on the right, and in that one you see that one knot is going down inside the vagina. Most people will tie that, have the ability to tie that down after you've finished closing the remainder of the vaginal mucosa and vagina, so you can tie the apex down at the very end of the case using that suture as well, and that helps kind of cinch the vagina up to the ligament is the idea. We have a question here about if you have any experience in a post-hysterectomy patient with making a diamond-shaped incision at the apex, so in a sense pre-trimming, particularly if the patient has a redundant interior wall. So when I do this on someone who's had a previous hysterectomy, I will identify my two areas, again, bilaterally, so if I'm doing it bilaterally, I will place my Alice clamps on the ligament where I wish the vagina to be held. I see how much anterior defect is there, and I will make a transverse incision at the vaginal cuff anteriorly, and almost perform like a reverse anterior repair. So I'm going, well, it's not a reverse anterior repair, it's the same as an anterior repair. So I've just basically created a transverse incision at the vaginal cuff, so now I'm back to where I would be if I had just finished a hysterectomy, and I then make a midline incision and do an anterior repair, or a paravaginal repair, depending on where the defect appeared to be coming from. Most of the time I'm doing an anterior repair. I have not felt like a paravaginal repair, the extra dissection for the paravaginal repair gave me such a great increased response that I felt like that was necessary. I know there's a number of people who are putting a biological graft in that location from arcus to arcus, I've just not felt like that was necessary. If I feel like there's a huge kind of defect coming in laterally, I tend to then perhaps suggest that the patient should probably go with an abdominal procedure if possible, and a sacrococcal pexy rather than a vaginal approach if I feel like there's a problem with a lateral defect like that. And then you also have a question about, is it okay to leave a suture bridge? It is not ideal. If you leave a suture bridge, the concern about a suture bridge is if you've left a suture bridge, the suture is all that's holding things if there's a suture bridge. I'm not sure, if you look back and you go back in and look at someone who's had a suture bridge, there certainly is a tremendous amount of fibrous scar tissue in around that suture, so I'm not sure that it is completely not without any strength other than the suture, but ideally you would like to not leave a suture bridge. I tie, because of that, I always tie down my right side first because that's the typical side for a unilateral repair, so if I get that side tightened down and right up next to the ligament first, if I do end up having mismeasured my bilateral approach, I may have a suture bridge on the left, but I don't have a suture bridge bilaterally, so you certainly want to get one of them. If you're doing it bilaterally, you want to make sure you get one of them tightened up, and as you do a bilateral approach more often, you get better and better at deciding exactly where to go. The way I measure is in the vagina, I feel for the spine through the vagina, I put a long Alice clamp on the vagina where I think it should go, and I push it right up against the ligament on that side. I then check to see if it's got the correct distance along the vaginal wall posteriorly and laterally in order to reach that location without being on too much tension or without distorting the anatomy, and then I reach over to the other side and I try to identify the same spot on the other side with my finger and place an Alice there. By crisscrossing the Alice's and pushing them into those ligaments, I can then stand back and look at the entire repair, what I expect the entire repair to look like, if all I did was do that part of the procedure. So I can then look to see, well how much posterior defect do I have? Is something too tight? Am I pulling on the vagina and distorting the levator anus off to the side or the perineum off to the side? And how much anterior repair am I going to have to have in order to keep her from having an anterior bulge? So that's the first part that I do in order to make sure that it's going to be a successful operation. By doing it that way, I've pretty much identified an area of the vagina that's going to end up without a suture bridge because I've made sure I've gotten them far enough lateral. If I'm consistently and make sure that when I take that Alice clamp off, I put the stitch right where it was, it should tie down appropriately. Does that make sense? I think so. Okay. So unilateral or bilateral? And I threw a trick question in there at the bottom because I think there's a lot of people that prefer to do a uteroscleral ligament suspension as well. Dr. Barr, do you do unilateral or bilateral or do you prefer a uteroscleral? I usually do unilateral or uteroscleral. Yeah. Nobody's fessing up to the uteroscleral. While we're waiting on answers, we have another question about thoughts on an apical sling. So basically a piece of mesh that's attached to both the sacrospinous ligament and the apex of the vagina. That would be similar to some of the mesh kits. I mean, certainly an uphold. You could say an uphold mesh would be similar to an apical sling on someone who is status post-hysterectomy. And I think that is a valid procedure. I've not used any biological graphs in that area. And I guess my thought is if I'm going to use an apical synthetic, I would probably approach it from the abdomen. I would probably approach it from the abdomen and do a sacrocopalpexy laparoscopically in that scenario. As we get further in here, there's not good evidence that it's going to improve your outcome. So if you look at the outcome data, you would say, well, there's not any compelling reason to add something into that location unless you felt like you were unable to get enough repair with your anterior and posterior repair of the non-apical portion of the prolapse. So that's pretty much straight up the middle, isn't it? 50-50. We've got 10% doing the utero-sacral, somebody joined in. So the information in the literature on the bilateral sacrospinous ligament, and this is where I started doing it, was based on this information by Cespedes. And this is done out of, I believe it's either Wilford Hall, which would explain why I'm exposed to it, or one of the other medical branches, and I can't remember which one he was at. But they put information out on both. And they, excuse me for a second, sorry about that. So they felt like the narrowing of the vagina, improving the area of scar, and then also getting a, improving the direction of the forces that are applied to the vagina were some of the reasons to perform a bilateral procedure. Obviously incontinence procedures can be performed anytime we do any of them, so that doesn't really have, they mentioned it, I didn't want to leave it out, but it could be applied to any repair, it's not just a bilateral. Delta Reed also looked at how many women had enough vagina, so these are women who had either uterine prolapse or vaginal vault prolapse, and how many had enough vaginal width in order to be able to reach both sacrospinous ligaments and do a bilateral repair. And they found that over half of women having a hysterectomy, as well as 70% of women who were having a vaginal vault prolapse, could have a bilateral approach performed. The approach that they're both describing is an anterior approach to the sacrospinous ligament, and doing it bilaterally at that point in time. The theory is that the narrowing of the upper vagina by bringing both the left and right sides of the apex of the vagina to one ligament, causing the vagina to narrow at the top, could be one of the sources of dyspareunia with this operation. That's not been well studied or proven, so that's more of a theoretical, I would have to say that's more of a theoretical consideration rather than something that's got good evidence. But here we can see a comparison of what the, a drawing of the aftermath of either of those procedures. So on the left we have a unilateral, and you can see that the vagina narrows because both sides of the apex of the vagina are being brought to a single point. And on the right we see a bilateral sacrospinous ligament support with an anterior incision that led to the access to those repair aspects. And in my opinion, it's just a nice looking procedure, and when you're able to feel the vagina afterwards, you feel that the vagina goes back to the ligaments, and there's an area in between where intercourse can occur without running into anything obstructive from the repair work that you've done. And I think it gives a nice repair, as well as increasing the support of the anterior vagina compared to a unilateral. So here's their data, and one of the things that's interesting, and you'll see as we talk more about as we go through the rest of these slides, is that they have almost universally concomitant surgeries performed. And then the results show that they have very few recurrences of the apical or anterior prolapse in these studies. The biggest risk was the transient buttocks pain, and that's with any of the ligaments, and we'll talk about that at the end as well. An interesting study that's a really good read is Chris Shank's publication, and he actually, they looked at longitudinal cohort of women with prolapse undergoing procedures, and then broke them out into three different sections as they altered and improved on their surgical techniques. An interesting thing is that the sacrospinous ligament became very good when it was accompanied by site-specific multi-compartment repairs, peroneal repairs, and urethrapexies, either retropubic or minimally in the U.S. procedures. And so as they evolved from 1985 through into the 2000s, you could see a huge, you could see a shift in what they were doing as well as their outcomes. Additionally, a review of procedures reported showed that a large series had tremendous, had 82% of anterior repairs and 92% had posterior repairs as well as apical interstitial repairs and hysterectomies a third of the time. The Optimal Trial is another one that's more recently been published. The Optimal Trial compared sacrospinous ligament fixation to uterus sacral ligament fixation, found them to be equally well, do equally well. And this is the data from that. And so I show it to just look at the one, the study showed no superiority between the two. But the kind of important part of this is it shows the failure rate of the procedures. So if we look at that, we can see that it's a fairly high success rate. When we look at the apical descent in that first line, it shows that both do well with the 10 to 15% recurrence rate of apical descent to a third. If you look at the patient satisfaction with the procedure, the subjective cure rate, so to speak, they were even better than that. This is from a study that was looked at sacrospinous ligament fixation and compared it to a mesh repair of the vagina. And the take home from here was that the mesh didn't actually improve anything, but you can also see that on a POPQ that women with a large anterior defect, which is what we were concerned about. So you can see point BA on these patients was the leading edge on average. And that at three and 12 months postoperatively, for the most part, they were improved. Meaning that if you had good results from a sacrospinous ligament fixation, you probably will have a good result long term. When we look at the studies that have looked at outcomes, if there is a failure or a reoperation, it usually is within the first 24 months. So studies that go out through 24 months, there is indications that those outcomes probably continue long term and that the original failure rates are probably before that. Objective success is always higher than objective and there's a difficulty and no clear definition of what a successful objective outcome should be in the literature. Complications, things we can run into with problems. So the biggest problem with the sacrospinous ligament fixation is either going to be not getting good support, not getting the apex of the vagina and our sutures placed in the correct location in order to get a good anatomical result. But if we take that out of the equation and actually look for things that can go bad, obviously injury to veins and arteries of the pudendal that should be avoided. They are so well protected by the spine itself. It's not a reported incident that we have very often. If we do have bleeding from the area, it's typically from the inferior gluteal vessels because they pass closer to the ligament and are more medial than lateral. And usually we don't have to, if we have hemorrhage from those, packing and or IR if bleeding continues is the way to treat those. So re-operation or exploration is very rarely needed in that scenario. The sciatic nerve could be injured. The report of that is extraordinarily low and is unlikely to be encountered. The key sign for sciatic nerve injury would be to have radiating pain and numbness that extends along the course of the sciatic nerve. The pudendal nerve, if involved, would cause pain or discomfort or numbness in the distribution of the pudendal nerve and is also not very common. The pudendal nerve, its location and behind the ligament, the key to not getting any of these structures that are important is to make sure that you don't go behind the ligament with your device and your stitch, which is why I think the Capio is such a great device because it's just incapable of grabbing anything that's a centimeter behind the ligament. Its design is such that you could not do so. The risk is that it doesn't grab enough of the ligament, but well applied, it should give you a good purchase on the ligament without risking going behind the ligament and capturing one of the nerves that lies just a centimeter or so cephalad. Rectal perforation is very uncommon. The most common complaint is pain in the buttocks region and that comes from picking up a small amount of the nerve that runs along the sacrospinous complex as part of the sacral plexus. Those are transient pains and usually go away within the first few weeks, rarely lasting over six weeks. This is an article that had a unilateral sacrospinous ligament and they followed these patients through. You can see that the indications were uterine prolapse and vaginal vault prolapse. You can see that the main 6.5% of the patients had experienced some buttocks pain and it resolved in 100% of those patients. Those are the main complications. I wanted now to open up and see if we had additional questions and anything we want to talk about or debate. We have a question here about your thoughts on the AnchorSure device. I have not used it. I have seen, I saw it, I looked at it at the conference last week. My concern with the AnchorSure device, I think it's probably would be a fine device to use. My concern is in a teaching institution, if it's not in the right place, it has to be left in place and another one put in. In other words, you can't remove it. Once you fire the device, it's in unless I misunderstand how it works. My understanding is you can't remove it once it's placed in the ligament. Being involved in resident teaching, I want something where I can remove the suture without leaving a piece of plastic or hardware, whatever you want to call it, in the ligament that's not utilized and not for the patient's best interest, particularly if it were fired into a bad area. In other words, if it was placed in the muscles or placed too superior, I would be concerned about that device being, having to leave that device in there. And then we have another question regarding any technique tips on sacrospinous ligament fixation for hysterepexy. Yeah, so if you want to perform a hysterepexy, it's really the same thing. And I think the advantage there is with the uterus, once you've done the dissection, if you take your posterior, I would approach it from a posterior. I would not come in anterior. If you're going to, I would approach it with a posterior, use a posterior approach. Assess my, get my ligaments the exact same way I would any other patient. And then when I go to secure them to the vagina, I would want to reach up and actually secure it really straight to the uterus sacral ligament and posterior cervix. So really get right into that tissue, that massive tissue at the base of the cervix. And draw that ligament up to that area. So you want to be kind of in that, right into the uterus sacral area just south of the cervix is where you kind of want to grab the tissue from. With a hysterepexy, I don't feel that you could necessarily do it bilateral. Being able to move those tissues to both sides and getting that area in between to stretch with the cervix there, I'm not sure that you would be able to accomplish that well. I think you would probably be doing a unilateral hysterepexy and applying sutures into both uterus sacrals and bringing them over to the right sacrospinous ligament. I wouldn't try to do a bilateral hysterepexy. And we have one last question here and it's regarding the extended optimal trial. It says data supports a 70% failure in sacrospinous ligament fixation and it wants to know how you counsel patients given this information. Yeah, so I actually, I talk to my patients and I actually do quote the optimal trial with the 70% and it's, you know, 70% objective failure and that's the problem with some of these is the objective failure versus the subjective failure. I tell the patients they have a 70% chance of not continuing to have full support of the vagina if they go with a vaginal sacrospinous ligament fixation or uterus sacral ligament suspension and with a sacrocopalpexy that it's over 90% long-term success. So I quote them a difference in the two but then point out that the sacrocopalpexy has a higher risk of complications than the vaginal approach and that this procedure doesn't have any mesh. As I explain those issues to the patient and walk them through that, if they're leaning towards or if they're undecided or leaning towards a native tissue repair, I explain to them that if they have a failure, they can still get a sacrocopalpexy and have very good results from that procedure if they have a native tissue repair and it fails. So I don't try to oversell the vaginal repair but I make sure that they realize that it's a trade-off. There may be an increased risk of failure but it does come with no mesh exposure and also with less complication risk. Okay. I think we have time for one last question here and that is, any concerns about obstructing the rectum with the bilateral sacrospinous ligament fixation? I don't and everybody that has reported on the bilateral, one of the original descriptions of this procedure was bilateral. So I mean it was originally described kind of as a bilateral procedure but I've not had any difficulty with obstruction of the rectum. And when you look at a, if you get a pelvic model out and look at it and you just kind of drew a line between the two sacrospinous ligaments, you can see that there's a lot of pelvis still behind that. There's a lot of pelvis along the coccyx coming down past the sacrospinous, a line between the two ischial spines. So even if you put them straight across, you're going to have, there's going to be enough space there. Certainly it's a reason to not go all the way back but we do a, you know, the utero-sacral ligaments end basically at the sacrospinous ligament as they attach to the coccyx anyway. I mean that's where our utero-sacral is and we do a bilateral utero-sacral ligament suspension all the time. So as we move our SSLF procedures and we've moved them medial and done it bilaterally, it's not terribly different than a bilateral utero-sacral suspension as well. So it's not been reported. I've not seen it and so I would not, I would certainly not counsel a patient that there's a risk of obstructing the rectum. Great. On behalf of the Augs Education Committee, I'd like to thank you Dr. Burke for your presentation today and thank everyone for joining us. Just a reminder, our next webinar will be coding and reimbursement updates and that will take place on December 5th. Thank you. Thank you, Susan.

sacrospinous ligament fixation

webinar

Dr. Kent Burke

female pelvic medicine

reconstructive surgery

suturing techniques

pulley stitch

approaches to the procedure

permanent sutures

absorbable sutures