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Vagina and Urethra

Anterior Repair and Kelly Plication
Site Specific Posterior Repair
Sacrospinous Ligament Suspension of the Vagina
Vaginal Repair of Enterocele
Vaginal Evisceration
Excision of Transverse Vaginal Septum
Correction of Double-Barreled Vagina
Incision and Drainage of Pelvic Abscess via the Vaginal Route
Sacral Colpoplexy
Le Fort Operation
Vesicovaginal Fistula Repair
Transposition of Island Skin Flap for Repair of Vesicovaginal Fistula
McIndoe Vaginoplasty for Neovagina
Rectovaginal Fistula Repair
Reconstruction of the Urethra
Marsupialization of a Suburethral Diverticulum by the Spence Operation
Suburethral Diverticulum via the Double-Breasted Closure Technique           
Urethrovaginal Fistula Repair via the Double-Breasted Closure Technique
Goebell-Stoeckel Fascia Lata Sling Operation for Urinary Incontinence
Transection of Goebell-Stoeckel Fascia Strap
Rectovaginal Fistula Repair via Musset-Poitout-Noble Perineotomy

Sigmoid Neovagina

Watkins Interposition Operation

Sacrospinous Ligament Suspension of the Vagina

Sacrospinous ligament suspension of a prolapsed vagina is an ideal procedure for a sexually active woman who has a complete prolapse of the vaginal canal. Prolapse of the vagina can occur following a hysterectomy or can evolve with the uterus in place. If the uterus is still in place, it is best to remove it by vaginal hysterectomy, as shown in the section Uterus. The sacrospinous ligament suspension operation has the advantage of retaining an adequate length and width of the vaginal canal.

Physiologic Changes. Total prolapse of the vagina may interfere with bladder function, defecation, and sexual intercourse. Some women with total prolapse of the vagina have no evidence of urinary incontinence. There are, however, some women who after correction of the prolapse may experience urinary incontinence unless certain surgical techniques are employed to ensure that the intravesical pressure does not exceed the intraurethral pressure, other than in the act of micturition. After suspension of the prolapsed vagina, rectal function should improve, and the patient should be able to defecate without digital manipulation of the rectum. Comfortable sexual intercourse can be achieved if the vagina is of adequate length and diameter and if the vaginal outlet has not been constricted.

Points of Caution. To achieve a safe and permanent sacrospinous ligament suspension of the vagina, there must be appropriate attention to detail. The rectovaginal space must be entered and dissected prior to entering the pararectal space through the vagina. If the lateral extent of the cardinal ligament is inadvertently entered, copious hemorrhage can occur from the hypogastric venous plexus that resides in the upper two-thirds of this area (the web).

The sacrospinous ligament must be visualized and identified. Failure to place sutures directly into the ligament is the most common cause of recurrent prolapse. Care must be taken to avoid the pudendal artery and nerve, since these are immediately posterior and inferior to the ischial spine. The sutures must be placed at least 2 cm medial to the ischial spine to avoid injury to the pudendal nerve, which could result in chronic pain. The type of suture material used must be carefully chosen to avoid recurrence. We prefer a synthetic nylon suture mounted on a small Mayo needle or a Deschamps ligature carrier for placement.


The patient is placed in the dorsal lithotomy position and is prepped and draped in the usual manner.

If the patient has not had a hysterectomy, the procedure is started by circumscribing the vaginal mucosa at the junction of the cervix and vagina in the routine manner for starting a vaginal hysterectomy.

A sagittal view of total prolapse of the urethra, bladder, uterus, and rectum is shown. The vaginal hysterectomy is completed at this point according to the technique shown in the section Uterus.

A perineal view of total prolapse of the vagina following the vaginal hysterectomy and anterior repair is shown.

The prolapsed vagina is returned to its original position.

The suture line can be seen in the anterior vaginal mucosa following the anterior repair. The posterior vaginal mucosa is opened in the routine fashion as described previously in Posterior Repair. A finger is inserted through the incision in the posterior vaginal mucosa, dissecting out the rectovaginal space (RVS). The rectal pillars on both sides can be immediately identified. The right rectal pillar (RRP) is identified. The rectal pillar can be bluntly perforated either with the finger or with the tip of a long Kelly clamp.

A Breisky-Navratil retractor is ideal for exposing the rectovaginal space in order to enter the pararectal space. The narrow Deaver retractor may also be used, but the curve of the Deaver retractor is less effective than that of the Breisky-Navratil retractors. Adequate retraction of the cardinal ligament, vagina, and rectum is essential for safe operative exposure. Visualization and illumination can be achieved by a bright fiberoptic head lamp focused onto the pararectal space.

With long thin retractors, the surgeon displaces the rectum to the left and the cardinal ligament and ureter anteriorly. A narrow right-angle retractor is used to displace the side walls of the pelvis and perineum. The superior surface of the pelvic diaphragm is exposed. A sponge dissector is used to bluntly dissect the sacrospinous ligament. It is important for the surgeon to remove the areolar tissue from the surface of the right sacrospinous ligament in order to visualize it directly.

The ischial spine should be palpated directly, and a zone approximately 2 cm medial to the spine should be selected for insertion of the suture needle.

The Deschamps ligature carrier, loaded with a 0 monofilament nylon suture, can be inserted directly into the ligament. The suture is grasped with a skin hook and held while the Deschamps carrier is removed. If the suture is placed too close to the ischial spine, it may entrap the pudendal nerve.

A second suture is loaded into the Deschamps ligature carrier and passed through the sacrospinous ligament in a similar manner.

One end of the suture previously inserted through the sacrospinous ligament is placed through the muscular layer of the vagina. In a similar manner, the second suture is placed. The opposite end of the suture in the sacrospinous ligament is left free and held on a small hemostat. Traction on this suture will draw the vaginal vault directly to the ligament, where a square knot will promptly affix it to the sacrospinous ligament.

The pulley stitch has been tied, and the ends of the suture have been cut. The safety stitch is then tied.

A posterior colporrhaphy is carried out in the routine fashion, and the vaginal mucosa is closed.

The completed sacrospinous ligament suspension with the apex of the vagina suspended from the sacrospinous ligament approximately 2 cm from the ischial spine is shown.

A Foley catheter is inserted into the bladder and left for a minimum of 4 days. Thereafter, management of bladder function is similar to that following surgery for urinary incontinence. No vaginal packs or drains are used.





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