RICHTER'S骶棘韧带固定术-阴道穹窿脱垂（图文演示）

RICHTER'S   SACROSPINOUS   LIGAMENT   FIXATION   OF   THE   PROLAPSED   VAGINAL   VAULT
Authors
M Cosson, B Occelli, D Querleu
Abstract
The description of the Richter's sacrospinous ligament fixation of the prolapsed vaginal vault covers all aspects of the surgical procedure used for the management of vaginal vault prolapse following hysterectomy.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: posterior colpotomy, opening of fossae, exposure, sutures, checking the hemostasis, myorrhaphy, suspension of vaginal floor, end of procedure, complications.
Consequently, this operating technique is well standardized for the management of this condition.

中文版：RICHTER'S骶棘韧带固定术-阴道穹窿脱垂（中文图文演示）

1. Introduction
The fixation of the vaginal vault to the sacrotuberal ligament (“vaginae fixura sacrotuberalis vaginalis”) was described in 1951. This technique has been modified by the choice to use the sacrospinous ligament (Richter, 1968). It involves opening the pararectal space, identifying the ischial spine and placing 3 sutures through the sacrospinous ligament. These sutures are then anchored to the posterior surface of the vaginal wall, and the floor of the vagina is drawn over the sacrospinous ligament.
This technique was initially indicated for vaginal vault prolapse following hysterectomy (Richter and Albrich, 1981; Richter and Dargent, 1986). The technique is now used for prolapse operated on transvaginally.

2. Anatomy
• Sacrospinous ligament

The sacrospinous ligament, or anterior sacrosciatic ligament, courses posteriorly and medially and inserts into the last 2 sacral vertebrae and the first 2 coccygeal vertebrae. It resembles a fibrous triangle with a lateral apex. Its anterior surface faces the pelvic peritoneum, and its posterior surface faces the inferior border and the anterior surface of the coccygeus muscle to which it is joined so intimately that there is no dissection space between these 2 muscular and fibrous structures. It is limited caudally by the ileococcygeus muscle and cranially by the piriformis muscle.
1. Sacrospinous ligament
2. Coccygeus muscle
3. Ileococcygeus muscle
4. Piriformis muscle

• Anatomical relationships

Knowledge of the relationships of the posterior surface of the sacrospinous ligament is essential. These relationships may lead to intraoperative complications secondary to suture.
- the internal pudendal vessels wrap around the ligament at its origin (ischial spine);
- the roots of the sciatic plexus converge obliquely towards the subpyramidal canal that is limited superiorly by the pyramidal muscle and inferiorly by the sacrospinous ligament itself.
1. Needle passage

3. Indications

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Indications
Indications include vaginal vault prolapse after previous hysterectomy and prolapses operated on transvaginally.

Contraindications
In addition to contraindications to anesthesia, the technique is contraindicated if transvaginal access is difficult (osteoarthritis, hip prosthesis).

4. Operating room
• Patient

- pubis and vulva shaved the evening before surgery;
- shower with betadine surgical scrub the evening before and on the morning of surgery;
- general or local-regional anesthesia;
- lithotomy position with thighs drawn back over abdomen and legs as straight as possible;
- urinary catheter (optional);
- betadine applied by compress to the vulva and perineal and subpubic areas up to the umbilicus and down to the upper thighs;
- sterile drapes used: beneath the buttocks, 2 sterile boots, large suprapubic drape, 2 small perineal drapes excluding the anus.

• Team

1. The surgeon is positioned between the patient’s legs, facing her vulva.
2. The first assistant is to the right of the surgeon, below the patient’s left leg.
3. The second assistant is to the left of the surgeon, below the patient’s right leg.
4. The scrub nurse with the instrument table stands behind and to the right of the surgeon, or in the position of the first assistant.

• Equipment

The equipment on the instrument table is to the surgeon’s right.
1. Instrument table

5. Instrumentation
• Specific instruments

1. Eight Allis (atraumatic vaginal) clamps
2. Narrow Breisky retractor (bayonet-shaped retractor)
3. Wide Breisky retractor
4. Two medium-width Breisky retractors
5. Mangiagalli retractors

• Non-specific instruments

- four toothed (Péan) clamps;
- Kocher clamp;
- two grasping forceps with wide jaws (Jean-Louis Faure) for ball-shaped sponges,
- two long needle holders;
- medium-length needle holder;
- straight scissors;
- suture scissors;
- surgical knife;
- electrosurgical knife (optional);
- toothed dissection forceps;
- blunt dissection forceps;
- four cups;
- suction cannula (optional);
- Bingoléa grasping forceps.
1. Péan clamp
2. Kocher clamp
3. Bingoléa grasping forceps

• Disposable instruments

- prostate dressing;
- radiopaque sponges;
- radiopaque ball-shaped sponge;
- sterile gloves;
- sterile fingercots;
- two No. 23 surgical knife blades;
- xylocaine 1% with epinephrine combined with an equal amount of saline;
- syringe with IM needle.
Ligatures:
- for the sacrospinous ligament suspension: non-absorbable Filapeau 1 type (dec 4) 1/2c 35 mm monofilament suture or non-absorbable Mersuture 1 type (dec 4) 1/2c 35 mm braided suture;
- for myorrhaphy of the levator ani muscles (optional): absorbable PDS II 1 type (dec 4) 1/2c braided suture;
- for the vaginal suture: delayed absorbable Vicryl 1 type (dec 4) 1/2c 35 mm braided suture.
1. Prostate dressing
2. Radiopaque sponges
3. Radiopaque ball-shaped sponges

• Variation

Chromium-plated catgut suture was used in the past. Currently, there are 2 possibilities:
- non-absorbable, non-transfixing suture at the level of the vagina, to approximate the vagina without attaching it to the sacrospinal ligament. We have chosen this method;
- use of a delayed absorbable suture that transfixes the vagina and attaches it to the sacrospinal ligament. This variation is based on the development of fibrosis.

6. Major principles

The procedure involves anchoring the vaginal vault to the sacrospinous ligament:
- bilaterally, but this is often excessive;
- or unilaterally, with a risk of pelvic static disequilibrium.
Two operative strategies may be used:
- during treatment for a prolapse after a previous hysterectomy with elytrocele or rectocele;
- during treatment for a total prolapsus, after previous colpohysterectomy and colporrhaphy.
We always perform myorrhaphy of the levator ani muscles with Richter’s sacrospinous ligament suspension because it completes the posterior step of the procedure and recreates the physiologic angle of the vagina.

7. Posterior colpotomy
• Localization


Two mid-sized Breisky retractors are positioned on either side of the posterior vaginal wall. Three Kocher clamps are then placed on the midline of the posterior vaginal wall, between the vaginal floor and the vestibule.
1. The first Kocher clamp is positioned on the vaginal vault (old or recent hysterectomy scar, posterior to the cervix if the uterus is preserved).
2. The second Kocher clamp is placed 1 or 2 cm above the superior angle of the vulva.
3. The third Kocher clamp is placed on the midline between the first 2 clamps, at an equal distance from both.
       
• Vaginal wall infiltration

60 mL of diluted epinephine solution is administered by infiltration to the posterior vaginal wall and the pararectal fossae (optional step). This infiltration serves 2 purposes: hydrodissection that facilitates dissection of planes and hemostasis for a bloodless procedure. In case of an anesthesia-related contraindication, it is possible to use only saline in the infiltration for the purpose of hydrodissection.

• Vaginal incision

An incision is made with the surgical knife on the posterior vaginal midline, between the Kocher clamps.
This incision is begun at the level of the vaginal floor (vaginal hysterectomy scar or point of closure of the previous colphorrhaphy) and ends 1 to 2 cm above the superior angle of the vulva.

• Placing Allis clamps


Eight Allis clamps are placed on the edges of the vaginal incision between the 3 Kocher clamps. The Kocher clamp that is situated in the middle of the posterior colpotomy is removed. The posterior vaginal incision is completed.
The 2 Breisky retractors are removed, as well as the 2 remaining Kocher clamps.

8. Opening/fossae
• Recto-vaginal dissection



Using the 8 Allis clamps, the 2 assistants exert a star-shaped traction. The rectum is grasped with the blunt dissecting forceps. A divergent traction is exerted relative to one of the pararectal fossae. The tented fibers are incised with the surgical knife. This is repeated on the opposite side.
The infiltration makes it possible to visualize a minimum-risk rectal zone during the dissection.
The recto-vaginal dissection is completed with the index finger, using gentle, lateral, back and forth movements, remaining in contact with the levator ani muscles. This step prepares the levator ani muscles for the myorrhaphy. The dissection must be done sufficiently to the rectum and should enable visualization or palpation of the levator ani muscles. In case of doubt, the integrity of the rectum can be checked during the dissection by digital examination, using a sterile fingercot. Digital examination of the rectum is systematically performed at the end of the recto-vaginal dissection.

• Opening the fossa

The left pararectal fossa is incised first. The right pararectal fossa may be chosen instead (sacrospinous ligament is better perceived, and dissection seems to be easier).
The pararectal fossa is opened after introducing the index finger in a 2 o’clock position on the upper part of the colpotomy incision, using lateral sweeping movements down to the rectum.
The Mangiagalli retractor is then placed in the pararectal fossa in a posterior position. A wide or mid-width Breisky retractor is positioned against the lateral pelvic wall. The narrow or mid-width Breisky retractor is inserted against the first Breisky retractor, pushing the rectum back towards the midline; the retractors are pulled in opposite directions by the 2 assistants (one in a 10 o’clock position and the other in a 4 o’clock position), opening the pararectal fossa.
The retraction should be effective but gentle, because it can cause a small tear in the lower part of the rectum. It is important to adequately dissect the rectum, notably on the lower midline, before introducing the retractors, and to systematically conduct a digital examination of the rectum. The Allis clamps are progressively removed as the retractors are introduced.
1. Mangiagalli retractor
2. Breisky retractor in 4 o’clock position
3. Breisky retractor in 10 o’clock position

• Rectal reflection



A plane between the mesorectum and the levator ani muscles is exposed at the tip of the retractor placed against the pelvic wall. This plane is opened 2 cm with dissection scissors.
A ball-shaped sponge is inserted into this opening with a Jean-Louis Faure grasping forceps. The opening of the plane is extended by gently moving this sponge laterally and back and forth against the levator ani muscles. At the same time, the mesorectum is reflected towards the midline with a blunt dissecting grasping forceps.
1. Mesorectum reflected towards midline

9. Exposure
• Exposure


The prostate dressing is packed into the 10 cm space created in the previous step along the wide or mid-width Breisky retractor pressed against the pelvic wall. The narrow or mid-width median Breisky retractor is removed. It is reintroduced between the dressing and the wide retractor pressed against the pelvic wall, making it possible to retract the rectum and mesorectum toward the midline, and to visualize the posterior lateral pelvic wall.
The large retractor must be positioned for visualizing the sacrospinous ligament posterior to the ileococcygeus muscle that partially covers it (we suggest bringing the tips of the retractor together and carefully pushing it in to flatten the levator ani muscle; it should then be progressively opened and removed until the sacrospinous ligament is revealed). A ball-shaped sponge can also help the surgeon to expose the sacrospinous ligament.
The Mangiagalli retractor is then repositioned between the 2 retractors in a 7 o’clock position, enabling a maximal opening of the pararectal fossa and an excellent view of the sacrospinous ligament. If the space created by the 2 Breisky retractors is not wide enough for the Mangiagalli retractor, however, this part of the step may be omitted.
1. Mangiagalli retractor in 7 o’clock position
2. Sacrospinous ligament

• Warning

The surgeon must avoid palpating the ischial spine in order to view it (this can be dangerous). In addition, the lateral retractor pressed against the pelvic wall is sometimes pushed in too far by the assistant. This can damage the internal pudendal neuro-vascular pedicle located just behind the ischial spine. The lateral retractor must be progressively removed following the levator ani muscle until the sacrospinous ligament is revealed.