RICHTER'S骶棘韧带固定术-阴道穹窿脱垂（图文演示）

10. Sutures
• Placing the sutures


A long needle holder threaded with non-absorbable suture is used. The curve of the needle is positioned perpendicular to the large axis of the needle holder. The needle is passed perpendicularly into the ligament, 2 cm medial to the ischial spine (to prevent vascular and nerve complications to the internal pudendal). A back and forth movement is used, with a clockwise rotation of the wrist. Often the needle comes out at the posterior part of the ileococcygeus muscle, which reinforces the hold.
This needle is grasped by the second needle holder while completing the clockwise rotation. The suture is kept in place with the needle on the Péan clamp.
A second suture is placed on the ligament (medial or lateral to the first suture, taking care to respect the 2 cm security zone around the ischial spine). This is facilitated by the traction created by the first suture. The second suture is held along with its needle on the Péan clamp.

• Variation

An “Endostitch” grasping forceps may be used to pass the suture through the sacrospinous ligament without exposing the ligament with the retractors, but under direct palpation of the ligament with a finger.
The surgeon uses the absorbable suture and transfixes the vagina to tie the sacrospinous ligament fixation sutures at the end of the procedure with an intravaginal knot.
It is possible to perform only one sacrospinous ligament fixation suture. We use 2 sutures to increase solidity and to avoid having to repeat the entire process if a suture breaks when the sutures are tightened at the end of the procedure.

11. Checking the hemostasis
• Checking the hemostasis

The Mangiagalli retractor is removed. The median narrow or mid-width Breisky retractor is then progressively removed, as well as the dressing, using a toothed dissection retractor to control the hemostasis of the mesorectum. The lateral wide or mid-width Breisky retractor is then removed. The 8 Allis clamps are repositioned on the edges of the vaginal incision.
After removing the retractors, the integrity of the rectum must be checked by digital examination. It is particularly important to check for injury to the lateral inferior portion of the rectum linked to the tension between the 2 Breisky retractors. This risk is increased if the dissection of the lower part of the rectum was not sufficient.

• In case of bleeding

If bleeding occurs, direct pressure should be exerted on the pararectal fossa with a dressing for several minutes. The bleeding can usually be stopped in this way.
Hemostatic clips are used. When bleeding occurs behind the sacrospinous ligament, due to the depth and narrowness of the space, the use of a stitch threaded on a Bingolea grasping forceps is very difficult.
If the hemostasis fails, the area must be packed until an arterial embolization can be completed.

12. Myorrhaphy

Myorrhaphy of the levator ani muscles is optional. When it is performed, the 2 sacrospinous ligament fixation sutures are lifted upwards to avoid catching them in the sutures used for the myorrhaphy.
For the myorrhaphy suture of the levator ani muscles, the Allis clamps must be taut and spread out. With a finger, the surgeon pushes back the rectum medially to protect it, while the other hand pierces the levator ani muscle with a rotational movement of the needle holder. The needle is picked up by a second needle holder held by one of the assistants.
One or two absorbable sutures are performed for the myorrhaphy of the levator muscles. They should not be tight. They are held on a Kocher clamp.
It is necessary to always check that the myorrhaphy sutures do not transfix the vagina, in which case the surgeon must remove and redo the suture. The integrity of the rectum is checked by digital examination.

13. Suspension/vaginal floor
• Vaginal floor landmarks

The 2 sacrospinous ligament fixation sutures held in the grasping forceps are lowered. They are joined to the levator ani myorrhaphy suture that is also held in a grasping forceps.
A Kocher clamp is repositioned on the median vaginal floor, 1 cm above the superior angle of the posterior colpotomy.
A trial reintegration of the vagina towards the sacrospinous ligament is then carried out using the Allis clamps, which are held together by the surgeon. This is done to place the vaginal strips on which the sacrospinous ligament fixation sutures are attached at the correct height.

• Vaginal fixation


The surgeon begins the vaginal running suture for closure of the posterior colpotomy with absorbable No. 1 suture (vicryl). This is placed below the Kocher clamp situated on the vaginal vault that is removed just before beginning the suture. The running suture is held upwards in a grasping forceps used as a landmark.
Two strips, 3 cm long and 1 cm wide, are fashioned with scissors on either side of the vaginal border held by the Allis clamps, approximately 2 cm from the vaginal floor. These strips remain attached to their base on the vaginal border. While they are being created, the strips are held by the toothed grasping forceps. They are then de-epithelialized by gently scraping their vaginal surface with the surgical knife, to prevent mucoceles.
Each strip is threaded through with one of the sacrospinous ligament fixation sutures, which are put back on the Péan clamp.

• Variation

Strips are created to increase the solidity of the sacrospinous ligament fixation, as the vaginal hold with a wide base of implantation is more solid than a hold on the thickness of each vaginal edge. In addition, this gesture is easily reproducible.
In a classical vaginal fixation, surgeons fix the 2 sacrospinous ligament fixation sutures on the thickness of each vaginal edge, keeping in mind that the vaginal hold must not be transfixing when nonabsorbable suture is used. Other surgeons use absorbable suture and transfix the vagina to join it to the sacrospinous ligament when the sutures are tightened. The solidity of this process is based on postoperative fibrosis formation.

14. End of procedure
• Closure

The posterior colpotomy is closed in a classic manner. The levator ani muscles of the myorrhaphy are also closed.
The surgeon takes hold of the vaginal running suture of the posterior colpotomy, threading the base of the 2 vaginal strips that are then buried below the running suture and left free. The Allis clamps are progressively removed as the vaginal running suture progresses.

• Tips

To make sure that the edges of the colpotomy coincide correctly, the 2 parts of the vaginal border are fixed with suture and maintained in the midline by a toothed grasping forceps before tightening each stitch of the vaginal running suture.
The tightening of the sacrospinous ligament fixation sutures is performed one suture at a time, 5 cm from the superior angle of the vulva, resulting in the reintegration of the posterior vagina towards the back of the pelvic cavity. The sutures should be cut and tied as soon as they are tightened. The sutures of the myorrhaphy of the levator ani muscles are then tightened.
The surgeon finishes the vaginal running suture by burying the knot of the running suture above the superior angle of the vulva. There may be a small vaginal dog-ear before complete closure of the running suture. The vaginal resection should not be performed until this step, and it must be done sparingly.
The surgeon finishes the procedure by counting the sponges and checking the hemostasis at the level of the vaginal suture. Vaginal packing may be left for 24 hours with a Foley catheter.

15. Complications
• Vascular injury

Considered the most serious complication by surgeons, vascular injuries usually involve the hypogastric venous plexus or the internal pudendal vein, although the perirectal veins, sacral veins or internal pudendal artery may also be damaged. Serious vascular accidents are rare. They may be avoided if the surgeon respects the limits of the dissection (Barksdale, 1998).

• Rectal bladder injuries

These are rare and usually not serious (Sze and Karram, 1997).

• Specific pain

Transient pain is reported with a mean severity rating of 3 (Sze and Karram, 1997). Gluteal pain (42%) and pudendal pain (30%) are most common. Sciatic pain (14%) or vaginal pain leading to dyspareunia (14%) is also observed. Persistent pain including pudendal neuropathies is observed in 1% of cases.

16. Reference

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Barksdale PA, Elkins TE, Sanders CK, Jaramillo FE, Gasser RF. An anatomic approach to pelvic
hemorrhage during sacrospinous ligament fixation of the vaginal vault. Obstet Gynecol 1998;91:715-8.
Richter K, Dargent D. La spino-fixation (vaginae fixatio sacro spinalis) dans le traitement des prolapsus du
dôme vaginal après hystérectomie. J Gynecol Obstet Biol Reprod 1986;15:1081-8.
Richter K, Albrich W. Long-term results following fixation of the vagina on the sacrospinal ligament by the
vaginal route (vaginaefixatio sacrospinalis vaginalis). Am J Obstet Gynecol 1981;141:811-6.
Richter K. Die chirurgische Anatomie der Vaginaefixatio sacrospinalis vaginalis. Ein Beitrag zur operativen
Behandlung des Scheidenblindsackprolapses. Geburtshilfe Frauenheilkd 1968;28:321-7.
Sze EH, Karram MM. Transvaginal repair of vault prolapse: a review. Obstet Gynecol 1997;89:466-75.