Goldberg_EU_Genito.qxp 1/8/07 10:20 Page 81
Urinary Incontinence
Sacrospinous Ligament Suspension Using the Capio™ Suture Capture Technique
a report by
Roger P Goldberg
Assistant Professor of Obstetrics and Gynaecology, Northwestern University Medical School, and
Director of Research, Evanston-Northwestern Hospital Urogynaecology, Evanston, Illinois
Sacrospinous vaginal vault suspension was first described in Europe in • anatomy is identified by palpation, with minimal to no use of retractors:
1958
1
and has been utilised for the repair of vaginal vault prolapse for the simple engineering of the Capio suturing device allows safe and
several decades. Although ‘traditional’ sacrospinous suspension secure suturing into the ligament, which has drastically reduced our
techniques have been associated with successful suspension of the operative time and need for assistance during sacrospinous repairs; and
vaginal apex in 81–100% of cases,
2–5
limitations of the technique have • bilateral fixation of the vaginal apex, resulting in a more balanced and
included the technical challenge of exposing the deep vaginal anatomy anatomically correct suspension compared with ‘traditional’ unilateral
and unilateral suspension (usually to the right side) resulting in sacrospinous fixation (see Figure 2).
deviation of the vaginal apex to one side. In this article, we summarise
a new and improved approach to sacrospinous fixation using the Anterior Approach
Capio™ (Boston Scientific Corporation, Natick, Massachussetts) Suture Access to the sacrospinous ligament and coccygeus muscle can be
Capturing Device. This one-step suturing device (see Figure 1) allows achieved by several means. The traditional approach, described by
for sutures to be placed by palpation with less dissection and no use Nichols,
6
involves a posterior vaginal incision and posterior colporrhaphy
of trocars. dissection, facilitating perforation of the rectal pillar near the ischial spine.
In contrast, the ‘anterior’ sacrospinous suspension technique is
Sacrospinous ligament suspension
performed through an anterior colporrhaphy incision, with blunt
dissection of the ipsilateral paravesical and paravaginal area from the
carries the advantages of the
level of the bladder neck to the ischial spine. This technique was first
transvaginal approach performed
reported by our centre in 2000,
7
and it now accounts for more than 90%
of our vault fixation cases.
within the retroperitoneal rather
than the intraperitoneal space… Technique by Palpation
Before the Capio device, we frequently utilised Breisky-Navratil retractors
The technique addresses the basic limitations and disadvantages of the to expose the coccygeus muscle and sacrospinous ligament without
traditional sacrospinous repair, offering an improved anatomic obstructing the surgical field, and such retractors are still useful to have in
outcome with bilateral fixation of the vaginal apex and, in appropriate the instrument tray for specific cases. Using the Capio technique, we have
cases, the ability quickly and safely to incorporate materials for mesh or found that few cases require visual exposure of deep vaginal anatomy.
graft augmentation.
Regardless of the type of suture
For women with pelvic ligaments and connective tissue supports that are
severely attenuated or absent, the sacrospinous ligament provides a used or the anatomical approach
consistently strong site for apical fixation. Sacrospinous ligament
to the ligament, the surgeon should
suspension carries the advantages of the transvaginal approach performed
within the retroperitoneal rather than the intraperitoneal space, thereby
take care to avoid the creation of a
minimising the risk of ureteral, bowel or other intra-abdominal injury.
‘suture bridge’ between the vagina
Moreover, using the Capio suturing device allows for fairly minimal
dissection beyond that which is performed for traditional cystocele or
and ligament.
rectocele repair. Whereas ‘traditional’ sacrospinous repairs once required
two surgical assistants and a challenging dissection, the Capio-assisted Step-by-step Procedure
procedure has transformed the process into a quick, efficient and easier
repair from the standpoints of both patient and surgeon. Step 1 – Anterior Approach
A single, vertical anterior vaginal incision is made – a comfortable
Capio Suture Capturing Device Modified approach for any surgeon performing standard anterior colporrhaphy. This
Sacrospinous Technique anterior approach to the sacrospinous ligament is a change in orientation
The Capio device provides the following modifications: offering several advantages: it is suitable for bilateral suspension of the
vaginal apex; it offers superior vaginal width, with no narrowing of the
• ‘anterior’ approach to the sacrospinous ligament, rather than apical suspension points; and it offers the ability to incorporate mesh
‘posterior’ approach; reinforcement (‘arcus to arcus’) for advanced cystocele repair.
© TOUCH BRIEFINGS 2007 81
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