1

M Cosson (France), B Occelli (France), D Querleu (France)

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.
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.
Anatomy

2
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
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
Indications
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).
Operating room
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

3
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.
1. The surgeon is positioned between the patients legs, facing her vulva.
2. The first assistant is to the right of the surgeon, below the patients
left leg.
3. The second assistant is to the left of the surgeon, below the
patients 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.
The equipment on the instrument table is to the surgeons right.
1. Instrument table
Instrumentation
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
- four toothed (Pan) 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);
- Bingola grasping forceps.

4
1. Pan clamp
2. Kocher clamp
- 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. Bingola grasping forceps
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.
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;

5
- during treatment for a total prolapsus, after previous colpohysterectomy
and colporrhaphy.
We always perform myorrhaphy of the levator ani muscles with Richters
sacrospinous ligament suspension because it completes the posterior step
of the procedure and recreates the physiologic angle of the vagina.
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 anesthesiarelated 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
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

6
scar or point of closure of the previous colphorrhaphy) and ends 1 to 2 cm
above the superior angle of the vulva.
Opening/fossa
Rectovaginal 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
oclock 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 oclock position and the other in a 4 oclock
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,

7
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 oclock position
3. Breisky retractor in 10 oclock 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
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 oclock 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 oclock 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.
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 Pan
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 Pan 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.

9
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.
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.
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.
Suspension/ vaginal floor

10
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 Pan 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

11
End of the 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.
Complications
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).

12
Bladder and rectal complications. These are rare and usually not serious
(Sze and Karram, 1997).
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.

REFERENCES 01/03/2002
1
RICHTERS SACROSPINOUS LIGAMENT FIXATION OF PROLAPSED VAGINAL VAULT
M Cosson, MD
Maternit Paul Gell,
Roubaix, France

B Occelli, MD
Maternit Paul Gell,
Roubaix, France

D Querleu, MD
Centre Oscar Lambret,
Lille, France

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
dme vaginal aprs hystrectomie. 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.

13