Anterior Approach to Sacrospinous Hysteropexy: Anatomic and Technical Considerations

INTRODUCTION: In recent years, we have seen an increase in the popularity of hysteropexy, with evidence that shows comparable anatomic success and recurrence rates to vaginal hysterectomy with uterosacral ligament suspension. OBJECTIVE: To discuss the anterior approaches to the sacrospinous dissection, demonstrate a pericervical incision for entry to the sacrospinous ligament, and review relevant anatomy and highlight technical considerations to the anterior approach. METHODS: There are multiple approaches to the entry of the sacrospinous dissection, such as the midline vertical, diamond, and pericervical incisions. Consideration should be given to the predominant compartment of prolapse and the patient’s anatomy. For an apical predominant prolapse, we prefer a curvilinear pericervical incision. A semilunar incision is made along the right aspect of the cervix using a scalpel, and then a full-thickness dissection is created through the epithelium and muscularis. The paravesical space is entered, and the bladder is swept medially. Anatomically, the anterior approach varies from the posterior approach as the dissection begins above the arcus tendineus fascia pelvis (ATFP), and the dissecting finger must break through the dense attachment of the ATFP to reach the ischial spine. The sacrospinous ligament is then cleared of overlying tissue by bluntly sweeping medially from the ischial spine toward the sacrum. In a posterior approach, less tissue is encountered as the dissecting finger is deep to the paravaginal attachments. RESULTS: When using a suture carrier device after an anterior dissection, it should be noted that the release-point and the catch-point are on a bias. The surgeon should take care to drop their hand before deploying in order to avoid missing the inferior aspect of the ligament. Once the fixation point in the middle third of the ligament is determined, pressure is applied to the head of the suture carrier device with care taken to avoid entrapping the suture. The surgeon’s hand is dropped to become more parallel with the floor and the device is deployed. Two sutures are placed through the ligament and then passed through the cervical stroma. The cervical epithelium is closed, and then an anterior colporrhaphy is performed. The sutures are then tied down, and a posterior repair is performed if indicated. CONCLUSIONS: In this video, we have demonstrated the entry via a pericervical incision, reviewed the anterior approach and anatomical considerations to the sacrospinous dissection, and illustrated the technical necessity to lower the suture carrier device prior to deploying. The anterior approach to sacrospinous ligament hysteropexy offers effective anatomical correction, making it a valuable option in the surgical management of pelvic organ prolapse.