Sacrospinous Ligament Fixation: Trainee Learning Experience Using Unembalmed Cadaver Model

Objectives: Sacrospinous ligament fixation (SSLF) has traditionally been accomplished via a posterior and/or apical approach, with exposure of coccygeus-sacrospinous ligament (C-SSL) complex and suture placement under direct visualization. Access to the C-SSL through an anterior approach using limited dissection and suture-capturing devices has increasingly been described. Limited data exists on the extent of training required to accurately and safely perform a SSLF using the latter method. The objective of this study was to determine the number of unembalmed cadaver procedures it took a first-year FPMRS fellow—naive to SSLF—before consistently placing sutures in the intended C-SSL location using a suture capturing device. In addition, the anatomic paths traversed by the SSLF sutures were examined.

Methods: First, two pelvic dissections were performed to review C-SSL anatomy. The intended (target) ligament location was specified at its mid segment and below its upper margin. Bilateral SSL fixations were performed in nine unembalmed female cadavers via an anterior approach using the Capio (Boston Scientific, Marlborough, Mass) Suture Capturing Device. Dissection of vesicovaginal space was extended laterally and superiorly into the paravesical space until the ischial spine was palpated. The surgeon’s finger was displaced 2-3cm medially over the C-SSL. The suture-capturing device was introduced through the dissected channel and guided by surgeon’s finger to target ligament location and sutures deployed. Two sutures were placed on the right and left ligament. Suture placement was examined after transecting the pelvis in the mid-sagittal plane

Results: Consistent suture placement into the intended ligament segment was noted after the fourth procedure (Table). Suture placement outside target ligament location included the iliococcygeus muscles, S3 and pudendal nerve, and pudendal canal. In one pelvic half, sutures placed in desired mid ligament section also traversed the connective tissue surrounding the S2-S4 parasympathetic nerves. All sutures were noted posterior to the ureters. Of sixteen sutures placed on C-SSL complex, thirteen penetrated the actual ligament while remaining three only passed through the coccygeus muscle and/or fascia.

Conclusions: This study suggests that a minimum of four to five SSLF procedures are needed before a trainee naïve to the procedure consistently captures the SSL using a suture capturing device and limited dissection. Incorrect dissection can lead to entrapment of parasympathetic nerves, which may lead to pelvic organ dysfunction. The unembalmed cadaver model allows high-fidelity simulation as well as post-procedure dissection and feedback that is not possible during live surgery. Further studies are needed to evaluate whether clinical and educational experience with traditional SSLF translates to more accurate SSL suture placement using a suturing capturing device and limited dissection.