A Deschamps ligature carrier then can be inserted through the middle of the coccygeus muscle and rotated clockwise to expose its tip around the sacrospinous ligament. The initial bite should be placed 1 cm medial to the ischial spine to avoid the pudendal complex. A second suture can then be placed 1–2 cm medial to the first, again with care taken to place it through the middle of the coccygeus muscle and not posterior to this muscle, where it could injure the vessel and nerve of the pudendal complex.
When the Deschamps ligature carrier is brought through the muscle, a colpotomy or nerve hook can be used to mobilize one end of the suture and withdraw it back out into the operative field. Once this is mobilized, the Deschamps ligature carrier can be rotated counterclockwise—in an arc exactly opposite to that in which it was placed—to withdraw the posterior end of the suture.
Care should be taken to identify the posterior end of the suture and differentiate it from the anterior end. This may be accomplished through the use of a straight hemostat on one end and the placement of a curved hemostat across both ends of the suture.
(When we perform the surgery, we use a straight hemostat to identify the posterior end of suture on the patient's right side, or the lateral suture, and a straight Kocher clamp to identify the posterior end on the patient's left side.)
The Breisky-Navratil retractors can then be slowly withdrawn one at a time to allow for observation of the entire paravaginal space and assessment for any bleeders, which can be easily grasped and electrocoagulated or sutured.
The suture can then be placed on the undersurface of the apex of the vagina by use of a free Mayo needle. The anterior arm of the lateral suture can be placed approximately 1–2 cm away from the right apex of the vagina in a figure-eight fashion, and this one arm of the suture can be tied to itself with a loose surgeon's knot.
The same process can be followed with the left or medial anterior arm of the second sacrospinous suture, 1–2 cm away from the left apex of the vagina, and tied down in the same fashion. Care needs to be taken on the patient's left side to place the suture approximately 0.5 cm further away from the apical edge of the vagina, as this suture will traverse a longer distance to reach the sacrospinous ligament.
Now the sutures can be retracted anteriorly, and a rectocele repair and/or enterocele repair can be performed as needed.
After successful completion of such repairs, excess vaginal epithelium and smooth muscle can be resected as indicated and the posterior vaginal wall closed with either interrupted sutures or a running, locking suture approximately halfway down the posterior vaginal wall.
At this point, the sacrospinous sutures should be tied down, with the suture on the patient's right lateral side tied down first. The posterior arm of the sacrospinous suture should be taken in the nondominant hand, and slow traction should be applied while the apex of the vagina is guided back into position in the pelvis, toward the right sacrospinous ligament.
Once the excess slack is taken up by mobilization of this suture, the suture may be tied down, with care taken to leave no gap between the vaginal apex and the sacrospinous ligament. This suture is then held while the second suture is mobilized in the same fashion and then tied down similarly.
Retraction of the undersurface of the closed posterior vaginal wall will allow for visualization of the sacrospinous sutures, which can be cut approximately 1 cm above the knot. The posterior vaginal wall may be closed, and perineorrhaphy performed as indicated.
The choice of sutures is up to the individual operator. Although Dr. Nichols originally described using delayed-absorbable sutures, later in his career he changed to using one Gore-Tex suture and one polyglycolic acid suture. He informed me that his reason for this was that the permanent suture would offer longer-lasting strength, whereas the delayed-absorbable suture would create more inflammatory response and possibly elicit more scarring.
Variations of the Original Approach
Some surgeons have suggested that a bilateral attachment of the vaginal apex—or attachment of the cervix, when the uterus is preserved—may offer a superior anatomical reconstruction of the vaginal vault, and may avoid deviation of the vagina to the right or the left side.
Instead of placing two sutures on one sacrospinous ligament, a single suture can be placed on the right sacrospinous ligament at its midportion and on the left sacrospinous ligament at its midportion. These sutures are attached to the right and left apex of the vagina, respectively.