An anatomic approach to pelvic hemorrhage during sacrospinous ligament fixation of the vaginal vault.

OBJECTIVE: To examine the current clinical problem of life-threatening hemorrhage during sacrospinous vaginal vault suspension, define a management solution, and validate current anatomic knowledge of the area involved. METHODS: Ten cadaveric female pelves were dissected from a posterior gluteal approach and from an abdominal approach. The vascularity of the region of the sacrospinous ligament was mapped. RESULTS: There are multiple and varied collateral vascular supplies and anastomoses in the region of the sacrospinous ligament and buttock, including: 1) superior gluteal, 2) inferior gluteal, 3) internal pudendal, 4) vertebral, 5) middle sacral, 6) lateral sacral, and 7) external iliac via the circumflex femoral artery system. Anastomoses occurred in all pelves examined. The frequency of each type of anastomosis varied from 20-100%. CONCLUSION: Surgical ligation of the internal iliac artery would not likely curb massive hemorrhage during sacrospinous ligament fixation, except in certain cases of internal pudendal vascular injury. The inferior gluteal artery is probably the most commonly injured vessel in sacrospinous ligament suspension because of its location. Inferior gluteal vessel injury should be approached by the use of packing and vascular clips or packing and arterial embolization. These latter approaches should be of primary consideration in the control of hemorrhage at the time of sacrospinous ligament fixation.

Surgical landmarks of the ureter in the cadaveric female pelvis.

Our purpose was to delineate the course of the ureter in the female pelvis in relationship to several important surgical landmarks. Ten female cadavers with undissected pelves were used. The ureter was identified at the pelvic brim and traced inferiorly to the bladder. Sets of measurements (+/- 0.1 cm) that help define the location of the ureter were obtained at the three landmarks; the ischial spine, the obturator canal and the insertion of the arcus tendineus on the pubic bone. The mean distances from the ureter to the pelvic floor were ischial spine, 3.2 +/- 0.1 cm; obturator canal, 3.2 +/- 0.1 cm; and the insertion of the arcus tendineus on the pubic bone, 1.6 +/- 0.1 cm. The mean distances from the arcus tendineus to the pelvic floor were ischial spine, 1.9 +/- 0.1 cm; obturator canal, 2.8 +/- 0.1 cm; and the insertion of the arcus tendineus on the pubic bone, 3.2 +/- 0.1 cm. This study defines the relationship of the ureter to the pelvic floor through measurements taken at three landmarks. The data should be useful to pelvic surgeons and are important for the development of future surgical techniques.

Intraligamentous nerves as a potential source of pain after sacrospinous ligament fixation of the vaginal apex.

The aim of the study was to investigate the histology of the sacrospinous ligament to determine whether nerve fibers exist within the substance of the sacropinous ligament itself. Six sacrospinous ligaments were removed from 4 fixed female cadavers. Representative segments were taken from the lateral (ischial), middle and medial (sacral) portions of these specimens, sectioned by microtome, mounted, and stained with hematoxylin and eosin dyes. The fixed and stained sections were then examined using light microscopy. Nerve tissue was found to be concentrated in the medial portions of the sacrospinous ligaments, but nerves were found in all segments of the ligament. It was concluded that, nervous tissue is present and widely distributed within the body of the sacrospinous ligament. A wide variety of sizes and thicknesses are also demonstrated, suggesting a variety of functions, including possible pain reception. This fact should be taken into consideration when planning operative procedures for pelvic prolapse.