Sacrospinous Ligament Fixation, or SSLF, is a surgical procedure for women designed to correct specific structural support issues within the pelvis. The primary aim of the surgery is to restore the normal anatomical position of these organs and alleviate the symptoms caused by their descent. This is achieved by anchoring the weakened structures to a strong, stable point within the pelvis.
Conditions Treated by SSLF Surgery
SSLF surgery is principally performed to treat pelvic organ prolapse, specifically apical prolapse. Pelvic organ prolapse occurs when the muscles and connective tissues of the pelvic floor are weakened or damaged. This allows organs such as the uterus, bladder, or bowel to descend and bulge into the vaginal canal. Apical prolapse refers to the descent of the upper part of the vagina, which can involve the uterus (uterine prolapse) or the top of the vaginal wall in women who have had a hysterectomy (vault prolapse).
The symptoms that lead a person to seek treatment often involve a sensation of pressure or a noticeable bulge in the vaginal area. Some individuals experience urinary issues, such as difficulty urinating or incontinence, as well as discomfort or pain during sexual intercourse. Good candidates for SSLF are women with symptomatic apical prolapse who are seeking a durable surgical solution. The procedure can be performed whether the uterus is present or has been previously removed.
The weakening of the pelvic floor can be attributed to several factors, including the strain of vaginal childbirth, advancing age, and a history of prior pelvic surgeries. SSLF is considered a suitable treatment because it directly addresses the loss of support at the apex of the vagina. By re-suspending this structure, the procedure can be performed along with other repairs for prolapse in different parts of the vagina.
The Surgical Procedure
The central goal of SSLF surgery is to re-establish support for the top of the vagina by attaching it to the sacrospinous ligament. This ligament is a strong band of fibrous tissue that runs from the sacrum to a bony prominence in the pelvis called the ischial spine. During the operation, the surgeon uses sutures to securely fasten the apex of the vagina or the cervix to this durable ligament, lifting and holding it in its correct anatomical position.
This operation is performed transvaginally, meaning all surgical work is done through the vaginal canal without incisions on the abdomen. The surgeon makes an incision in the posterior wall of the vagina to access the space where the sacrospinous ligament is located. Through careful dissection, the ligament is identified, and one or two sutures are passed through it. These sutures are then anchored to the vaginal apex and tied, pulling the prolapsed portion of the vagina up into a supported position.
Patients are given either a general anesthetic, causing them to be asleep for the procedure, or a spinal anesthetic, which numbs the body from the waist down. The sutures used can be permanent or absorbable; absorbable ones dissolve over time and are replaced by the body’s own scar tissue, which continues to provide support. The fixation is done on one side, typically the right, though in some instances, both ligaments may be used for additional support.
Recovery and Post-Operative Care
Recovery begins with a short hospital stay, often just one to two days. A catheter is usually placed to drain the bladder and a pack may be placed in the vagina, both of which are generally removed before discharge. Post-operative pain is managed with medication to ensure comfort.
Once at home, it is important to avoid activities that could put strain on the surgical repair for several weeks. This includes a strict prohibition on heavy lifting, strenuous exercise, and sexual intercourse for a designated period, commonly around six to eight weeks. Patients are also advised to avoid constipation to prevent straining during bowel movements, which can be managed with diet and stool softeners.
Follow-up appointments are a standard part of post-operative care. The first follow-up visit is often scheduled within a few weeks of the surgery. Most individuals can expect to return to work and light activities within a few weeks, but a full return to all activities will take longer, pending the surgeon’s approval.
Outcomes and Potential Complications
The outcomes for SSLF surgery are generally positive, with reported success rates in resolving apical prolapse ranging from 80% to over 90%. Most patients experience a significant reduction in their prolapse symptoms, such as the feeling of a bulge and pelvic pressure.
Despite its high success rate, the procedure does carry potential risks. A common, though typically temporary, side effect is buttock pain on the side where the sutures were placed, which usually resolves on its own. Other potential issues include bleeding, infection, and injury to adjacent structures like the bladder, rectum, or nearby nerves. There is also a risk that the prolapse could recur over time.