Sacrospinofixation of Richter in 8 Points: Original Contribution of the Laparoscopic Column in the Visualization of the Sacrospinous Ligaments

Study Objective Although the standard technique is currently based on laparoscopic promontofixation, the standard vaginal technique for the treatment of uterine prolapse is sacrospinofixation according to Richter 1 , 2 , 3 . Described by Kurt Richter in 1968, this intervention corrects the middle floor and consists of fixing the vaginal dome (after hysterectomy or not) on the sacrospinous ligament(s) 4 , 5 . The technique includes a wide dissection of the pararectal fossa using several Breisky valves to grip the sacrospinous ligament under strict visual control. This crucial step of the intervention implies optimal visual control for the operator but does not allow visual access to the operative assistants, which is regrettable for the purpose of teaching 2 , 4 , 5 , 6 . The aim of this surgical video is to describe the different stages of the sacrospinofixation surgical technique, showing sacrospinous ligaments during the crucial step thanks to a laparoscopic camera. Design A step-by-step explanation of the surgery using a video (an instructive video [Video 1]) approved by the local ethics committee. Setting Gynecological Surgery Unit, University Hospital of Strasbourg, Strasbourg, France. Patients A 70-year-old woman with multicompartment pelvic organ prolapse. Interventions Installation in the conventional gynecologic position with 2 operating assistants on both sides of the operator. The steps are as follows: step 1, posterior colpotomy; step 2, rectovaginal dissection and opening of the pararectal fossa; step 3, dissection of the sacrospinous ligament; and step 4, gripping of the sacrospinous ligament. The following 4 steps are realized bilaterally: step 5, suspension of the vaginal dome; step 6, beginning of vaginal closure; step 7, tightening the spinofixation threads; and step 8, ending the closure of the vaginal colpotomy. Measurements and Main Results The operative time was 60 minutes. The operation was simple and shows precisely the sacrospinous ligaments. There were no intraoperative complications. The vaginal mesh urinary catheter was removed on day 1, and the patient was discharged on day 3. Conclusion Thanks to a laparoscopic column, this video of the surgical technique of sacrospinofixation using the Richter procedure is an original approach to show sacrospinous ligaments. The latter is a crucial step of this surgery, which remains the reference vaginal technique for the treatment of a uterine prolapse.