Pain may be elicited during application of pressure on the PN at the ischial spine
and palpation inferio-medially to the sciatic notch.
The surgery itself involves sectioning the sacrotuberous ligament into two parts to explore the proximal nerve, incising Alcock's canal, sectioning the sacrospinous ligament at the ischial spine
, and then transposing the pudendal nerve.
* We have come to realize that sutures placed medial and cephalad to the ischial spine
are often passed through a portion of the coccygeus muscle-sacrospinous ligament complex.
the distance between the tubercle of piriformis muscle and the tip of the Ischial spine
The Gynecare Prosima Pelvic Floor Repair System (Ethicon) is the newest kit on the market, and via anterior compartment dissection to the ischial spines
, it is placed up against the arcus tendineus fascia pelvis rather than anchoring into it.
The next step is placement of the apical arms into the sacrospinous ligament 2 to 3 cm medial to the ischial spine
to avoid neurovascular injury.
The relevant anatomy including the ischial spine
, the sacrospinous ligament, the coccygeus muscle, and the lateral side wall with White's line, is identified (Fig.
* Palpate the ischial spine
, with the preoperatively packed rectum retracted medially
The trapezoidal plane of the anterior wall results from the ventral and more medial attachments near the pubic symphysis and the dorsal and more lateral attachments near the ischial spine
. The wall is suspended on both sides to the parietal fascia overlying the levator ani muscles at the arcus tendineus fascia pelvis (ATFP).
The synthetic mesh is grafted with four-point fixation near the ischial spine
using color-coded inferior transobdurator and bilateral superior and inferior needles, which allows for minimal lateral dissection and therefore reduces blood loss.
The ureter lies near the anterior margin of the uterosacral ligament, with a mean distance of 4.1 [+ or -] 0.6 cm at the level of the sacrum and 2.3 [+ or -] 0.9 cm at the level of the ischial spine
.(8) In I series of high uterosacral ligament suspension with site-specific endopelvic fascia defect repair, ureteral complications occurred in 11% of patients.(5) Other series have reported rates of ureteral trauma in the range of 0.7%9 tO 2.4%.(6)
For repair of an anterior vaginal prolapse (a cystocele), the two most important landmarks are the ischial spine
and the junction of the inferior pubic ramus with the body of the pubic bone.