Optimal location and orientation of suture placement in abdominal sacrocolpopexy

To estimate the strongest location and optimal orientation of suture placement in the anterior longitudinal ligament for abdominal sacrocolpopexy in female cadavers.

The anterior longitudinal ligament was exposed below the level of the aortic bifurcation in 23 unembalmed female cadavers. To the right of midline of the vertebral column, sutures were placed in a horizontal orientation into the ligament at the sacral promontory, 1 and 2 cm above (sacral promontory+1 and sacral promontory+2), and 1, 2, and 3 cm below (sacral promontory-1, sacral promontory-2 and sacral promontory-3). At these same locations, but to the left of midline, sutures were placed in a vertical orientation. Pull-out force and ligament thickness at each level of testing were measured. Data were analyzed using Student t test and repeated measures analysis of variance.

Sutures (either horizontally or vertically placed) had greater pull-out strengths at or above, compared with those placed below, the level of the sacral promontory. At sacral promontory and sacral promontory+1, there were no differences in the pull-out strengths of the ligament when sutures were placed in either orientation. However, horizontally placed sutures had significantly greater pull-out strengths than vertically placed sutures at sacral promontory+2, sacral promontory-1 and sacral promontory-2. Ligament thickness decreased from 2 cm above (mean+/-standard error of the mean sacral promontory+2, 1.8+/-0.1 mm) to 3 cm below (sacral promontory-3, 1.3+/-0.1 mm) the sacral promontory.

Sutures placed in the anterior longitudinal ligament at or above the sacral promontory are more secure than those placed below. Horizontally oriented sutures should be considered for mesh attachment below the sacral promontory because they are significantly stronger when compared with vertically placed sutures.