Sacrospinous ligament fixation (SSLF) is the standard transvaginal procedure for correcting apical compartment prolapse . Traditionally performed in a semi-blind manner, it relies on digital palpation of the ischial spine to locate the sacrospinous ligament (SSL), followed by blind suturing with conventional suture device. Because the SSL lies adjacent to the pudendal nerve and vessels, blind suturing carries a substantial risk of vascular injury and postoperative chronic pelvic pain. Earlier automated devices (e.g., Endo-stitch) for vaginal SSLF [1] were limited by their large size and reduced maneuverability in the deep pelvic spaces. Recent endoscopic SSLF approaches via laparoscopy or single-port platforms enable real-time visualization and shorten the learning curve [2]. The latest cadaveric study achieved visualized SSL suturing using a miniature endoscope (NanoScope) and I-Stitch device [3].
The present study introduces a novel technique: transvaginal natural orifice endoscopic exposure of the SSL, assisted by a suture passer for single-handed, direct-vision automated suturing. This approach is designed to overcome the longstanding limitations of blind manipulation and single-handed blind suturing in SSLF.

This study was conducted at a tertiary referral center specializing in minimally invasive treatment of female pelvic organ prolapse. The participant was a 78-year-old multiparous woman with an 8-year history of vulvar prolapsing mass, third-degree uterine prolapse, and anterior and posterior vaginal wall prolapse. No surgical contraindications were identified.

Uterus-preserving pelvic floor reconstruction was performed, including transvaginal anterior pelvic reconstruction and posterior vaginal wall repair, followed by transvaginal SSLF. After submucosal injection of saline into the posterior vaginal wall, a midline incision was made. Via the right pararectal space, the right ischial spine was located by blunt digital dissection with the right index finger through the vaginal incision, followed by preliminary inferomedial dissection of the right SSL. A 10-mm laparoscope was then introduced, revealing the SSL as a white ligament-like fibrous structure; the mid-portion was further dissected and exposed under direct endoscopic vision.
A suture passer (grasper Φ 4.0 × 170 mm and disposable-needle-coreΦ 1.5 × 237 mm; Hangzhou Nanyu Medical Instrument Co., Ltd., China) was used. Under endoscopic guidance, the mid-portion of the SSL was grasped (maximum bite depth 22 mm) at a point 2 cm to the right ischial spine, and two stitches were placed. The device’s mechanical design enabled puncture and thread passage in a single maneuver, achieving a completely finger-free (“zero-finger intervention”) suturing process. The remaining steps followed the conventional SSLF technique.
At completion, the distance from the vaginal vault apex to the introitus exceeded 7 cm, indicating excellent anatomical recovery. Intraoperative blood loss was 50 mL, and the patient was discharged on postoperative day 2.

Compared with traditional blind suturing using conventional devices in transvaginal or vNOTES-assisted SSLF, the key innovation of the present technique is the integration of transvaginal manual dissection, endoscopic precise exposure of the SSL borders, and especially the suture passer. This approach completely eliminates the need for a second guiding finger. The passer’s 170-mm length is optimally suited to the anatomy, and its 22-mm maximum bite depth provides secure tissue tension. In the confined deep pelvic spaces, the suture passer offers superior maneuverability over standard gynecologic laparoscopic instruments. Single-handed, bottom-to-top puncture and thread passage—distinct from the top-to-bottom direction of the I-Stitch [3]—markedly improves the safety margin and achieves full-visualization automated SSL suturing, an approach not previously reported in the literature.
This “what you see is what you get” surgical paradigm has the potential to substantially lower the technical barrier of SSLF, shorten the learning curve, and represent a major transition from blind to anatomically precise direct-vision fixation. The technique offers high safety and potential for widespread clinical adoption.

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Liu Y, Wang C, Wang X, Yan R, Chu L, Chen X. Case report: Transvaginal single-port extraperitoneal laparoscopic sacrospinous  ligament fixation for apical prolapse: A single-center case series. Front Surg l2023;10: 1066622.
Chene G, Cerruto E, Moret S, Nohuz E. The minimally invasive sacrospinous fixation under visual guidance: An anatomical  study. Eur J Obstet Gynecol Reprod Biol l2024;297: 36-39.

Continence 19S (2026) 102522
DOI: 10.1016/j.cont.2026.102522