Background
The sacrospinous ligament is frequently accessed blindly during vaginal vault suspension with risk to inferior gluteal vessels. This article examines the vascular safety of six devices currently used for this purpose using cadaveric examination.

Method
Devices were evaluated for cost and for their ability to reliably avoid vessels behind the sacrospinous ligament by applying each to the traditionally described location, two fingerbreadths medial to the right ischial spine. We selected the five predissected, preserved pelves and right hemipelves where vessels remained attached.

Results
The i stitch® was seen to penetrate coccygeal branches of inferior gluteal artery. The Capio®, Caspari™ and Endostitch® remained confined within all, including thin, ligaments. The Miya® hook and Deschamp® impinged upon but deflected vessels behind thin ligaments.

Conclusions
VascuIar anatomy behind the sacrospinous ligament is enormously variable. Suture placement two fingerbreadths medial to the spine does not guarantee safety. The ligament may be thin in the elderly, who are unlikely to cope with haemorrhage yet who may represent a growing proportion of those requiring surgery. For vascular safety, the ideal device is compact. It impresses and enfolds but does not penetrate behind the ligament. The sharp penetrating component that carries suture should traverse the shortest distance at the shallowest depth allowing adequate bite. This was satisfied by the Caspari®, Capio® and less so by Endostitch®. The i stitch® was not safe in thin ligaments. The Deschamp® and Miya® devices may be a good compromise for the developing world where cost is important.