Miya Hook Ligature Carrier
The Miya Hook is a hook-shaped reusable ligature carrier designed by Frank S. Miyazaki and first described in 1987 — the earliest purpose-built instrument for transvaginal sacrospinous ligament fixation (SSLF). The device passes suture through the sacrospinous ligament by palpation alone (no direct visualization), threaded through the coccygeus / sacrospinous fibromuscular complex. It has the deepest long-term clinical track record of any SSLF instrument and the strongest biomechanical pull-out profile in head-to-head cadaveric testing, balanced by an intermediate vascular-safety position in thin ligaments.[1][2][3]
Design
- Long curved metal shaft matching the sacrospinous-ligament approach angle
- Hook-shaped distal end with eye for suture engagement
- Reusable — low per-case cost; autoclavable across many cases
- No power source / no integrated capture mechanism — operator-driven mechanic
Miyazaki's original observation, repeated by every subsequent author: "the coccygeus muscle and sacrospinous ligament are one and the same fibromuscular structure" — the conceptual foundation for any SSLF instrument's approach geometry.[1]
Technique
Original Miyazaki Technique
- Thread suture through the hook eye.
- Advance the hook into the paravaginal space under two-finger palpation; tip onto the sacrospinous ligament ~ 2 fingerbreadths medial to the ischial spine.
- Drive the hook through the ligament complex and back out.
- Disengage suture on the far side; retrieve.
- Withdraw the hook, leaving the suture through the ligament.
Mattox 1995 Modification
Mattox and colleagues modified the technique to pass the hook unloaded first, then back-thread the hook with suture and withdraw. Reported faster, fewer instruments required, no suture fraying, no complications in > 50 patients.[2]
Clinical Evidence — Deepest of Any SSLF Device
| Series | Design | Key Result |
|---|---|---|
| Miyazaki 1987 original | 74 procedures over 24 mo, chiefly performed by residents in training | No hemorrhages, no nerve injury, no rectal injury[1] |
| Hardiman & Drutz 1996 | 130 attempted vault suspensions; 125 completed (5 abandoned for technical difficulty); 6 mo–5 yr follow-up | Recurrent vault prolapse 2.4%; postop febrile morbidity 10%; no intraoperative device-related complications[3] |
| Pollak 2007 comparative | Retrospective 240 pts — direct-vision needle driver (n=46) vs Deschamps (n=173) vs Miya Hook (n=21) | No significant difference in intraoperative complications across the three; Deschamps had significantly higher postoperative complications vs direct-vision (18% vs 2%, p=0.002)[4] |
Biomechanical Strength — Strongest Pull-Out in Head-to-Head Testing
Lo 2026 cadaveric biomechanical comparison of pull-out forces between the Miya Hook and the Anchorsure system:[5]
| Device | Mean load at failure |
|---|---|
| SSLF with Miya Hook | 69.2 ± 5.9 N |
| SSLF with Anchorsure | 44.0 ± 15.9 N |
The authors attributed the Miya Hook's superior pull-out strength to greater tissue engagement: the suture-passing technique engages more ligament tissue than the point-fixation anchor-based approach.[5]
Vascular Safety — Manning 2014 Intermediate Position
The Manning 2014 six-device cadaveric comparison placed the Miya Hook in the intermediate safety category for thin sacrospinous ligaments:[6]
| Safety class | Devices |
|---|---|
| Safest (remained within ligament) | Capio, Caspari, Endostitch |
| Intermediate (impinged but deflected vessels behind thin ligaments) | Miya Hook, Deschamps |
| Unsafe (penetrated vessels) | i-Stitch |
Manning's conclusion: the Miya Hook and Deschamps "may be a good compromise for the developing world where cost is important" — reflecting the trade-off between reusable / low-cost / robust fixation and the contemporary slim-line safety profile.[6]
Advantages and Limitations
| Dimension | Detail |
|---|---|
| Cost | Reusable, low per-case cost — significant advantage over disposable Capio, Saffron |
| Biomechanical fixation | Strongest pull-out strength of any SSLF device tested (Lo 2026)[5] |
| Clinical track record | Deepest of any SSLF instrument — Miyazaki 1987, Hardiman 1996, Pollak 2007[1][3][4] |
| Vascular safety in thin ligaments | Intermediate — impinges but deflects vessels (Manning 2014)[6] |
| Visualization | Palpation-guided only; no direct visualization |
| Dissection required | Wider than slim-line contemporary devices |
| Resource setting | Workhorse instrument in low-resource and cost-constrained settings[6] |
Position in the SSLF Device Family
| Device | Mechanism | Reusable | Pull-out strength | Vascular safety | Cost | Evidence depth |
|---|---|---|---|---|---|---|
| Miya Hook | Suture-passing hook (palpation) | Yes | Strongest (69.2 N)[5] | Intermediate | Low | Deepest long-term |
| Deschamps ligature carrier | Suture-passing curved needle | Yes | — | Intermediate | Low | Extensive |
| Capio | Suture-capturing throw-catch-retrieve | No | — | Safest (within ligament) | High | Multiple RCTs + SR |
| Endostitch | Suture-capturing toggle-jaw | No | — | Safest | High | Schlesinger 1997 + cross-specialty |
| Anchorsure | Anchor-based | Mixed | Weaker (44.0 N)[5] | Tacker dislodgement 2.2% | High | RCT + retrospective |
| Saffron | Anchor-based | Mixed | 17.9 N (cadaver) | Cadaveric-only | High | Cadaveric only |
| i-Stitch | Suture-capturing blunt ball-tip | Yes | — | Penetrated vessels (thin ligaments) | Moderate | Limited (NanoScope variant emerging) |
Bottom Line
The Miya Hook occupies an important historical and practical niche:
- The first widely adopted purpose-built SSLF instrument and the device with the deepest long-term clinical data.[1][3]
- Strongest biomechanical pull-out in head-to-head cadaveric testing (69.2 N vs 44.0 N Anchorsure) — robust tissue engagement reflects the wider tissue bite of suture-passing technique.[5]
- Particularly relevant in resource-limited settings where reusability and low cost outweigh the vascular-safety gap vs slim-line disposable devices.[6]
- Largely supplanted by the Capio family at high-volume Western reconstructive centers for the vascular-safety profile and operative-time advantages.
The Amiri 2024 SR + meta-analysis frames the broader pattern: overall complication rates across all SSLF devices are low; the Miya Hook's intermediate vascular profile is matched against the strongest biomechanical anchoring of any tested device.[7]
See also: Deschamps Ligature Carrier, Capio Suture Capturing Device, Endostitch, i-Stitch, Anchorsure System, Saffron Fixation System, Bony Pelvic Anatomy, Pelvic Vascular Anatomy.
References
1. Miyazaki FS. "Miya hook ligature carrier for sacrospinous ligament suspension." Obstet Gynecol. 1987;70(2):286–8.
2. Mattox TF, Kelly T, Bhatia NN. "Modification of the Miya hook in vaginal colpopexy." J Reprod Med. 1995;40(10):681–3.
3. Hardiman PJ, Drutz HP. "Sacrospinous vault suspension and abdominal colposacropexy: success rates and complications." Am J Obstet Gynecol. 1996;175(3 Pt 1):612–6. doi:10.1053/ob.1996.v175.a74410
4. Pollak J, Takacs P, Medina C. "Complications of three sacrospinous ligament fixation techniques." Int J Gynaecol Obstet. 2007;99(1):18–22. doi:10.1016/j.ijgo.2007.04.028
5. Lo TS, Li CW, Ro AL, et al. "Pullout testing for sacrospinous ligament and uterosacral ligament in apical suspension: a cadaveric biomechanical study." Int J Gynaecol Obstet. 2026. doi:10.1002/ijgo.71036
6. Manning JA, Arnold P. "A review of six sacrospinous suture devices." Aust N Z J Obstet Gynaecol. 2014;54(6):558–63. doi:10.1111/ajo.12272
7. Amiri E, Bastani P, Mallah F, Mostafaei H, Salehi-Pourmehr H. "Comparison of the complications rate of different suture-passing techniques at the time of sacrospinous ligament fixation: a systematic review and meta-analysis." Arch Gynecol Obstet. 2024;310(6):2791–2809. doi:10.1007/s00404-024-07788-5