Pelvic organ prolapse (POP) is a common condition affecting women, particularly those who have undergone childbirth, hysterectomy, or aging-related weakening of pelvic support structures. It occurs when the pelvic floor muscles and ligaments become weak, causing descent of the uterus, vagina, or other pelvic organs. Traditionally, prolapse has been managed through vaginal or abdominal surgical techniques, with laparoscopic sacrocolpopexy long regarded as the gold standard. However, in recent years, laparoscopic pectopexy has emerged as an innovative and effective alternative, particularly for women with contraindications to sacrocolpopexy.

What is Laparoscopic Pectopexy?

Laparoscopic pectopexy is a minimally invasive surgical technique used to correct apical prolapse (uterine or vaginal vault prolapse) by suspending the prolapsed organ to the pectineal (Cooper’s) ligament bilaterally. Unlike sacrocolpopexy, which fixes the vagina or cervix to the sacrum, pectopexy provides lateral suspension, avoiding complications associated with the presacral area.

This technique was first described in Germany as a safer and equally effective alternative to sacrocolpopexy, especially for obese patients or those with limited pelvic anatomy.

Indications for Laparoscopic Pectopexy

Uterine prolapse or vaginal vault prolapse

Patients at risk of complications from sacrocolpopexy (e.g., presacral venous bleeding, constipation, or nerve injury)

Women desiring uterine preservation along with prolapse correction

Recurrent prolapse after other surgical interventions

Obese patients or those with narrow sacral promontory, where sacrocolpopexy is technically difficult

Advantages Over Sacrocolpopexy

Safety – Avoids dissection in the presacral space, reducing risk of major bleeding or injury to hypogastric vessels.

Bowel Function Preservation – Lower risk of constipation compared to sacrocolpopexy, since the rectum is not compressed.

Sexual Function – Maintains vaginal axis and length, reducing risk of dyspareunia.

Shorter Operating Time – Easier access to pectineal ligament compared to the sacrum.

Versatility – Suitable for both uterine-preserving surgeries and post-hysterectomy prolapse repair.

Surgical Technique

Anesthesia and Positioning
The procedure is performed under general anesthesia. The patient is placed in lithotomy position with a Trendelenburg tilt.

Port Placement
A 10-mm umbilical camera port and two or three additional 5-mm working ports are placed for laparoscopic instruments.

Preparation
The bladder is mobilized, and the pelvic anatomy is carefully inspected. In case of uterine preservation, the cervix is prepared for mesh fixation.

Identification of Pectineal Ligament
The peritoneum over the pelvic sidewall is incised. The external iliac vein is identified, and the pectineal (Cooper’s) ligament is exposed on both sides. This ligament is strong, flat, and easily accessible, making it an excellent anchoring point.

Mesh Placement
A synthetic mesh strip is fixed bilaterally to the cervix, vaginal vault, or uterus and anchored to the pectineal ligaments on both sides. Non-absorbable sutures or tackers are used for fixation.

Peritoneal Closure
The mesh is completely covered with peritoneum to prevent bowel adhesions.

Completion
After ensuring hemostasis, trocars are removed, and incisions are closed.

Postoperative Care

Most patients recover quickly after laparoscopic pectopexy. Pain is minimal due to small incisions, and hospital stay is usually 1–2 days. Patients are advised to avoid heavy lifting and sexual intercourse for at least six weeks. Postoperative follow-up includes assessment of prolapse correction, urinary and bowel function, and sexual health.

Outcomes of Laparoscopic Pectopexy

Clinical studies have shown that laparoscopic pectopexy offers:

High success rates in prolapse correction comparable to sacrocolpopexy

Improved quality of life, with reduced prolapse symptoms and better sexual satisfaction

Lower complication rates, particularly with bowel-related issues such as constipation

Durability, with low recurrence rates reported in medium-term follow-up studies

Complications and Risks

Although generally safe, laparoscopic pectopexy carries potential risks:

Injury to external iliac vein or vessels during ligament exposure

Mesh-related complications, such as infection or erosion (rare)

Urinary tract injury during dissection

Postoperative pelvic pain or dyspareunia

Recurrence of prolapse if mesh fixation is inadequate

These risks can be minimized by proper patient selection, meticulous surgical technique, and use of biocompatible mesh.

Future Perspectives

With increasing demand for uterine-preserving surgeries and minimally invasive options, laparoscopic pectopexy is gaining popularity worldwide. Ongoing studies comparing long-term outcomes with sacrocolpopexy suggest that pectopexy is equally effective, with specific advantages in certain patient populations. Robotic-assisted pectopexy is also being explored, offering enhanced precision in difficult pelvic dissections.

Conclusion

Laparoscopic pectopexy represents a significant advancement in the management of pelvic organ prolapse. By anchoring the uterus or vaginal vault to the pectineal ligament, it provides safe, durable, and anatomically favorable support while avoiding the risks associated with sacrocolpopexy. Women benefit from shorter recovery times, preserved sexual function, and reduced bowel complications. As expertise spreads and evidence accumulates, laparoscopic pectopexy is poised to become a standard option for prolapse surgery, particularly in women who desire uterine preservation or have contraindications to sacral suspension.