Salvage pectopexy using detached lateral suspension mesh arms

Laparoscopic lateral suspension is an alternative to sacrocolpopexy when access to the sacral promontory is restricted or unsafe. However, prolapse recurrence may occur due to mesh arm detachment or progressive fascial attenuation. Pectineal fixation is an alternative approach that may provide a stronger, more stable anchoring vector and improved force distribution.

To describe a minimally invasive salvage surgical strategy for managing recurrent anterior compartment prolapse in a patient with a history of laparoscopic lateral suspension and inaccessible sacral promontory.

A 73-year-old woman presented with symptomatic vaginal bulging fifteen years after undergoing laparoscopic lateral suspension with subtotal hysterectomy and bilateral adnexectomy following an aborted promontofixation. Examination revealed a grade 2-3 cystocele and a grade 2 hysterocele without mesh exposure. Laparoscopy confirmed bilateral detachment of the anterior mesh arms from the lateral abdominal wall.

Laparoscopic anterior colporrhaphy was undertaken to reinforce the pubocervical fascia, with exposure supported by a device. The detached mesh arm was carefully trimmed and then secured using non-absorbable Ethibond® 1 sutures, with one fixation point anchored to the Cooper's ligament and the other to the mesh itself, in accordance with the principles of tension-free pectopexy bilaterally. Peritonisation was completed to fully cover the mesh.

Recurrent anterior prolapse after lateral suspension where the sacral promontory is inaccessible promontory can be managed by reusing the detached mesh arms and refixing to Cooper's ligament as a salvage strategy.

Reinforcing the native fascia and refixing the mesh to the pectineal ligament provides an anatomically sound solution while avoiding the risks of sacral promontory dissection.