Pectopexy, an alternative to sacrocolpopexy for patients with colonic pathology. Mesh sacrocolpopexy is generally considered the gold standard for apical prolapse repair. However, certain patients have contraindications for the use of this technique. This is a patient with severe diverticulosis. A strap of material that came from the Vaginal apis to the sacrum would be directly near the colon. There are multiple reports of mesh erosion in the colon in patients with disease diverticular undergoing mesh sacrocolpopexy. And it has been suggested that diverticular disease should be considered a relative contraindication to this operation. Although this risk can be reduced by the use of cadaveric fascia, the results are consistently inferior to those of mesh when this material is used. Since diverticular disease is common in the prolapse age group, better options are needed for these patients. This is a patient who underwent sacrocolpopexy with cadaveric fascia 18 months previously. The graft has reduced to a fibrous band that does not provide support some. Pectopexy is a new operation that uses mesh to create similar support to an amica for the vaginal vertex using the pectineal ligaments as support points. The entire operation is in the anterior pelvis and no mesh is placed in the deep pelvis nor in the vicinity of the colon. Banerjee and Noé first reported pectopexy in 2010. The results were similar to those of sacrocolpopexy in a randomized trial of 85 patients. Postoperative intestinal symptoms were notably lower in patients who underwent to pectopexy. The only part of the pectopexy operation that is unfamiliar to surgeons who sacrocolpopexy is the dissection of the pectineal ligament. The pectineal ligament is located below the umbilical ligament near the origin of the round ligament. For locate the pectineal ligament, the umbilical ligament is clamped and the peritoneum lateral to the umbilical ligament is opened and a careful dissection is performed until identifying the pectineal ligament. A vaginal manipulator is placed and the bladder is desiccated from the anterior wall of the vagina. The peritoneum is desiccated to expose the posterior wall of the vagina. The mesh is prepared by dividing the upper arm of a sacrocolpopexy Y mesh. The anterior arm of the mesh is then attached to the anterior wall of the vagina with sutures. The posterior arm of the mesh is then attached to the posterior wall of the vagina in the same manner. On the right side, the pectineal ligament is exposed in its location between the epigastric vein and the obliterated umbilical artery. The same dissection is performed on the left side. The right lateral arm of the mesh is then attached to the right pectineal ligament with permanent polyester suture. The same steps are performed on the left side for symmetrical support of the upper part of the vagina. The peritoneum is then closed over the mesh with a running suture to avoid contact between the mesh and the intestine. The result is solid support for the vaginal apex without mesh in the vicinity of the colon. Other situations in which pectopexy may be preferred to sacrocolpopexy include extensive adhesions in the deep pelvis, antiplatelet or anticoagulant therapy, or patient intolerance to the pronounced Trendelenburg position required for sacrocolpopexy. Pectopexy was first performed in North America in 2019. An observational study that compared the results of 50 pectopexies with 207 sacrocolpopexies performed by the same surgeons revealed similar short-term results, even though pectopexy was typically used in more complex patients. The pectopexy was performed in Sinaloa, Mexico, in March 2023. Requires only basic laparoscopic instruments and is well suited to resource-limited situations, particularly because there is no presacral dissection with the consequent risk of catastrophic hemorrhage. Pectopexy has filled a gap in our practice by allowing us to offer similar results to sacrocolpopexy. to patients with contraindications such as colon disease. We recommend this excellent video by Dr. Noé for anyone interested in learning the technique.

pectopexy

surgical alternative

colonic pathology

mesh sacrocolpopexy

pectineal ligaments