Laparoscopic Lateral Suspension (LLS)
Laparoscopic lateral suspension (LLS) is a minimally invasive mesh-based technique for apical and anterior pelvic organ prolapse repair that suspends the vaginal vault or cervix to the lateral abdominal wall via retroperitoneal tunneling of mesh arms, avoiding presacral dissection entirely. First described by Jean-Bernard Dubuisson in the early 2000s, LLS has emerged as a prominent alternative to laparoscopic sacrocolpopexy, particularly for anterior-apical prolapse and uterine-preserving surgery.[1][2][3][4][5]
For the sacral-fixation alternative, see Sacrocolpopexy. For the Cooper's-ligament alternative, see Pectopexy. For the broader prolapse decision framework, see Prolapse Repair.
Definition and Rationale
LLS routes the lateral arms of a T-shaped mesh through retroperitoneal tunnels to the lateral abdominal wall, where they are anchored to the anterior abdominal wall fascia at the level of the lateral trocar sites — bypassing the sacral promontory entirely.[2][3][6]
| Theoretical advantage | Detail |
|---|---|
| No presacral dissection | Eliminates presacral venous plexus / middle sacral / hypogastric nerve risks |
| Limited surgical field | Vesicovaginal space + retroperitoneal tunnels — no deep pelvic dissection |
| Shorter operative time | Consistently reproduced across all comparative studies |
| Technically simpler | Shorter learning curve, more accessible field |
| Suited to uterine preservation | Mesh fixed to cervical isthmus without requiring hysterectomy[1][2][3] |
Indications and Patient Selection
POP-Q stage ≥ 2 anterior and / or apical prolapse.[1][7][8] Particularly advantageous in:
- Anterior-apical prolapse — LLS appears optimal for combined anterior + apical repair.[1]
- Uterine preservation — mesh fixed to cervical isthmus.[1][3][6]
- Obese patients — anterior pelvic field is more accessible than the sacral promontory.[1]
- Difficult promontory access — prior pelvic radiation, sacral anomalies, deep pelvis, severe adhesions.[2]
- Post-hysterectomy vault prolapse — mesh fixed to vaginal cuff.[4]
Less effective for severe posterior prolapse — LLS primarily addresses anterior and apical compartments; posterior defects typically require concomitant native-tissue posterior colporrhaphy.[1][9]
Surgical Technique — Standard Dubuisson LLS
Positioning and ports[2][6]
- Dorsal lithotomy, steep Trendelenburg.
- One 10-mm umbilical optical trocar, one 10-mm suprapubic trocar, two 5-mm lateral trocars placed ~5 cm above the ASIS bilaterally.
- The lateral trocars serve dual purpose: operative access and exit points for the mesh arms.
Step-by-step
-
Vesicovaginal dissection. Incise the uterovesical peritoneal fold transversely. Mobilize the bladder off the anterior vaginal wall to ~2 cm below the bladder neck.[2][6]
- Tip (Di Michele 2026): a segment of Foley catheter can be used to suspend the bladder to the anterior abdominal wall for atraumatic retraction and to measure the anterior vaginal wall length for mesh tailoring.[2]
-
Mesh preparation. T-shaped mesh with central (vertical) arm fixed to anterior vaginal wall + cervical isthmus / cuff, and two lateral (horizontal) arms tunneled retroperitoneally. Central arm 4–6 cm × 3–4 cm; lateral arms 15–20 cm × 1.5–2 cm.[2][6]
-
Mesh material — critical. Use Type 1 macroporous monofilamentous polypropylene (standard or titanized). Avoid Type 3 mesh (macroporous + multifilamentous / microporous components) — adjusted OR 13.0 (p = 0.02) for mesh erosion.[10]
-
Central-arm fixation. Suture central arm to the vesicovaginal fascia with absorbable sutures (e.g., Vicryl 2-0). First stitch at the most distal point (near bladder neck); additional sutures proximally. Proximal end fixed to cervical isthmus (uterine-preserving) or vaginal cuff (post-hysterectomy) — non-absorbable sutures at the cervical stroma.[2][6][9]
-
Retroperitoneal tunneling — the defining LLS step. A laparoscopic grasper introduced through each lateral trocar is advanced retroperitoneally:
- Stay anterior to the broad ligament (avoids uterine vessels and ureter)
- Stay lateral to the obliterated umbilical artery (medial umbilical ligament)
- Avoid the iliac vessels, ureter, and obturator nerve.[2][6]
The grasper creates a tunnel from the lateral abdominal wall to the vesicovaginal space; each lateral mesh arm is grasped and pulled retroperitoneally to exit at the lateral trocar site.
-
Tension-free adjustment. Pull lateral arms through the abdominal wall until the apex / cervix is elevated to anatomic position. Tension-free — excessive traction causes pain, dyspareunia, and increases mesh erosion. Fix lateral arms to the anterior abdominal wall fascia (rectus sheath or external oblique aponeurosis) at the lateral trocar sites with non-absorbable sutures or tacks. Trim excess mesh.[2][6]
-
Peritonization. Close peritoneum of the uterovesical fold over the mesh with running absorbable suture; round-ligament plication can be incorporated for additional support.[6]
-
Concomitants as needed. Posterior colporrhaphy (vaginally, native tissue — avoid posterior mesh); Burch / midurethral sling for SUI; supracervical hysterectomy when indicated.[1][9][10]
Mesh configurations
| Configuration | Use |
|---|---|
| T-shaped mesh (standard Dubuisson) | Standard anterior-apical prolapse[1][2] |
| Anterior-only mesh | Predominant cystocele[1] |
| Anterior + posterior mesh | Combined anterior + posterior prolapse — higher erosion risk[3] |
| Titanized polypropylene | Standard at some centers[4] |
Robot-Assisted LLS
Identical surgical steps with the da Vinci platform — 8-mm camera, two lateral robotic trocars 5 cm above ASIS, 10-mm assistant. Retroperitoneal tunneling is performed with a standard laparoscopic forceps through the lateral trocars (not robotic arms). Advantages: 3D visualization, enhanced suturing maneuverability.[6]
Modifications
LLS combined with uterosacral ligament folding and shortening (LLS-ULFS, Xiong 2025): adds USL plication to standard LLS. In a 445-patient retrospective cohort: apical anatomical success 94.84% vs 96.98% for sacrocolpopexy (NS), with shorter operative time (85 vs 105 min, p < 0.05).[11]
Outcomes (pooled meta-analyses 2021–2025)
| Endpoint | Result |
|---|---|
| Apical anatomical success | 92.9% (95% CI 89.8–95.1)[1] |
| Anterior anatomical success | 86.9% (95% CI 81.4–90.9)[1] |
| Posterior anatomical success | 86.55%[2] |
| Subjective success (PGI-I) | 88.9% (95% CI 85.3–91.7)[1] |
| Recurrence | 9.6% (95% CI 7.0–13.2)[1] |
| Reoperation | 6.2% (95% CI 4.3–8.9)[1] |
| Patient satisfaction | > 90%[2] |
| OR time (LLS alone) | 78–160 min[2][3][4] |
| OR time (with concomitants) | 123–254 min[2][4] |
vs Laparoscopic Sacrocolpopexy
| Parameter | LLS | LSC | Significance |
|---|---|---|---|
| Apical correction | Comparable | — | OR 1.24, p = 0.55 (NS)[1] |
| Anterior correction | Comparable | — | OR 0.78, p = 0.39 (NS)[1] |
| Subjective success | Comparable | — | NS[1] |
| Operative time | 43 min shorter | — | p = 0.001[1] |
| Blood loss | Less or comparable | — | NS to p < 0.001[2][3] |
| Intraoperative / postoperative complications | Comparable | — | NS[1] |
| De novo SUI | Comparable | — | NS[1] |
| Sexual function | Comparable | — | NS[1] |
| Bowel dysfunction | Comparable | — | NS[1] |
| Total vaginal length | Shorter | Longer | p < 0.05[4] |
Three-way comparison (sacropexy vs pectopexy vs LLS, n = 180): LLS took less than half the OR time of sacropexy, with no increase in surgical failure (Sánchez-Ferrer 2025).[5]
A multicenter non-inferiority RCT (preliminary, n = 106 operated): no differences in POP-Q, symptom scales, or body image; only significant difference was shorter OR time for LLS.[14]
Complications
| Complication | Rate |
|---|---|
| Overall complication rate | 5.7% (95% CI 3.4–9.4)[1] |
| Mesh-related complications | 1.9% (95% CI 1.0–3.8)[1] |
| Clavien-Dindo ≥ III | 1.9% (16/848)[1] |
| Mesh erosion | 0–10% (pooled 3.8% with mean 82-mo follow-up)[2][3] |
| Intraoperative bladder injury | Rare[2][4] |
| Conversion to laparotomy | Rare (3/93 in one RCT)[5] |
Risk factors for mesh erosion (Dällenbach 2016, n = 480, mean follow-up 82 mo)[10]
| Factor | Adjusted OR |
|---|---|
| Type 3 mesh (macroporous + multifilamentous / microporous) | 13.0 (p = 0.02) |
| Smoking | 10.4 (p < 0.05) |
| Posterior mesh placement | 5-fold increase (p < 0.05) |
Counsel smokers preoperatively and use only Type 1 monofilament polypropylene; avoid posterior mesh — treat posterior compartment with native-tissue colporrhaphy.
Advantages and Limitations
| Advantage | Limitation |
|---|---|
| Shorter OR time (43 min less; <half in some series)[13][5] | Less effective for severe posterior prolapse — needs concomitant native-tissue posterior repair[1][9] |
| Technically simpler — shorter learning curve[1][3] | Mesh-dependent — inherent erosion / exposure risks (low with Type 1 monofilament)[12][10] |
| Excellent for uterine preservation[1][2][6] | Limited long-term data (~ 20 mo mean follow-up) — durability beyond 5 yr less established than sacrocolpopexy[12][13] |
| Particularly suited to obese patients[1] | Lack of standardization across mesh / configuration / technique[1][3] |
| Comparable anatomical and functional outcomes to sacrocolpopexy[13][15][14] | Shorter total vaginal length than sacrocolpopexy[5] |
| Not yet declared an equally effective alternative to sacrocolpopexy for advanced (stage III–IV) prolapse — limited subgroup data[13] |
Key Principles
- LLS suspends the vault / cervix to the lateral abdominal wall via retroperitoneal mesh tunneling — avoiding presacral dissection entirely.[1][2]
- Type 1 monofilament polypropylene mesh is mandatory — Type 3 mesh carries a 13× erosion risk.[10]
- The retroperitoneal tunnel must remain anterior to the broad ligament and lateral to the obliterated umbilical artery.[2][6]
- Tension-free placement — apex elevated to anatomic position without traction; over-tension causes pain and erosion.[2]
- Avoid posterior mesh — 5× erosion risk; treat posterior compartment with native-tissue colporrhaphy.[10]
- Counsel smokers about the 10× erosion risk; recommend smoking cessation preoperatively.[10]
- Comparable anatomical and functional outcomes vs sacrocolpopexy with significantly shorter OR time (~43 min less).[1][13]
- Best fit: anterior-apical prolapse with uterine preservation, obese patients, or difficult promontory access.[1][3]
- Long-term data > 5 yr remain limited — sacrocolpopexy retains gold-standard status for stage III–IV prolapse.[13]
Videos
References
1. Plotti F, Martinelli A, Terranova C, et al. Laparoscopic lateral suspension (LLS) for pelvic organ prolapse (POP): update and systematic review of prospective and randomised trials. J Clin Med. 2025;14(9):3056. doi:10.3390/jcm14093056.
2. Di Michele S, Caiazzo A, D'Alterio MN, Angioni S. Laparoscopic lateral suspension according to Dubuisson: technical video guide with tips and tricks. J Minim Invasive Gynecol. 2026. doi:10.1016/j.jmig.2026.01.044.
3. Yu T, Liu L. The standardized procedure, technical key points and latest progress of laparoscopic lateral suspension surgery. Arch Gynecol Obstet. 2024;310(3):1745-1748. doi:10.1007/s00404-024-07686-w.
4. Campagna G, Vacca L, Panico G, et al. Laparoscopic lateral suspension for pelvic organ prolapse: a systematic literature review. Eur J Obstet Gynecol Reprod Biol. 2021;264:318-329. doi:10.1016/j.ejogrb.2021.07.044.
5. Sánchez-Ferrer ML, Ñíguez-Sevilla I, Ruiz-Cotorruelo VL, Arense-Gonzalo JJ. A cohort-based comparative study of three minimally invasive apical prolapse surgeries: sacropexy, pectopexy, and lateral suspension. J Clin Med. 2025;14(17):6073. doi:10.3390/jcm14176073.
6. Lange S, Chatziioannidou K, Dällenbach P. Robotically assisted laparoscopic lateral suspension: a step-by-step approach aiming to standardize a novel procedure. Int Urogynecol J. 2023;34(5):1131-1134. doi:10.1007/s00192-023-05477-6.
7. Malanowska-Jarema E, Starczewski A, Melnyk M, et al. A randomized clinical trial comparing Dubuisson laparoscopic lateral suspension with laparoscopic sacropexy for pelvic organ prolapse: short-term results. J Clin Med. 2024;13(5):1348. doi:10.3390/jcm13051348.
8. Wang XX, Xu Y, Song YF, Lin CQ, Jiang XX. Laparoscopic lateral suspension with mesh for severe anterior and apical pelvic organ prolapse: an observational cohort study for safety and efficacy at 2-year follow-up. Arch Gynecol Obstet. 2024;310(6):3259-3265. doi:10.1007/s00404-024-07792-9.
9. Chatziioannidou K, Veit-Rubin N, Dällenbach P. Laparoscopic lateral suspension for anterior and apical prolapse: a prospective cohort with standardized technique. Int Urogynecol J. 2022;33(2):319-325. doi:10.1007/s00192-021-04784-0.
10. Dällenbach P, De Oliveira SS, Marras S, Boulvain M. Incidence and risk factors for mesh erosion after laparoscopic repair of pelvic organ prolapse by lateral suspension with mesh. Int Urogynecol J. 2016;27(9):1347-55. doi:10.1007/s00192-016-2974-z.
11. Xiong X, Xia L, Mei T, et al. Laparoscopic lateral suspension combined with uterosacral ligament folding and shortening versus laparoscopic sacrocolpopexy for the treatment of pelvic organ prolapse: a retrospective cohort study. Front Med. 2025;12:1626735. doi:10.3389/fmed.2025.1626735.
12. Wang Q, Manodoro S, Jiang X, Lin C. Efficacy and safety of laparoscopic lateral suspension with mesh for pelvic organ prolapse: a systematic review and meta-analysis. Acta Obstet Gynecol Scand. 2025. doi:10.1111/aogs.15170.
13. Lombisani A, Tius V, Ferraro C, et al. Lateral suspension vs sacral colpopexy for treating pelvic organ prolapse: a systematic review and meta-analysis. Arch Gynecol Obstet. 2025. doi:10.1007/s00404-025-08210-4.
14. Ñíguez-Sevilla I, Sánchez-Ferrer ML, Ruiz-Cotorruelo VL, et al. Preliminary results of a multicenter randomized clinical trial for laparoscopic repair of pelvic organ prolapse: sacropexy vs laparoscopic lateral suspension. J Clin Med. 2025;14(6):2069. doi:10.3390/jcm14062069.
15. Isenlik BS, Aksoy O, Erol O, Mulayim B. Comparison of laparoscopic lateral suspension and laparoscopic sacrocolpopexy with concurrent total laparoscopic hysterectomy for the treatment of pelvic organ prolapse: a randomized controlled clinical trial. Int Urogynecol J. 2023;34(1):231-238. doi:10.1007/s00192-022-05267-6.