Laparoscopic, abdominal, and robot-assisted sacropexy are well-established standardprocedures for the treatment of apical (level I) pelvic organ prolapse. Over the past decade,complication rates related to mesh implantation have been significantly reduced through the use oflightweight, monofilament, large-pore meshes and absorbable sutures for vaginal stump attachment.Nevertheless, secure fixation of the mesh to the sacral promontory remains one of the mosttechnically demanding steps of the procedure, particularly in robotic surgery. Challenges includelimited working space, the need for precise tension control, the risk of suture pull-out, and frequentreliance on additional instruments or an assistant. This study aimed to evaluate the safety, feasibility, and efficiency of a novel robotic fixation technique using a pre-looped adjustable suture, referred to as the “Ney-Knot.”
The aim of this study was to evaluate the safety, feasibility, and efficiency of a novelrobotic fixation technique for sacral promontory attachment during sacropexy. Specifically, weassessed whether the use of a pre-looped, adjustable suture (“Ney-Knot”) enables secure meshfixation with reduced instrument requirements, shorter fixation time, and improved surgeon-controlled tension adjustment.

Between February 2025 and March 2026, 52 consecutive patients underwent robot-assisted sacropexy using the Ney-Knot technique. All cases were retrospectively analyzed. The Ney-Knot consists of a 15 cm suture with a preformed, adjustable loop designed to allow controlled meshfixation at the promontory. Promontory fixation was performed using only two robotic arms—a Johann grasper and a needle driver—without the need for additional assisting instruments. The firststitch was placed from cranial to caudal through the anterior longitudinal ligament at the promontory.The mesh was then inserted into the preformed loop and encircled by the running suture. Bytightening the loop, the surgeon could precisely adjust mesh position and tension. A second stitchwas subsequently placed from caudal to cranial, creating an additional loop around the mesh,analogous to a locking Z-stitch, to achieve final fixation. Peritoneal closure was performed in astandard fashion.

All procedures were completed successfully without intraoperative complications related tomesh fixation. Secure attachment of the mesh to the promontory was achieved in all patients, withno cases of suture tear-out, fixation failure, or postoperative pain attributable to the fixation site. Themean time required for promontory fixation was 11 minutes, indicating a high level of proceduralefficiency. The Ney-Knot technique offered several practical advantages: elimination of the need foran assistant to elevate the vaginal stump, full control of mesh tension and positioning by theoperating surgeon, and reduced instrument usage through reliance on only two robotic arms. Thesefactors contributed to a streamlined workflow and potentially reduced operative complexity.

The findings of this study indicate that the Ney-Knot technique provides a highly effective and reproducible method for mesh fixation to the sacral promontory during robotic sacropexy. The absence of intraoperative complications and fixation failures demonstrates that this novel approach is both safe and reliable. Importantly, the technique achieved secure mesh attachment in all patients, highlighting its mechanical stability and suggesting that concerns such as suture tear-out or fixation loss can be effectively mitigated with the pre-looped, adjustable design.

The Ney-Knot technique represents a safe, reliable, and time-efficient method for meshfixation during robotic sacropexy. Its high tensile stability, material-saving design, and minimalinstrument requirements make it a valuable alternative to conventional fixation techniques. Byenabling precise tension control and surgeon-directed mesh elevation, the Ney-Knot may simplify oneof the most challenging steps of sacropexy and enhance the overall efficiency and reproducibility ofrobotic prolapse surgery.