VM44 - Robotic Ventral Mesh Rectopexy After Perineal Rectosigmoidectomy

Purpose/Background: We present a case of a 61 year old woman with a history of perineal rectosigmoidectomy in 2019 that presented to our clinic with recurrent rectal prolapse. She noticed prolapse one year after her rectosigmoidectomy. Physical examination demonstrated a 3-4cm full thickness rectal prolapse with straining. She had concurrent vaginal prolapse for the past 25 years and stress urinary incontinence. We planned for robotic ventral mesh rectopexy in combination with uro-gynecology performing hysterectomy, bilateral salpingectomy, and mesh sacrocervicopexy.

Methods/Interventions: The mesh rectopexy was performed robotically. After port placement, we started the operation by exposing the sacrum at the site of the planned mesh fixation. A peritoneal incision was created in a “lazy J” configuration on the left side from the sacrum to the rectovaginal septum. The rectovaginal septum was opened and we carefully dissected this space. Given her previous perineal rectosigmoidectomy, there were adhesions in this space. After dissecting down to the pelvic floor, the space was measured and an acellular porcine intestinal submucosa mesh was fixated with interrupted polydioxanone sutures. Uro-gynecology laparoscopically performed a hysterectomy and bilateral salpingectomy, then the vagina was fully dissected. A lightweight polypropylene mesh in “Y” configuration was secured to the anterior and posterior vaginal walls. The meshes were put on tension to the sacrum and fixated with two interrupted monofilament ePTFE sutures. The peritoneum was closed over the mesh with reabsorbable monofilament suture.

Results/Outcomes: The patient tolerated surgery well without intraoperative complications. On postoperative day one she passed an active voiding trial and her diet was advanced. She was discharged on postoperative day one after having bowel function and no evidence of recurrent rectal prolapse.

Conclusion/Discussion: For patients with previous perineal rectosigmoidectomy, ventral mesh rectopexy is a feasible and effective operative approach for recurrent full thickness rectal prolapse. While it is expected that there will be adhesions in the rectovaginal septum, with careful dissection the pelvic floor can be exposed to allow for mesh fixation. Furthermore, when multiple pelvic floor compartments are involved, collaboration with uro-gynecology is often required to address weakness in the middle and anterior compartments.