VM10 - J-Pouch Prolapse Repair with Biologic Mesh - A Case Report

Purpose/Background: Proctocolectomy for ulcerative colitis can be accompanied by a permanent end ileostomy, but there is evidence that patients who are given the choice and elect to have an ileal pouch anal anastomosis have better body image and similar quality of life. With these improvements in patient-centered outcomes come various complications, including afferent limb syndrome, anastomotic sinus or fistula, pouch leak, stricturing, pouchitis, Crohn’s disease of the pouch, and pouch prolapse. Prolapse of the pelvic pouch has been described as a rare complication, occurring in only 0.3% of patients in a large, single-centered study of 3,176 patients who underwent ileal pouch creation. Risk factors for this complication include a low body mass index and a low amount of peri-pouch pelvic fat on cross-sectional imaging. Once present, pouch prolapse can result in symptoms mimicking obstructed defecation, but can also include seepage, pain, or prolapse of external tissue. Various surgical techniques for repair of ileal pouch prolapse have been described, but there are no high volume or prospective studies to show the efficacy of a given approach over any other. With this uncertainty in the optimal surgical treatment of this rare complication, we present the video of treatment of full thickness J pouch prolapse with a trans-abdominal ventral mesh rectopexy using biosynthetic mesh.

Methods/Interventions: Our patient is a 39-year-old woman who underwent a laparoscopic total abdominal colectomy with end ileostomy for medically refractory Crohn’s disease in 2013. This was followed by a robotic completion proctectomy, J pouch creation, and diverting loop ileostomy in 2014 with loop ileostomy takedown three months later. She recovered well and was asymptomatic until early 2022 when she began to develop symptoms of obstructed defecation. Pouchoscopy and enteroscopy revealed no obvious cause of her symptoms. Fluoroscopy revealed dilated small bowel leading up to her pouch consistent with intermittent obstruction and physical exam revealed tissue prolapse with valsalva. With these findings consistent with external full-thickness pouch prolapse, we proceeded with a robotic ventral mesh pouchpexy of her J pouch using biologic mesh.
After entry into her abdomen, exploration of the patient’s pelvis revealed marked mobility of her J pouch within her pelvis with minimal adhesions within the abdomen and pelvis. The pouch was fully mobilized to the level of the pelvic floor and ensured to be free of any inter-loop adhesions. We then affixed a 2cm wide and 15cm long strip of Phasix™ biosynthetic mesh in an “L” shape to the pouch and suspended the pouch to the presacral fascia, resulting in straightening of the pouch without any laxity toward the pelvic floor. Peritoneum was then closed over the mesh to exclude it from the abdomen.

Results/Outcomes: At 3 months postoperatively, our patient has had no recurrence of her prolapse or associated symptoms.

Conclusion/Discussion: Robotic ventral mesh pouchpexy using biologic mesh is a safe and effective treatment for ileal pouch prolapse. The use of absorbable mesh and absorbable suture as well as closure of the peritoneum over mesh should be considered to minimize the risk of erosion or adhesions.