Laparoscopic ventral rectopexy using biologic mesh for the treatment of obstructed defaecation syndrome and/or faecal incontinence in patients with internal rectal prolapse: a critical appraisal of the first 100 cases.

BACKGROUND: Laparoscopic ventral mesh rectopexy (LVR) is gaining wider acceptance as the preferred procedure to correct internal as well as external rectal prolapse associated with obstructed defaecation syndrome and/or faecal incontinence. Very few reports exist on the use of biologic mesh for LVR. The aim of our study was to report the complication and recurrence rate of our first 100 cases of LVR for symptomatic internal rectal prolapse and/or rectocele using a porcine dermal collagen mesh. METHODS: Prospectively collected data on LVR for internal rectal prolapse were analysed. Surgical complications and functional results in terms of faecal incontinence (measured with the Faecal Incontinence Severity Index = FISI) and constipation (measured with the Wexner Constipation Score = WCS) at 3, 6 and 12 months were analysed. It was considered an improvement if FISI or WCS scores were reduced by at least 25 % and a cure if the FISI score decreased to <10 and the WCS decreased to <5. RESULTS: Between April 2009 and April 2013, 100 consecutive female patients (mean age 63 years, range 24-88 years) underwent LVR. All patients had internal rectal prolapse (grade III [n = 25] and grade IV [n = 75] according to the Oxford classification) and rectocele. Mean operative time was 85 ± 40 min. Conversion rate to open technique was 1 %. There was no post-operative mortality. Overall 16 patients (16 %) experienced 18 complications, including rectal perforation (n = 1), small bowel obstruction (n = 2), urinary tract infection (n = 8), subcutaneous emphysema (n = 3), wound haematoma (n = 2), long lasting sacral pain (n = 1) and incisional hernia (1). Median post-operative length of stay was 2 days. Ninety-eight out of 100 patients completed follow-up. At the end of follow-up, the mean FISI score improved from 8.4 (±4.0 standard deviation (SD) p = 0.003) to 3.3 ± 2.3 SD (p = 0.04). Incontinence improved in 37 out of 43 patients (86 %), and 31 patients (72 %) were cured. Similarly, the mean WCS score improved from 18.4 ± 11.6 SD to 5.4 ± 4.1 SD (p = 0.04). Constipation improved in 82 out of 89 patients (92 %), and 70 patients (79 %) were cured. No worsening of continence status, constipation or sexual function was observed. Fourteen patients (14 %) experienced persistence or recurrence of prolapse. CONCLUSIONS: LVR using biologic mesh is a safe and effective procedure for improving symptoms of obstructed defaecation and faecal incontinence in patients with internal rectal prolapse associated with rectocele.

The role of biologics in pelvic floor surgery.

The advent of laparoscopic surgery and with it Laparoscopic Ventral Mesh Rectopexy (LVMR) has revolutionised the management of internal/external rectal and vaginal vault prolapse. These procedures have traditionally been performed with synthetic meshes. Biologics have gained a prominent role over the last decade in LVMR as well as perineal procedures for rectocoele and cystocoele repair. We examine the existing literature on the use of biologics in pelvic floor surgery comparing this with literature on synthetic mesh for the key outcomes of infection rates, bowel/sexual function and recurrence.

Saving time stitching thick biological mesh during laparoscopic ventral rectopexy.

We present a trick to save time at stitching of thick biological mesh during laparoscopic ventral mesh rectopexy by the use of a belt hole puncher.