Laparoscopic Ventral Mesh Rectopexy and Lateral Suspension for Multicompartment Prolapse: A Video Vignette

What does the future hold for ventral rectopexy?: Functional outcome after laparoscopic posterior sutured rectopexy versus ventral mesh rectopexy for rectal prolapse: six-year follow-up of a double-blind, randomised single-centre study

BackgroundThe aim of this study was to assess, whether robotic-assistance in ventral mesh rectopexy adds benefit to laparoscopy in terms of health-related quality of life (HRQoL), cost-effectiveness and anatomical and functional outcome.MethodsA prospective randomized study was conducted on patients who underwent robot-assisted ventral mesh rectopexy (RVMR) or laparoscopic ventral mesh rectopexy (LVMR) for internal or external rectal prolapse at Oulu University Hospital, Finland, recruited in February–May 2012. The primary outcomes were health care costs from the hospital perspective and HRQoL measured by the 15D-instrument. Secondary outcomes included anatomical outcome assessed by pelvic organ prolapse quantification method and functional outcome by symptom questionnaires at 24 months follow-up.ResultsThere were 30 females (mean age 62.5 years, SD 11.2), 16 in the RVMR group and 14 in the LVMR group. The surgery-related costs of the RVMR were 1.5 times higher than the cost of the LVMR. At 3 months the changes in HRQoL were ‘much better’ (RVMR) and ‘slightly better’ (LVMR) but declined in both groups at 2 years (RVMR vs. LVMR, p > 0.05). The cost-effectiveness was poor at 2 years for both techniques, but if the outcomes were assumed to last for 5 years, it improved significantly. The incremental cost-effectiveness ratio for the RVMR compared to LVMR was €39,982/quality-adjusted life years (QALYs) at 2 years and improved to €16,707/QALYs at 5 years. Posterior wall anatomy was restored similarly in both groups. The subjective satisfaction rate was 87% in the RVMR group and 69% in the LVMR group (p = 0.83).ConclusionsAlthough more expensive than LVMR in the short term, RVMR is cost-effective in long-term. The minimally invasive VMR improves pelvic floor function, sexual function and restores posterior compartment anatomy. The effect on HRQoL is minor, with no differences between techniques.

Obstructive defecation syndrome (ODS) is a widespread but poorly understood complex multifactorial illness that is initially treated with dietary changes, pelvic floor exercises and biofeedback. Surgical care can be administered in patients with anatomical anomalies who do not respond to conservative treatment. Laparoscopic ventral mesh rectopexy (LVMR) is a relatively new surgical method that has gained acceptance for the treatment of ODS with long-term success. The objective of this study was to find out the outcome of laparoscopic ventral mesh rectopexy in patients with obstructive defecation syndrome. This longitudinal descriptive study was carried out in the Department of Colorectal Surgery, Rajshahi Medical College Hospital, Rajshahi among 40 patients having ODS for a period of 3 years from July 2021 to June 2024. The study was conducted after obtaining ethical clearance from the Ethical Review Committee (ERC) of Rajshahi Medical College and consent from the patients. Based on predefined eligibility criteria, a total number of 40 patients of obstructive defecation syndrome due to rectocele and rectorectal intussusception were included in the study by purposive sampling technique. Patients were followed up at the end of two weeks, three and six months of performing laparoscopic ventral mesh rectopexy. Data were analyzed by SPSS software, version-24 and p value < 0.05 was considered statistically significant for all tests. Out of 40 patients, 16 (40.00%) were within the age group of 35-45 years with mean age of the patients 41.97±9.99 years. Majority 32 (80.00%) of the patients were female with female male ratio 4:1. Half 20 (50.00%) of the patients had class VI-X level of education and 23 (57.50%) were housewives. Mean BMI of the patients was 23.73±3.62 kg/m2. Only 7 (17.50%) of the patients had history of smoking and 11 (27.50%) had history of OCP intake. Before operation, 22 (55.00%) of the patients had rectorectal intussusception with rectocele, 12 (30.00%) had rectorectal intussusception alone and 6 (15.00%) had rectocele alone. Mean Modified Longo ODS Score was 21.97±1.07 before operation followed by 7.77±1.61, 4.23±2.03 and 2.87±1.80 after two weeks, three and six months of laparoscopic ventral mesh rectopexy, respectively. Modified Longo ODS Score was significantly reduced after six months of laparoscopic ventral mesh rectopexy in comparison to preoperative period (p <0.001). The mean modified Longo ODS score decreased significantly by 87.05% after six months of the procedure. None of the patient had rectocele, rectorectal intussusception and urinary stress incontinence after laparoscopic ventral mesh rectopexy but only one patient experienced loose stool incontinence and another patient experienced having persistence of ODS symptoms. Laparoscopic ventral mesh rectopexy is a safe surgical procedure with minimal complications and good functional results for ODS patients with rectal anatomical abnormalities.

To compare perioperative results of laparoscopic and robotic ventral mesh rectopexy for pelvic floor disorders at the beginning of the surgical experience. Between 2017 and 2022, the first 30 laparoscopic ventral mesh rectopexies and the first 30 robotic ventral mesh rectopexies at the beginning of the experience of 2 surgeons were retrospectively analyzed. Perioperative (demographic characteristics, surgical indication, conversion rate, operative time), and postoperative (complications, length of stay, unplanned reintervention) data were compared between groups. Demographic characteristics were similar between groups. Conversion rate was lower (0 vs 17%, p = 0.05), but the operative time was significantly longer (182 [146-290] vs 150 [75-240] minutes, p < 0.0001) during robotic procedure when compared with laparoscopic approach. In terms of learning curve, the number of procedures to obtain the same operative time between the 2 approaches was 15. Postoperative results were similar between groups, in terms of pain (visual analogic scale = 2 [0-8] vs 4 [0-9], p = 0.07), morbidity (17 vs 3%, p = 0.2), and unplanned reintervention (1 vs 0%, p = 0.99). Mean length of stay was significantly reduced after robotic approach when compared with laparoscopic approach (3 [2-10] vs 5 [2-11] days, p < 0.01). Functional results were better after robotic than laparoscopic ventral mesh rectopexy, with higher satisfaction rate (93 vs 75%, p = 0.05), and reduced recurrence rate (0 vs 14%, p = 0.048). Despite longer operative time at the beginning of the learning curve, robotic ventral mesh rectopexy was associated with similar or better perioperative results than laparoscopic ventral mesh rectopexy.

Ventral mesh rectopexy (VMR) is an established, minimally invasive, nerve-sparing procedure for the treatment of various symptomatic morphological changes in the posterior pelvic compartment. We present the short-term functional outcome and patient satisfaction after laparoscopic and robotic VMR with biological mesh. We analyzed data from 123 patients who underwent laparoscopic ventral mesh rectopexy (LVMR) or robotic ventral mesh rectopexy (RVMR) from August 2012 to January 2017. Included in these data were patient demographics, intra- and postoperative findings, Cleveland Clinic Constipation Score (CCCS), Obstructed Defecation Score Longo (ODS), Cleveland Clinic Incontinence Score (CCIS), and patient satisfaction as measured by visual analog scale (0-10). Improvements in CCCS, CCIS, and ODS were statistically significant at 6 and 12months (p < 0.001). Patient satisfaction was excellent at 6 and 12months (8.2/10 and 8.3/10, respectively). The overall complication rate was 14%, with a major complication rate of 2%. No mesh-related complications were observed. The need for surgical re-intervention because of relapse, symptom persistence or recurrence, or new symptoms was 3%. Outcome appears to be similar between LVMR and RVMR. Both LVMR and RVMR with biological mesh are safe and effective in reducing symptoms, as measured by CCCS, CCIS, and ODS, and patient satisfaction is high.

The purpose of this prospective randomized study was to compare robot-assisted and laparoscopic ventral rectopexy procedures for posterior compartment procidentia in terms of restoration of the anatomy using magnetic resonance (MR) defaecography. Sixteen female patients (four with total prolapse, twelve with intussusception) underwent robot-assisted ventral mesh rectopexy (RVMR) and 14 female patients (two with prolapse, twelve with intussusception) laparoscopic ventral mesh rectopexy (LVMR). Primary outcome measures were perioperative parameters, complications and restoration of anatomy as assessed by MR defaecography, which was performed preoperatively and 3months after surgery. Patient demographics, operation length, operating theatre times and length of in-hospital stay were similar between the groups. The anatomical defects of rectal prolapse, intussusception and rectocele and enterocele were similarly corrected after rectopexy in either technique as confirmed with dynamic MR defaecography. A slight residual intussusception was observed in three patients with primary total prolapse (two RVMR vs one LVMR) and in one patient with primary intussusception (RVMR) (P=0.60). Rectocele was reduced from a mean of 33.0±14.9mm to 5.5±8.4mm after RVMR (P<0.001) and from 24.7±17.5mm to 7.2±3.2mm after LVMR (P<0.001) (RVMR vs LVMR, P=0.10). Robot-assisted laparoscopic ventral rectopexy can be performed safely and within the same operative time as conventional laparoscopy. Minimally invasive ventral rectopexy allows good anatomical correction as assessed by MR defaecography, with no differences between the techniques.

Bowel function after laparoscopic posterior sutured rectopexy versus ventral mesh rectopexy for rectal prolapse: a double-blind, randomised single-centre study

Laparoscopic ventral mesh rectopexy (LVR) is a treatment with promising results in external rectal prolapse, rectal intussusception, and rectocele. Because of the emergence of robotic-assisted surgery and the technical advantage it provides, we examined the potential role and place of robotic surgery in ventral rectopexy. MEDLINE, PubMed, and other databases were searched, by two independent reviewers, to identify studies comparing robotic to laparoscopic ventral mesh rectopexy. The primary outcome was the rate of unplanned conversion to open. The secondary outcomes were morbidity, length of hospital stay and recurrence rate. Five studies (4% male, n = 259) met the inclusion criteria. All 5 studies reported on conversion rate and showed no significant difference between the conversion rate of robotic and laparoscopic groups [OR 0.58 (95% CI 0.09-3.77)]. Robotic surgery was also similar to laparoscopic surgery for both morbidity [OR 0.71 (95% CI 0.34-1.48)] and recurrence rate [OR 0.56 (95% CI 0.18-1.75)]. Operative time was longer in the robotic group with a MWD of 22.88 minutes (CI 5.73-40.04, p < 0.0007). There was a statistically significant reduction in length of stay with robotic surgery [mean difference - 0.36 days (95% CI - 0.66 to - 0.07)]. This systematic review shows that robotic-assisted ventral rectopexy requires longer operative time with no significant added benefit over laparoscopic ventral rectopexy. The conversion rate was low in both groups and the trends to benefit did not reach statistical significance. More studies are required to clarify whether the potential technical advantage of robotic surgery in ventral rectopexy translates to an improvement in clinical outcome.

The pelvic structures are anatomically and functionally interconnected, forming an integrated system. The diagnosis and management of multi-compartment pelvic organ prolapse (POP) often require multidisciplinary collaboration among urogynecologists, colorectal surgeons, and radiologists. Individualized surgical planning should be tailored according to the patient’s condition and preferences, aiming to correct all compartmental defects in a single procedure whenever possible. In this study, we report a case of a patient presenting with rectal prolapse, anterior vaginal wall prolapse, and uterine prolapse accompanied by severe constipation, who achieved satisfactory outcomes following laparoscopic lateral suspension (uterus preservation) combined with ventral mesh rectopexy. This combined surgical approach is particularly suitable for patients with multi-compartment POP presenting with rectal prolapse and anterior vaginal or apical prolapse, who also express a desire for uterine preservation and report symptoms of constipation. The key technical considerations involve utilizing lateral suspension to correct anterior vaginal and/or apical prolapse, while employing ventral mesh rectopexy to address rectal prolapse. Compared to the combination of ventral mesh rectopexy and sacrocolpopexy, this procedure is technically simpler and maintains appropriate independence between the posterior vaginal wall and the rectum. It not only achieves favorable outcomes in correcting prolapse across all pelvic compartments but also reduces the risks of mesh-related complications and postoperative constipation. The purpose of this video is to share our experience and insights into the multidisciplinary management of multi-compartment POP.

PurposeObstructed defecation syndrome represents 50–60% of patients with symptoms of constipation. We aimed to compare the two frequently performed surgical methods, laparoscopic ventral mesh rectopexy and transperineal mesh repair, for this condition in terms of functional and surgical outcomes.MethodsThis study is a retrospective review of 131 female patients who were diagnosed with obstructed defecation syndrome, attributed to rectocele with or without rectal intussusception, enterocele, hysterocele or cystocele, and who underwent either laparoscopic ventral mesh rectopexy or transperineal mesh repair. Patients were evaluated for surgical outcomes based on the operative time, the length of hospital stay, operative complications, using prospectively designed charts. Functional outcome was assessed by using the Initial Measurement of Patient-Reported Pelvic Floor Complaints Tool.ResultsFifty-one patients diagnosed with complex rectocele underwent laparoscopic ventral mesh rectopexy, and 80 patients diagnosed with simple rectocele underwent transperineal mesh repair. Mean age was found to be 50.35 ± 13.51 years, and mean parity 2.14 ± 1.47. Obstructed defecation symptoms significantly improved in both study groups, as measured by the Colorectal Anal Distress Inventory, Constipation Severity Instrument and Patient Assessment of Constipation-Symptoms scores. Minor postoperative complications including wound dehiscence (n = 3) and wound infection (n = 2) occurred in the transperineal mesh repair group.ConclusionLaparoscopic ventral mesh rectopexy and transperineal mesh repair are efficient and comparable techniques in terms of improvement in constipation symptoms related to obstructed defecation syndrome. A selective distribution of patients with or without multicompartmental prolapse to one of the treatment arms might be the preferred strategy.

Su1786 Laparoscopic Ventral Mesh Rectopexy Compared to Stapled Trans-Anal Rectal Resection (STARR) to Treat Internal Rectal Prolapse: A Matched Cohorts Study

BackgroundThe aim of this study was to compare patients’ mid-term functional and quality of life (QoL) outcomes following robotic ventral mesh rectopexy (RVMR) and laparoscopic ventral mesh rectopexy (LVMR).MethodsThe data of consecutive female patients who underwent minimally invasive ventral mesh rectopexy for external or symptomatic internal rectal prolapse at 3 hospitals in Finland between January 2011 and December 2016 were retrospectively collected. Patients were matched by age and diagnosis at a 1:1 ratio. A disease-related symptom questionnaire was sent to all living patients at follow-up in July 2018.ResultsAfter a total of 401 patients (RVMR, n = 187; LVMR, n = 214) were matched, 152 patients in each group were included in the final analyses. The median follow-up times were 3.3 (range 1.6–7.4) years and 3.0 (range 1.6–7.6) years for the RVMR and LVMR groups, respectively. The postoperative QoL measures did not differ between the groups. Compared with the LVMR group, the RVMR group had lower postoperative Wexner Incontinence Score (median 5 vs. median 8; p < 0.001), experienced significant ongoing incontinence symptoms less often (30.6% vs. 49.0%; p < 0.001) and reported less postoperative faecal incontinence discomfort evaluated with the visual analogue scale (median 11 vs. median 39; p = 0.005). RVMR patients had a shorter hospital stay (2.2 days vs. 3.8 days; p < 0.001) but experienced more frequent de novo pelvic pain (31.8% vs. 11.8%; p < 0.001).ConclusionRVMR and LVMR patients had equal functional and QoL outcomes. Those who underwent RVMR had lower mid-term anal incontinence symptom scores but suffered more frequent de novo pelvic pain.

Laparoscopic ventral rectopexy (LVR) is a widely used technique in the treatment of rectal prolapse but faces limitations due to restricted working space within the narrow confines of the pelvic cavity and suboptimal ergonomics. The advent of robotic platforms, particularly the da Vinci Xi system, has offered solutions by enhancing visualization and precision. This study retrospectively compares outcomes between LVR and robotic ventral rectopexy (RVR), and between the da Vinci Si and Xi robotic systems. This retrospective cohort study analyzed 315 a consecutive series of patients who underwent minimally invasive ventral mesh rectopexy between March 2019 and October 2024 by a single operator at a single institution. Patients were divided into laparoscopic (n = 72) and robotic (n = 243) groups, with the robotic cohort further categorized into Si (n = 159) and Xi (n = 84) subgroups. The outcomes measures included operative time, console time, hospital stay and perioperative complications. The robotic group demonstrated a shorter median length of stay (1vs.2days, p < 0.01) with similar operative times. Prior hysterectomy was associated with increased operative time, while age and redo surgery were not. The Xi platform significantly reduced operative and console times compared to the Si (80vs.100min, p < 0.01; 55vs.68min, p < 0.01). This is the first study to demonstrate that the robotic-assisted technique has shorter operative times as compared to laparoscopic technique. Among robotic platforms, the da Vinci Xi system further enhances these benefits, surpassing the Si platform in efficiency. These findings establish robotic rectopexy, particularly with the Xi system, as the preferred method for optimizing surgical outcomes in the surgical treatment of rectal prolapse syndromes.

PurposeThis review reports the incidence of mesh-related erosion after ventral mesh rectopexy to determine whether any difference exists in the erosion rate between synthetic and biological mesh.MethodsA systematic search of the MEDLINE and the Ovid databases was conducted to identify suitable articles published between 2004 and 2015. The search strategy capture terms were laparoscopic ventral mesh rectopexy, laparoscopic anterior rectopexy, robotic ventral rectopexy, and robotic anterior rectopexy.ResultsEight studies (3,956 patients) were included in this review. Of those patients, 3,517 patients underwent laparoscopic ventral rectopexy (LVR) using synthetic mesh and 439 using biological mesh. Sixty-six erosions were observed with synthetic mesh (26 rectal, 32 vaginal, 8 recto-vaginal fistulae) and one (perineal erosion) with biological mesh. The synthetic and the biological mesh-related erosion rates were 1.87% and 0.22%, respectively. The time between rectopexy and diagnosis of mesh erosion ranged from 1.7 to 124 months. No mesh-related mortalities were reported.ConclusionThe incidence of mesh-related erosion after LVR is low and is more common after the placement of synthetic mesh. The use of biological mesh for LVR seems to be a safer option; however, large, multicenter, randomized, control trials with long follow-ups are required if a definitive answer is to be obtained.

Function, morbidity and recurrence of symptoms after robotic-assisted ventral mesh rectopexy (RVMR) and laparoscopic ventral mesh rectopexy (LVMR) for pelvic floor disorders (PFDs) were compared. Forty-four patients operated on for PFD with RVMR were compared with 74 of 144 patients who had had LVMR performed between 2008 and 2011. The groups were matched for age, body mass index, American Society of Anesthesiologists status and previous hysterectomy. The same surgical technique and type of mesh were used. Early postoperative morbidity and function [obstructed defaecation syndrome (ODS), incontinence scores (CCF) and sexual activity] were compared. Operation time was longer in RVMR compared with LVMR (191 ± 26 vs 163 ± 39 min; P = 0.0002). RVMR showed less blood loss (8 ± 34 vs 42 ± 88 ml; P = 0.012) and fewer early complications (2% vs 11%; P = 0.019). ODS and CCF scores improved in both groups. Patients after RVMR reported a better improvement in digitation, straining and satisfaction after defaecation. There was a statistically significant difference in the postoperative ODS score in favour of RVMR (P = 0.004). Sexually active patients in both groups reported a similar improvement. There was no difference in early recurrence (P = 0.692). Although not a randomized comparison, this study shows that ventral mesh rectopexy performed by the robot was followed by better function then LVMR.