Modified laparoscopic ventral mesh rectopexy

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.

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

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.

Laparoscopic ventral mesh rectopexy (LVR) is an emerging technique for selected patients with rectal prolapse and obstructed defaecation syndrome. Data are insufficient to conclude which type of mesh affords the greatest benefit. Our aim was to compare the outcomes of LVR using a non-cross-linked biologic versus a permanent mesh. Twenty nine cases of LVR with permanent mesh were matched based on age and surgical indication with an equal number of patients using biologic mesh. Cases were retrospectively reviewed from a prospectively maintained database. Symptom resolution, patient satisfaction and recurrence of prolapse were measured among those who underwent LVR with either a biologic (Biodesign(®), Cook Medical) or polypropylene mesh. Age, American Society of Anesthesiologists (ASA) class, surgical indication and primary symptoms were not different between the two groups. After a median follow-up of 15.4 months, all patients reported being either completely or partially satisfied. Rates of complete or partial symptom resolution (p = 0.26) or satisfaction (p = 0.27) did not differ between groups. After LVR, similar rates of additional procedures were performed in the biologic (21 %) and the permanent (28 %) mesh group. Among patients with full-thickness prolapse (n = 33), there were five cases (15 %) of recurrence, one in the biologic group and four in the permanent mesh group (p = 0.37). There were no mesh-related complications in either group. LVR using a non-cross-linked biologic mesh appears to have comparable rates of symptom improvement and patient satisfaction in the short term. Longer follow-up will be required to determine if prolapse recurrence depends on mesh type.

Introduction: Laparoscopic ventral mesh rectopexy (VMR) is the standard procedure for the treatment of posterior pelvic organ prolapse. Despite significant functional improvement and anatomical corrections, severe complications related to mesh augmentation can occur in a few proportions of patients. In order to decrease the number of rare but severe complications, we developed a variant of the conventional VMR without any rectal fixation and using a robotic approach with biological mesh. The aim of this study was to compare the results of laparoscopic ventral rectopexy with synthetic mesh (LVMRS) to those of robotic ventral rectopexy with biological mesh (RVMRB). Methods: Between 2004 and 2021, patients operated on for VMR in our unit were identified and separated into two groups: LVMRS and RVMRB. The surgical technique for both groups consisted of VMR without any rectal fixation, with mesh distally secured on the levator ani muscles. Results: 269 patients with a mean age of 62 years were operated for posterior pelvic floor disorder: rectocele (61.7%) and external rectal prolapse (34.6%). 222 (82.5%) patients received LVMRS (2004–2015), whereas 47 were operated with RVMRB (2015–2021). Both groups slightly differed for combined anterior fixation proportion (LVMRS 39% vs. RVMRB 6.4%, p < 0.001). Despite these differences, the length of stay was shorter in the RVMRB group (2 vs. 3 days, p < 0.001). Postoperative complications were comparable in the two groups (1.8 vs. 4.3%, p = 0.089) and mainly consisted of minor complications. Functional outcomes were favorable and similar in both groups, with an improvement in bulging, obstructed defecation symptoms, and fecal incontinence (NS in subgroup analysis). In the long term, there were no mesh erosions reported. The overall recurrence rate was 11.9%, and was comparable in the two groups (13% LVMRS vs. 8.5, p = 0.43). Conclusions: VMR without rectal fixation is a safe and effective approach in posterior organ prolapse management. RVMRB provides comparable results in terms of recurrence and functional results, with avoidance of unabsorbable material implantation.

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.

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.

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 &lt; 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 &lt;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.

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

Laparoscopic Ventral Rectopexy for Internal Rectal Prolapse Using Biological Mesh: Postoperative and Short-Term Functional Results

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.

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.

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. 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 12months 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. Between April 2009 and April 2013, 100 consecutive female patients (mean age 63years, range 24-88years) 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±40min. 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 2days. 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. 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.

We read with great interest the article titled “Laparoscopic ventral rectopexy for rectal prolapse and rectal intussusception using a biological mesh” [1] published in Colorectal Disease. We believe this work is an important addition to the current literature on laparoscopic ventral Mesh rectopexy (LVMR) for rectal prolapse; however we do have a few remarks on this manuscript. This article is protected by copyright. All rights reserved.

<h3>Introduction</h3> Laparoscopic ventral mesh rectopexy (LVMR) is gaining wider acceptance. The aim of this study is to present that LVMR can be learnt and safely performed with short term results similar to that of establish centres <h3>Method</h3> All patients presented with obstructed defecation (ODS) and rectal prolapse from January 2011 to January 2015 underwent anorectal physiology, defecation proctography, colon transit studies, colonoscopy or sigmoidoscopy as appropriate, pelvic floor MDT and biofeedback. Patients with high grade intussusception who did not respond to laxatives and biofeedback were offered LVMR. Surgical technique was as described by A. D’Hoore <i><i>et al</i></i>. and was performed by both authors who are experienced laparoscopic surgeons. We initially used lightweight monofilament polyester mesh (Parietex™) 4 × 20 cm. This was later changed to Titanium coated lightweight polypropylene mesh (TiLENE®) 4 × 20 cm or 4 cm × 18 cm × 1 mm biological mesh (Permacol™) in young patients. Suturing was Intracorporeal and Ethibond Excel®2/0 was used to attach the mesh to the rectum. Vicryl® 2/0 was used for Colpopexy and ProTack™ 5mm for attaching the mesh to the sacral promontory. Data concerning demographics, operative data, complications, length of stay, recurrence and patient reported outcome were gathered from a prospective data base. Data are presented as median, range and proportions. <h3>Results</h3> Median age, ASA and BMI were 60.5 (34–78), 2 (1–3), 26.1 (20.4–33.1). Previous pelvic surgery included hysterectomy (35%), Vaginal wall repair (15%) and rectal prolapse surgery (20%). 2 patients had undergone Delorme’s procedure whereas 2 patients had previous laparoscopic suture rectopexy. 60% had Oxford prolapse grades 3/4 and rest were grade 5. Enterocele (25%), Rectocele (40%) and Middle compartment prolapse (5%) were associated. Median operative time was 229 min (175–330). Synthetic mesh was used in 16 patients (Parietex 30%, TiLENE 50%) and Permacol in 4(20%). Colpopexy was performed in 90%. 30 day mortality was zero. There were no conversions and overall complication rate was 10% (1 wound infection and 1 port site hernia). No intraoperative complications, mesh related complications or sexual dysfunction were reported. Median length of stay was 3(2–6). 17 patients (85%) had 6 months or more follow up. Median patient reported outcome for satisfaction was 9.5 on a scale of 1 to 10(2–10). One patient developed recurrence of ODS after 1 year. One patient (Permacol) developed recurrent prolapse as well as anterior and posterior vaginal prolapse after 6 months. <h3>Conclusion</h3> We suggest that experienced laparoscopic surgeons can learn and safely perform laparoscopic ventral mesh rectopexy <h3>Disclosure of interest</h3> None Declared.