Robotic-Assisted Laparoscopic Rectal Prolapse Repair in a Patient with Indiana Pouch.

Abstract

Study Objective To highlight the surgical techniques for ventral rectopexy with sacrocolpopexy in the face of extensive abdomino-pelvic adhesions and to present the use of strattice reconstructive tissue matrix as a viable option in a patient with significant previous abdominal surgeries and decreased peritoneum available for mesh coverage. Design Surgical video presentation. Setting Academic tertiary care center. Patients or Participants We present a 26-yo nulliparous patient with recurrent rectal prolapse. She had failed a previous rectopexy repair 4 years prior. Her medical history is significant for Ehlers Danlos Syndrome, chronic pelvic pain and interstitial cystitis refractory to medical management. This prompted surgical interventions in the form of hysterectomy with bilateral salpingectomy, cystectomy and creation of an Indiana Pouch. Interventions Evaluation with a dynamic MRI proctogram showed pelvic floor laxity with a moderate anterior rectocele and large enterocele. At laparoscopy there was significant adhesions of omentum and bowel to the anterior abdominal wall, extending into the pelvis. Careful lysis of adhesions was started laparoscopically in order to create safe entry points for the robotic trocars and to delineate the anatomical landmarks for the rectopexy and sacrcolpopexy. Prolene mesh was secured to the exposed levator ani muscles, attached to the rectal wall and then extended to the sacral promontory. Strattice mesh was then fashioned and extended from the back of the pubic symphysis to the sacral promontory. Measurements and Main Results The patient was discharged on post op day 1 and at her postoperative review she was recovering well with no bowel dysfunction or rectal prolapse symptoms. Her Indiana Pouch remained functional. Conclusion The safety and feasibility of a robotic-assisted laparoscopic rectopexy was demonstrated in this surgical video even with extensive pelvic adhesive disease. Strattice matrix can safely be used to separate Prolene mesh from the intra-abdominal contents therefore, minimizing postoperative morbidity and increasing the chances of good functional outcomes. To highlight the surgical techniques for ventral rectopexy with sacrocolpopexy in the face of extensive abdomino-pelvic adhesions and to present the use of strattice reconstructive tissue matrix as a viable option in a patient with significant previous abdominal surgeries and decreased peritoneum available for mesh coverage. Surgical video presentation. Academic tertiary care center. We present a 26-yo nulliparous patient with recurrent rectal prolapse. She had failed a previous rectopexy repair 4 years prior. Her medical history is significant for Ehlers Danlos Syndrome, chronic pelvic pain and interstitial cystitis refractory to medical management. This prompted surgical interventions in the form of hysterectomy with bilateral salpingectomy, cystectomy and creation of an Indiana Pouch. Evaluation with a dynamic MRI proctogram showed pelvic floor laxity with a moderate anterior rectocele and large enterocele. At laparoscopy there was significant adhesions of omentum and bowel to the anterior abdominal wall, extending into the pelvis. Careful lysis of adhesions was started laparoscopically in order to create safe entry points for the robotic trocars and to delineate the anatomical landmarks for the rectopexy and sacrcolpopexy. Prolene mesh was secured to the exposed levator ani muscles, attached to the rectal wall and then extended to the sacral promontory. Strattice mesh was then fashioned and extended from the back of the pubic symphysis to the sacral promontory. The patient was discharged on post op day 1 and at her postoperative review she was recovering well with no bowel dysfunction or rectal prolapse symptoms. Her Indiana Pouch remained functional. The safety and feasibility of a robotic-assisted laparoscopic rectopexy was demonstrated in this surgical video even with extensive pelvic adhesive disease. Strattice matrix can safely be used to separate Prolene mesh from the intra-abdominal contents therefore, minimizing postoperative morbidity and increasing the chances of good functional outcomes.