Mesh invasion of the rectum: an unusual late complication of rectal prolapse repair

From intraperitoneal onlay mesh repair to preperitoneal onlay mesh repair

Laparoscopic repair for ventral and incisional hernias was first reported in the early 1990s. It uses intraperitoneal only mesh placement to achieve a tension-free repair of the hernia. However, in recent years, there has been greater concern about long-term complication involving intraperitoneal mesh placement. Many case reports and case series have found evidence of mesh adhesion, mesh fistulation, and mesh migration into hollow organs including the esophagus, small bowel, and large bowel, resulting in various major acute abdominal events. Subsequent management of these complications may require major surgery that is technically demanding and difficult; in such cases, laparotomy and bowel resection have often been performed. Because of these significant, but not common, adverse events, many surgeons favor open sublay repair for ventral and incisional hernias. Investigators are therefore searching for a laparoscopic approach for ventral and incisional hernias that might overcome the mesh-induced visceral complications seen after intraperitoneal only mesh placement repair. Laparoscopic preperitoneal onlay mesh is one such approach. This article will explore the fundamental of intraperitoneal only mesh placement and its problems, the currently available peritoneal visceral-compatible meshes, and upcoming developments in laparoscopic ventral and incisional hernia repair. The technical details of preperitoneal onlay mesh, as well as its potential advantages and disadvantages, will also be discussed.

Laparoscopic Rectopexy for Rectal Prolapse: Will it be the Gold Standard?

A review of the current literature is presented regarding the surgical management of full thickness rectal prolapse, comparing laparoscopic rectopexy with open abdominal operations and perineal procedures. Outcome measures include length of stay, short- and long-term outcomes and financial burdens. Current evidence suggests that laparoscopic rectopexy as treatment for full thickness rectal prolapse is a safe alternative to the other options.

Mesh-free Ventral Rectopexy for Women with Complete Rectal and Uterovaginal Prolapse

Background:

Mesh rectopexy may be associated with infective complications, erosion into the vagina or rectum, and disintegration or dislodgement. A mesh-free rectopexy will avoid these complications. Objective of the study was to perform mesh-free ventral rectopexy and assess its safety and effectiveness.

Materials and Methods:

Nine women with complete rectal and uterovaginal prolapse were treated with total abdominal hysterectomy, closure of the vaginal vault, extirpation of the pouch of Douglas and suture of anterior rectal wall to the posterior vaginal wall (ventral suture rectopexy). The ventral suture rectopexy was achieved by three pairs of interrupted silk sutures, 2.5 cm above each other, and the first pair very close to the pelvic floor. This composite structure (anterior rectal wall and posterior vaginal wall), sits astride the perineal body. Intussusception and subsequent prolapse of the sutured rectum and vaginal wall is prevented. Vaginal vault prolapse was prevented by the suture of each round ligament of the uterus to the corresponding lateral vaginal fornix. No mesh was used.

Results:

Nine multiparous women aged between 52 and 70 years had the procedure. The mean operative time was 135 minutes (range 110-220). The follow-up period was between 29 months and 7 years. Full continence was restored in all patients within eight weeks of the operation. Bowel habit returned to once daily in four patients and once every other day in the remaining five patients, within thirteen weeks of surgery. One patient had intermittent mucus discharge per rectum for six months. This stopped without a specific treatment. There has been no known recurrence in these nine patients. One patient developed wound infection as a complication. There was no mortality. All the patients are now asymptomatic.

Conclusion:

Ventral suture rectopexy is a safe and effective treatment for complete rectal prolapse in a selected group of patients.

Common transabdominal surgical options for rectal prolapse

Rectal prolapse is a troublesome anorectal disorder. Surgical procedures for rectal prolapse contain transabdominal and transperineal approaches. There are hundreds of transabdominal procedures currently available for treatment of the disease, such as Ripstein procedure, Wells procedure, Orr procedure, Nigro procedure, anterior resection, Frykman-Goldberg procedure, and Roscoe Graham procedure. Laparoscopic repair represents the latest advance in surgical treatment of rectal prolapse. As each procedure has its strength and weakness, personalized selection of appropriate procedure can greatly improve surgical outcome. Individualized diagnosis and treatment plan may represent a new direction for transabdominal surgical treatment of rectal prolapse.