Case Study By Marissa Anderson, MD
Case Study By Marissa Anderson, MD
A female patient in her 20s has a history of bulimia nervosa and was referred to Rush for evaluation of rectal prolapse. She has had a lap appendectomy. She has a history of bulimia nervosa, which was treated a few years ago with improvement.
The patient states that about one month prior to seeing me that she had a bout of constipation following a diarrheal illness; after, she noticed a painless tissue protrusion, which reduced spontaneously. She said this has happened with many bowel movements since then.
The patient brought photo documentation, which showed a full-thickness prolapse. The patient had a presurgical colonoscopy to rule out lesions as a cause for prolapse, which came back normal.
The patient was a candidate for either robotic suture rectopexy or robotic ventral mesh rectopexy, and she opted for the ventral mesh transabdominal repair.
The patient underwent surgery using the da Vinci Xi robot. Four 8mm incisions were used. The operation took approximately 90 minutes.
The peritoneum was incised down to the anterior peritoneal reflection. The mesorectum was mobilized laterally off the pelvic sidewall. The right ureter and pelvic veins were preserved. The pouch of Douglas was then dissected down to the levator muscles, and care was taken to not injure the rectum or vagina.
Scar and nodularity were noted at the upper aspect of the pouch of Douglas, with a 5-mm nodular bluish lesion, which was concerning for endometriosis. This was excised with the robotic monopolar scissors and sent to Pathology for diagnosis.
A Gore Dual mesh was cut in a hockey-stick configuration and placed into the abdomen. The mesh was secured to the serosa of the distal rectum with six interrupted 3-0 Vicryl sutures. The proximal end of the mesh was secured to the sacral promontory with several interrupted 0-Ethibond sutures. The peritoneal defect was closed with absorbable V-Loc suture to protect the viscera from exposure to the mesh. The patient tolerated the procedure well.
The patient was observed overnight and discharged the morning after her operation. She was advised to supplement her diet with fiber and to use stool softeners and laxatives as needed.
Robotic-assisted ventral mesh rectopexy (VMR) is a safe and effective procedure for managing rectal prolapse. It provides significant symptomatic relief for patients, offering low recurrence rates and minimal morbidity.
VMR allows many patients to recover quickly with minimal disruption to their daily lives. This innovative approach is particularly beneficial for treating rectal prolapse, internal intussusception and large rectoceles, addressing debilitating symptoms like constipation and obstructive defecation.
Additionally, the use of bioabsorbable mesh is a safe option that may reduce mesh erosion while maintaining low long-term recurrence rates as compared to traditional suture rectopexy. Diseases of the Colon & Rectum has recently published expert consensus guidelines that support the performance of minimally invasive ventral mesh rectopexy for both primary and recurrent prolapse in male and female patients, with consideration of alternative approaches in selected cases.
