Overview
Definition:
Laparoscopic Ventral Mesh Rectopexy (LVMR) is a minimally invasive surgical procedure performed to correct significant rectal prolapse
It involves the fixation of the posterior aspect of the rectum to the sacral promontory using a synthetic mesh, thereby restoring anatomical support and preventing further descent.
Epidemiology:
Rectal prolapse, while not exceedingly common, affects a notable proportion of the population, with a higher incidence in multiparous women, the elderly, and those with chronic constipation or straining
The prevalence of symptomatic pelvic organ prolapse, often co-existing with rectal prolapse, is significant and impacts quality of life.
Clinical Significance:
Undiagnosed or untreated rectal prolapse can lead to debilitating symptoms such as fecal incontinence, constipation, tenesmus, and rectal bleeding
LVMR offers a durable and effective solution for selected patients, improving functional outcomes and significantly enhancing patient quality of life
Understanding this procedure is crucial for surgical residents preparing for DNB and NEET SS examinations.
Indications
Patient Selection:
Patients with symptomatic full-thickness rectal prolapse, particularly those with associated rectocele or enterocele, and who are candidates for abdominal surgery are typically considered
Absolute indications include prolapse causing severe symptoms like fecal incontinence or intractable constipation.
Contraindications:
Absolute contraindications include unresectable malignancy of the rectum or pelvis, active pelvic infection, and patients unfit for general anesthesia
Relative contraindications include severe comorbid conditions that significantly increase surgical risk, and significant cognitive impairment that may affect postoperative compliance.
Specific Indications:
Significant full-thickness rectal prolapse impacting daily life
Failure of conservative management
Association with rectocele or enterocele contributing to defecatory dysfunction
Absence of significant anal sphincter dysfunction or irreparable sphincter damage as the primary cause of incontinence.
Preoperative Preparation
Patient Assessment:
Comprehensive history focusing on bowel habits, fecal incontinence, straining, and quality of life
Detailed physical examination, including digital rectal examination to assess the degree of prolapse and resting anal tone
Assessment for co-existing pelvic organ prolapse (cystocele, uterine prolapse).
Investigations:
Endoanal ultrasound to assess sphincter integrity
Defecography to confirm rectal prolapse and evaluate anorectal function
Colonoscopy to rule out underlying colonic pathology
Routine blood work, ECG, and chest X-ray as per standard surgical protocols.
Bowel Preparation:
Mechanical bowel preparation with clear fluids and laxatives for 24-48 hours preoperatively
Prophylactic antibiotics are administered intravenously prior to incision, typically a broad-spectrum agent such as a cephalosporin or a combination of a cephalosporin and metronidazole.
Procedure Steps
Laparoscopic Approach:
The procedure is typically performed under general anesthesia using a laparoscopic approach with 4-5 trocars placed in the abdomen (umbilical, suprapubic, bilateral paracolic).
Dissection And Mesh Placement:
Creation of a dissection plane posterior to the rectum, extending from the peritoneal reflection down to the levator ani muscles
Mobilization of the posterior rectal wall
Placement of a large, synthetic, non-absorbable mesh (e.g., polypropylene) covering the posterior rectal wall and extending to the sacral promontory.
Fixation And Closure:
The mesh is secured to the anterior longitudinal ligament overlying the sacrum using sutures or tacks
Careful attention is paid to avoid injury to the sacral nerves and the mesorectal vasculature
The mobilized anterior rectal wall is then brought forward and sutured to the mesh, creating a shelf-like support
The abdominal ports are closed, and the specimen, if any, is removed through the umbilical port.
Postoperative Care
Pain Management:
Adequate analgesia is provided, including patient-controlled analgesia (PCA) if necessary
Epidural anesthesia can also be used for postoperative pain control.
Bowel Management:
Early mobilization is encouraged
Patients are typically placed on a soft diet and stool softeners are prescribed to prevent straining
Regular bowel movements are monitored
Opioid analgesics are used cautiously due to their constipating effect.
Monitoring And Discharge:
Vitals, urine output, and abdominal distension are monitored
Patients are typically discharged within 2-4 days if they are ambulating, tolerating a diet, and have adequate pain control
Follow-up appointments are scheduled to assess wound healing and functional outcomes.
Complications
Early Complications:
Bleeding from dissection sites or mesh fixation
Infection of the surgical site or mesh
Injury to surrounding structures (sacral nerves, ureters, bowel)
Ileus
Urinary retention.
Late Complications:
Mesh erosion into the rectum or vagina
Chronic mesh infection
Rectal obstruction due to mesh contraction
Recurrence of prolapse
Fistula formation
Chronic pain.
Prevention Strategies:
Meticulous surgical technique to minimize tissue damage
Careful handling and secure fixation of the mesh
Use of appropriate mesh material and size
Judicious use of antibiotics
Close postoperative monitoring for early signs of complications.
Prognosis
Success Rates:
LVMR has demonstrated high success rates in terms of prolapse recurrence and improvement in symptoms like constipation and incontinence, with recurrence rates generally reported between 2-10% in the long term.
Functional Outcomes:
Significant improvement in fecal incontinence and constipation is typically observed
Patient satisfaction is generally high due to improved bowel function and quality of life.
Long Term Follow Up:
Regular follow-up is essential, especially in the first year, to monitor for recurrence and late complications
Patients are advised to maintain healthy bowel habits and avoid excessive straining
Long-term surveillance may involve physical examination and patient questionnaires.
Key Points
Exam Focus:
LVMR is indicated for full-thickness rectal prolapse with associated rectocele/enterocele, aiming for anatomical restoration and functional improvement
Key surgical steps involve posterior dissection, mesh placement, and fixation to the sacrum
Complications include mesh-related issues and recurrence.
Clinical Pearls:
Always consider co-existing pelvic organ prolapse in women
Defecography is crucial for accurate diagnosis and understanding anorectal dynamics
Careful dissection to avoid sacral nerve injury is paramount.
Common Mistakes:
Inadequate mobilization of the rectum
Improper mesh placement or fixation leading to recurrence or erosion
Overlooking or undertreating associated rectocele or enterocele
Inadequate bowel preparation leading to postoperative complications.