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What is a laparoscopic ventral mesh rectopexy?

The term “rectopexy” refers to an operation in which the rectum (the part of the bowel that is nearest the anus) is put back into its normal position in the body.

When is laparoscopic ventral rectopexy performed?

The most common reason for a ventral mesh rectopexy (‘VMR’ for short) is to repair an external rectal prolapse (bowel coming out through the anus). Another reason for surgery is internal prolapse or “intussusception” when the rectum ‘telescopes’ in on itself, without coming out of the anus. This may cause obstructive defaecation syndrome (ODS), a sensation of a blockage in the bowel, difficulty in passing a motion (having a poo) and prolonged, often unsuccessful visits to the toilet. It can also mean you need to apply pressure with a finger or hand on the perineum (skin between the vagina/testicles and the anus), in the vagina or the anus to empty your bowels. Internal rectal prolapse sometimes also causes faecal incontinence (when you are unable to hold a bowel movement in).

What other tests will I need before the operation?

We will need to see you in clinic to assess your symptoms and to perform an examination. Most patients who have this operation will have an endoscopic (telescope) test on the bowel. We may also look at how well the back passage muscles (anal sphincter muscle) work using manometry (to assess the strength of the sphincter muscles) and an ultrasound scan to look at the sphincter muscles. We may also assess the motility of the gut with an X-ray (slow transit study). This is because some patients who have obstructive defecation syndrome (ODS) could have a slow colon which if not managed, could affect the results of the operation. These tests are helpful to check that having a laparoscopic ventral rectopexy is right for you.

What does the operation involve?

The operation is laparoscopic (keyhole surgery) and it involves a little cut just below the umbilicus (belly button) and two other small cuts on the right side of the tummy. There may be another small cut on the left side of the tummy. It is performed under general anaesthetic (whilst you are asleep) and usually takes about two-three hours.

This operation pulls the bowel up out of the pelvis and a mesh is put in place to hold the bowel in its normal place in the abdomen. The mesh will also prevent it from prolapsing back down into the pelvis (intussusception).

The mesh we use is biological tissue which allows your own tissue to grow onto the mesh. It has a much better safety profile compared to synthetic or man-made mesh.

What is the recovery like after surgery?

After the operation you will have a urinary catheter in place (a tube into your bladder) and a drip in your arm. You will be allowed to eat and drink as soon as you want to after the operation, and your drip will be removed once you are drinking enough. Your anaesthetist will talk about pain control with you before the operation, but usually painkilling tablets and liquids will be enough. Please be aware that medication containing codeine is likely to cause some constipation.

Usually, early on the morning after your operation your catheter will be removed, and you can walk to the toilet to pass urine. You may be able to go home the same day of the operation, in which case it will be removed in theatre. It is important to avoid constipation and straining in the first few weeks after surgery. We will give you laxatives to take (usually Laxido) until you are reviewed in the clinic.

You should be fit to drive after a week and return to work after 2-4 weeks. You should not lift anything heavier than a full kettle for at least 6 weeks as this can cause excess strain on the pelvic floor muscles and can delay healing; this includes supermarket shopping, housework, lifting children and sports.

What are the results like from surgery?

If the operation is performed due to an internal prolapse, obstructed defaecation syndrome or faecal incontinence, about 4 out of 5 patients report a significant improvement in their symptoms.

Unsuccessful outcomes

• Operation makes no difference to symptoms (about 1 in 5 or 20%).

• Prolapse recurs (about 1 in 5 or 20%)

• Constipation gets worse not better (very uncommon).

Specific complications

• Bowel leakage (incontinence) is not resolved, or can become worse, especially if the surgery is for an external prolapse. Occasionally new-onset incontinence can occur    (uncommon).

• Bleeding (rarely significant).

• Vaginal or rectal injury requiring repair (rare). A vaginal injury can be safely repaired but an injury to the rectum may result in an infection requiring a stoma.

• Infection (1-2%).

• Urinary retention (<10%) or worsening of urinary incontinence.

• Mesh erosion (where the mesh wears away surrounding tissue) (2-3%).

• Sexual dysfunction in men (rare).

• Severe constipation (rare).

• Pain during sexual intercourse (uncommon and usually gets better with time).

• Infection of the sacrum (inflammation of one of the discs of the spine) (rare).

• A false passage between the rectum and the vagina (fistula). The false passage may allow bowel gas and content to pass through the front passage. This can be corrected with a further operation (rare).

• Injury to other abdominal structures (rare).

• Pelvic pain and / or back pain.

• Blood clots in the legs / lungs (thrombosis) (rare).

This is relatively low risk surgery because no bowel is removed. With ventral rectopexy, the nerves are avoided, and constipation only very rarely gets worse. Most patients with pre-existing constipation report that this improves after ventral rectopexy. Some patients with obstructed defaecation and incontinence will not have a significant improvement in their symptoms but are rarely worse after rectopexy. There are small risks of other problems including bleeding, infection, a hernia, or bulge at one of the wounds or a problem with the mesh entering or piercing the bowel or vagina. This can happen months or even years after surgery. A problem with the mesh can occur in about 2-3% (Pelvic Floor Society) and if it does, further surgery may be needed to correct it. You will have the opportunity to discuss all the risks and benefits of the operation with your surgeon before signing the consent form.

Is anyone not suitable for surgery?

We have operated on elderly patients (over 85 years old) with external prolapse with good results, though these patients are at increased risk due to their age. Occasionally it is impossible to perform this operation on patients who have had extensive previous abdominal surgery because of adhesions (scar tissue in the abdomen), though a previous appendicectomy or hysterectomy is not normally a problem.

Is laparoscopic ventral mesh rectopexy better than other prolapse operations?

A laparoscopic (keyhole) procedure leaves less scarring and is less painful than open surgery (a cut down the middle of the tummy). We use mesh as this gives a longer lasting result than not using it. We carefully avoid damaging the important pelvic nerves which can cause constipation. Prolapse rarely comes back after laparoscopic surgery (2%) as opposed to operations through the perineum (10-30%.

Figure 1: Start of a laparoscopic ventral mesh rectopexy. The surgeon retracts the uterus forwards and starts dissection on the front (ventral) part of the rectum, following the red line on this diagram and into the rectovaginal septum (the space between rectum and vagina).

Figure 2: The surgeon creates a pocket between the lower rectum and vagina and the mesh is sutured on to the front of the rectum, whilst the other end is fixed to the sacrum (backbone).

Figure 3: Diagram showing the  rectum telescoping down into itself. In this diagram, this is an internal prolapse though in time,  this may progress to an external         prolapse.

Figure 4: Cross sectional view with the mesh supporting the rectovaginal septum. In this manner a rectocoele (bulge into the vagina) and enterocoele (small bowel coming into the pelvis) are corrected.

DO’s                                             

Do get up and about both during your hospital stay and after going home.

Do take regular laxatives (we usually recommend movicol 1 sachet 3 times a day) to keep your motions soft.

Do gradually reduce your laxatives in the eight weeks after surgery, if your bowels are too loose, remain taking a small dose. Patients differ enormously in their need for laxatives but it is important that for eight weeks, your bowels are on the loose side of normal.

Do take exercise in the form of walking and swimming as soon as comfortable.

Don't 

Do expect that your bowel function will be different after surgery compared to before

Don’t lift anything heavier that a kettle for six weeks after surgery.

Don’t get constipated or strain when on the toilet.

Don’t ignore the urge to go to the toilet.

Don’t be concerned if you do not open your bowel for 4-5 days after surgery. This is quite normal.

Don’t do running or gym work for six weeks after the surgery.

Don’t have sexual intercourse for four weeks after the surgery.

Don’t drive for two weeks after surgery.

Don’t suffer discomfort unnecessarily. You should take paracetamol regularly if needed. This will not cause constipation.