VA104 - Robotic Repair of Enterocele with Ventral Mesh Rectopexy

Purpose/Background: This video illustrates a robotic repair of enterocele with ventral mesh rectopexy.

The patient is a 78yo female with remote history of pelvic organ prolapse repair. More recently, she underwent a primary repair of enterocele, with early recurrence at 4 month followup

She presented with large pelvic hernia extending to the right labia with significant rectal prolapse as confirmed on MRI

Methods/Interventions: Decision was made to proceed with a multidisciplinary surgical approach. Mechanical bowel preparation with oral antibiotics was administered the day before surgery.

Intravenous antibiotics and DVT prophylaxis were given preoperatively

A 4 robotic arms approach was elected with an assistant 5mm port.

Laparoscopic access to the abdomen is obtained and exposure achieved by placing the patient in Trendelenburg position. The herniated small bowel is reduced with autraumatic graspers. The sigmoid colon is released from pelvic adhesions bluntly and sharply. The left ureter is clearly identified and preserved.

The large defect in the perineal body is shown here

The rectum is grasped and gently retracted cranially and to the left.

Starting at the pelvic brim, the peritoneum overlying the sacral promontory is scored taking care to preserve the hypogastric nerve. This dissection is carried distally to the anterior reflection. The peritoneum is scored and dissected off the vaginal cuff with a combination of blunt and sharp dissection. This is made particularly difficult by the dense fibrosis. The dissection is carried all the way down to the perineal body and the sac is transected anteriorly at the level of the defect. Proper identification of the rectum is confirmed by digital exam. The hernia sac is dissected off the levator plate bilaterally, which is confirmed by noting the skeletal muscle response to cautery on the levator plate. The sac is then dissected off the anterior rectal wall, avoiding injuries to the bowel wall. Once the dissection is completed, attention is turned to the perineum. The redundant skin with the subcutaneous portion of the sac is excised and the defect in the perineal body is reapproximated in a transverse fashion with interrupted sutures.

The repair is reinforced internally with a running barbed permanent suture.

Next, a piece of microporous polypropylene mesh is selected and trimmed to 4 x 4 cm on the distal enlargement tapering to 2 cm at the promontory. This is secured distally into the rectovaginal septum with Two stabilizing permanent sutures into the levator plate on the left and right and 3 rows of partial thickness absorbable sutures on the anterior rectum.. After selecting the appropriate amount of tension, the mesh is then secured to the sacral promontory using two permanent sutures, taking care to avoid the sacral veins as well as the hypogastric nerves. The right ureter is clearly visualized through this portion of the procedure. Flexible sigmoidoscopy is then performed to rule mucosal violation.

Lastly the hernia sac is excised and the physiologic peritoneal reflection is restored with a running absorbable barbed suture. Care is taken to avoid including the mesh in the sutures and, along the right lateral aspect, to prevent injuries to the right ureter.

A transversus abdominis plane (TAP) block is performed under vision.

Results/Outcomes: Procedure was uneventful. Patient was discharged on postoperative day 2 and is recurrence-free at 1 month follow up.

Conclusion/Discussion: The robotic approach is safe and effective for the repair of large enterocele with rectal prolapse

Pelvic anatomy
Diagram of the pelvic anatomy at the end of the dissection
Enterocele
Large enterocele