V67 - Robotic mesh sacral pexy for recurrent neorectum prolapse after failed perineal repair

CME Eligible

Purpose/Background: Neorectum prolapse after rectal cancer surgery has a reported incidence of 1.3% to 8%. There are only sporadic reports and small case series addressing the problem and most are managed almost exclusively by a perineal approach. Recurrent neorectal prolapse following prior perineal repair has rarely been reported and poses a reconstructive challenge due to altered pelvic anatomy and adhesions. Robotic mesh sacral pexy offers enhanced visualization and dexterity for precise dissection and secure pelvic fixation.

Methods/Interventions: The patient Is a 69 year old female with recurrent neorectum prolapse. She underwent robotic ultra-low anterior resection with partial intersphincteric resection 2 years ago for rectal cancer 3cm from anal verge. She presented with neorectum prolapse after ileostomy reversal for which she underwent a perineal mucosal sleeve resection (Delorme procedure) a year prior. The patient had recurrence of full thickness neorectum prolapse and hence was prepared for robotic ventral mesh sacral pexy.

The patient is placed in Lloyd-Davies position in Trendelelnberg and slight rightward tilt. After bowel positioning, the uterus is hitched to the anterior abdominal wall. Adhesiolysis was performed, aiming to straighten and reduce the prolapsed neorectum. Careful mobilization was performed down to the pelvic floor and at the neorectum-vaginal interface. Dissection was performed just enough to reduce and straighten the neoectum from the pelvis without unnecessary mobilization of the mesocolon. Because of loss of native peritoneum from prior surgery, a peritoneal flap was developed along the right pelvic wall to cover the mesh after fixation. A biologic mesh (15cm x 3cm) was placed on the anterior aspect of the neorectum, extending to the most distal point of dissection. The mesh was secured to the neorectum using long-term absorbable monofilament sutures in rows of 2 along the edge of the mesh. The mesh was then fixed proximally to the sacral promontory with nonabsorbable sutures. The mesh was reperitonealized using the previously developed flap. Final inspection confirmed a fully reduced and straightened neorectum within the pelvis.

Results/Outcomes: The patient recovered uneventfully, resumed bowel movements and was discharged on postoperative day two. At one month follow-up, there was no note of recurrence and with markedly improved Wexner incontinence scores.

Conclusion/Discussion: In conclusion, recurrent neorectal prolapse after perineal repair is a challenging scenario that requires meticulous surgical planning. Robotic mesh sacral pexy offers a safe, precise, and effective salvage approach that restores durable pelvic support while minimizing morbidity.