Tunneling of Mesh during Ventral Rectopexy: Technical Aspects and Long-Term Functional Results

Abstract

Avoiding the extensive damage of pelvic structures during ventral rectopexy could minimize secondary disfunctions. The objective of our observational study is to assess the safety and functional efficacy of a modified ventral rectopexy. In the modified ventral rectopexy, a retroperitoneal tunnel was created along the right side of rectum, connecting two peritoneal mini-incisions at the Douglas pouch and sacral promontory. The proximal edge of a polypropylene mesh, sutured over the ventral rectum, was pulled up through the retroperitoneal tunnel and fixed to the sacral promontory. In all patients, radiopaque clips were placed on the mesh, making it radiographically "visible". Before surgery and at follow up visits, Altomare, Longo, CCSS, PAC-SYM, and CCFI scores were collected. From March 2010 to September 2021, 117 patients underwent VR. Modified ventral rectopexy was performed in 65 patients, while the standard ventral rectopexy was performed in 52 patients. The open approach was used in 97 cases (55 and 42 patients in modified and standard VR, respectively), while MI surgery was used in 20 cases (10 and 10 patients in modified and standard VR, respectively). A slightly shorter operative time and hospital stay were observed following modified ventral rectopexy (though this was not statistically significant). Similar overall complication rates were registered in the modified vs. standard ventral rectopexies (4.6% vs. 5.8%, p = 0.779). At follow-up, the Longo score (14.0 ± 8.6 vs. 11.0 ± 8.2, p = 0.042) and "delta" values of Altomare (9.2 ± 6.1 vs. 5.9 ± 6.3, p = 0.008) and CCSS (8.4 ± 6.3 vs. 6.1 ± 6.1, p = 0.037) scores were significantly improved in the modified ventral rectopexy group. A similar occurrence of symptoms recurrence was diagnosed in the two groups. Radiopaque clips helped to accurately diagnose mesh detachment/dislocation. The proposed modified VR seems to be feasible and safe. Marking the mesh intraoperatively seems useful.

Keywords: fecal incontinence; obstructed defecation syndrome; pelvic disorders; rectal prolapse; ventral rectopexy.

Figure 1

Peritoneal incisions were performed at the pouch of Douglas (a,b) and sacral promontory (c,d) in open and robotic surgery.

Figure 2

A retroperitoneal tunnel was created in open (a) and robotic (b) surgery.

Figure 3

The mesh was sutured over the ventral rectum with three couples of 3-0 PDS stitches in open (a) and robotic (b) surgery. Two radiopaque clips were positioned at the distal edge of the mesh (circles).

Figure 4

Comparison between postoperative values of clinical scores in patients who underwent standard vs. modified ventral rectopexy (Mann–Whitney U test). Altomare = Altomare score; Longo = Longo score; CCSS = Cleveland Clinic Constipation Scoring System; PACSYM = Patient Assessment of Constipation-Symptoms questionnaire; CCFI = Cleveland Clinic Fecal Incontinence score.