The patient is a 69-year-old female with complaints of pelvic pressure. She has a remote history of a vaginal hysterectomy. Recently, she underwent repair of a rectal prolapse via a perineal approach. On exam, however, she had recurrent rectal prolapse, as well as a rectocele and mild ball prolapse. She was brought to the operating room for a combined laparoscopic repair of her pelvic flora defects. A lathotomy position is preferred. The combined approach uses a right upper quadrant 5mm trocar, a left lower quadrant 11mm trocar, an inframedical camera trocar, and a left lower quadrant 5mm trocar. Access is gained with a varus needle and an optical view trocar. Here we see the rectum and in an extremely deep cul-de-sac, as well as the sacral promontory and the IMA pedicle. The first step is to expose the sacral promontory by scoring the peritoneum at the sacral promontory. The goal is not to do a posterior mobilization of the rectum. It is important to mobilize the upper rectum and peritoneum so the mesh may be covered at the end of the case. While not entirely necessary, here we've exposed the left ureter and left iliac. The dissection is carried down along the right side of the rectum using traction-counter-traction. When using a combined repair, the initial mesh placement is on the anterior rectum. Here we are using oethobond plegited sutures in a horizontal mattress fashion. We are using a monofilament polypropylene mesh cut to 8 by 3 centimeters. The bites in the rectum are seromuscular. A knot pusher is used to secure the knots. Three rows of two sutures are placed and the mesh will be secured ultimately to the sacral promontory. With the mesh secured to the rectum, attention is turned to securing the mesh to the posterior aspect of the vagina. As the knots are secured, the codisac is obliterated. The obliterated codisac can be visualized here. With an EEA scissor in the vagina, further sutures are needed to secure the mesh along the back of the vaginal wall. In patients with anterior vaginal wall prolapse, additional mesh may be placed along the anterior wall of the vagina after mobilization of the bladder. The mesh should be placed relatively tension free. Here it is being secured to the previously exposed sacral promontory using oethabond in a horizontal mattress fashion. As you can see, there is a good bite through the ligament. An additional suture is placed adjacent to the previously placed suture. The mesh is covered with the previously mobilized perineum. This is done using 3-O-Vicryl in a figure of eight fashion. As the mesh is on the anterior surface of the rectum, the remaining perineum is brought up and over the mesh and secured to the perineum over the bladder. You can see there is no twisting or twerking of the rectum.

pelvic pressure complaints

laparoscopic approach

recurrent rectal prolapse

rectocele

mesh placement