Pelvic floor disorders affect 24% of women in the United States. A weakened pelvic floor and poor structural support can result in the simultaneous prolapse of both the rectum and pelvic organs. Although the incidence of concomitant rectal and pelvic organ prolapses is uncommon, reconstructive pelvic surgeons in conjunction with colorectal surgeons have pioneered surgical techniques to correct both during a combined multidisciplinary operation. Surgeons have previously described using open abdominal, laparoscopic, vaginal, and transperineal approaches to simultaneously address multi-compartment prolapse. Although data remain limited, initial studies suggest a combined surgical procedure is both safe and effective. Sacroculpoperoneopexy with concomitant ventral rectopexy attaches the vaginal apex, peroneal body, pubococcygeus muscles of the levator ani complex, peroneum, and anterior rectum to the anterior longitudinal ligament of the sacrum using a combination of macroporous lightweight polypropylene mesh and an eight-ply quilted porcine submucosal intestinal xenograft. The goals of the operation are to restore normal anatomy and to reestablish normal urinary, defecatory, and sexual function. The objectives of our video are to demonstrate the surgical technique for performing a robotic sacroculpoperoneopexy with concomitant ventral rectopexy and to identify the key anatomic landmarks critical to safely performing the procedure. The following is our approach to trocar placement. After the umbilical trocar is introduced, two 8-millimeter robotic trocars are placed 9 to 10 centimeters lateral and 15 degrees caudal to the umbilicus bilaterally. A third robotic trocar corresponding to the fourth robotic arm is placed 9 to 10 centimeters lateral and 45 degrees cephalad to the ipsilateral trocar on the patient's left side. A fifth 10-millimeter conventional laparoscopic port is often introduced for use by the first assistant. The angles and distances between robotic trocars are crucial to preventing collision of the robotic arms. We now routinely dock the robot on the patient's left side. This allows for the use of a second surgical assistant who is critical to elevating and separating the vagina from the rectum during the rectovaginal dissection. An understanding of the anatomy of the pelvic floor is critical to safely performing the surgery. In this illustration, the muscles of the pelvic floor are clearly visualized. Unique to this surgery is the extensive rectovaginal dissection, which is carried down to the level of the perineal body. By attaching the graft distally to the perineal body, pubococcygeus muscles of the levator anti-complex and anterior rectum, then securing it proximally to the sacrum, reduction of the rectal prolapse can be achieved. An examination under anesthesia reveals the extent of the rectal and pelvic organ prolapse. The presacral space is dissected until the anterior longitudinal ligament overlying the sacrum is visualized. The perineal incision is extended caudal towards the vaginal apex. The rectovaginal dissection is performed using a combination of blunt and sharp dissection. One EEA sizer is placed in the vagina and a second in the rectum to clearly delineate the rectovaginal septum. Unique to this procedure is the rectal mobilization. The rectovaginal dissection is carried caudal to the level of the perineal body. Care is taken to avoid transection of the lateral ligaments of the rectum, which contribute to the support and function of the rectum. With gentle pressure placed on the perineum by the second surgical assistant and an EEA sizer in the rectum, the perineal body and pubococcygeus muscles of the levator ani complex are clearly visualized and completely dissected. The vesicovaginal dissection is performed using standard techniques. Next, an 8 by 15 piece of 8-ply quilted porcine submucosal intestinal xenograft is introduced. It is cut into the shape of a trapezoid. The most distal aspect of the graft is attached to the perineal body, followed by the pubococcygeus muscles bilaterally and the anterior rectal muscularis. The most distal aspect of the graft is attached to the perineal body using delayed absorbable suture. Interrupted stitches attach the graft to the pubococcygeus muscles. With an EEA sizer in the rectum to delineate the lateral margins of the rectum, interrupted stitches attach the graft to the anterior rectal muscularis bilaterally. With two interrupted stitches in each row, multiple rows secure the graft in place. Next, a 4 by 15 piece of macroporous lightweight polypropylene mesh is introduced and attached to the anterior vaginal apex using a technique standard to sacrocopalpexy. With EEA sizers in the rectum and vagina, the vaginal apex and rectum are elevated to ensure proper tensioning and reduction of the prolapse. The polypropylene mesh and the graft are secured to the anterior longitudinal ligament using permanent suture. A second stitch is placed to further secure the mesh to the sacrum. The mesh is retroperitonealized using a barbed, bidirectional, delayed absorbable suture. Once hemostasis is confirmed, cystoscopy is performed to ensure bladder integrity and confirm ureteral patency. The ports are closed using standard laparoscopic techniques. Since 2009, we have safely performed this operation on 10 patients. There have been no conversions to conventional laparoscopy or laparotomy. Preliminary analysis of our data reveal favorable objective and subjective outcomes with minimal morbidity. In conclusion, concomitant rectal and pelvic organ prolapse can be safely treated with a combined surgical operation. A multidisciplinary team improves the surgical outcomes for these patients. Public assistance facilitates the technical aspects of the surgery.

pelvic floor disorders

prolapse

rectum

pelvic organs

surgical technique