We present an unusual case report of rectal mesh injury that occurred at the time of posterior vaginal mesh placement and specifically how this was repaired. Since the 1970s, gynecologists have been using surgical mesh for the repair of pelvic organ prolapse. Market data from 2010 revealed that 300,000 women underwent surgical procedures to repair pelvic organ prolapse. According to industry estimates, one out of three pelvic organ prolapse surgeries used mesh. In 2010, the FDA conducted a search of the MAW database that revealed 3,979 adverse events associated with urogynecologic surgical mesh products. The common complications of surgical vaginal mesh include mesh erosion with a risk of 10 to 30 percent. Other risks include perioperative risks such as a 1 to 2 percent risk of bladder injury for mesh placed in the anterior compartment and a 0 to 1 percent risk of bowel injury during dissection for mesh placed in the posterior compartment. During our literature search of perioperative and postoperative complications of synthetic vaginal mesh placement, we did not find any reports of penetrating rectal injury at the time of vaginal mesh placement. Our patient is a 41-year-old Gravitatou Peratou who was referred to our institution with multiple complaints following her repair of a rectocele five months prior. A posterior mesh kit was used and her surgery was uncomplicated per the operative report. However, after awakening from surgery, she experienced new onset severe pain radiating down her right leg which significantly limited her mobility for several weeks. She also reported severe pelvic pain, dyspareunia, dyskinesia with new onset fecal incontinence, foul-smelling vaginal discharge, vaginal flatus, and diarrhea. Following a course of physical therapy, she had a moderate improvement in her pain but continued to complain of vaginal and fecal symptoms. At that time, she presented to our institution for a second opinion. Vaginal examination revealed tight mesh arms at the vaginal apex which were tender to palpation, particularly on the right, with no evidence of mesh erosion. However, on rectal exam, mesh could be palpated traversing the rectal lumen approximately six centimeters from the anal verge. Pelvic MRI showed inflammation surrounding the right sciatic nerve plexus. On this image, you can see significant inflammation surrounding the vagina and rectum, and in this image, the radiologist believed that there was a rectovaginal fistula present. The patient was seen by colorectal surgery. After physical exam and review of the images, it was decided to proceed with abdominal approach for removing the mesh and repair of rectal injury. Factors that contributed to this decision included 1. Close proximity of the mesh to the right iliac vessels with the risk that any bleeding encounter would be difficult to control from a rectal approach. 2. The possibility that a bowel resection and ostomy would be required. 3. The need to remove fecal contaminated mesh. 4. The application of mesh, with most literature supporting a transabdominal approach for injuries in the mid to proximal rectum. In the OR, a flexible sigmoidoscopy was performed, which revealed mesh in the rectum. The surrounding mucosa appeared to be healthy, proximal to the injury. This image clearly shows that the mesh had not eroded through the rectal mucosa, but was cleanly perforating the rectum. For orientation purposes, our footage is oriented from the patient's left side, with cranial aspect to the viewer's right and the caudal aspect to the viewer's left. After the small bowel was packed out of the field, there was a dense induration noted around the right rectum. The peritoneal reflection was opened and the dissection was carried towards the levator anus muscles. After the body of the mesh was freed from the posterior aspect of the vagina, the right mesh arm was found to be extending through the right rectal lumen to the right pelvic sidewall. This mesh arm was transected from the mesh body, and after careful dissection from the fibrotic tissue, was removed in its entirety. Here a finger in the rectum demonstrates the right rectal defect, with the right mesh arm transected from the mesh body, but still attached to the levator anus muscles. A pinrooted strain is placed under the left mesh arm for visualization. The dissection was carried down to the peritoneal reflection on the left, and the left mesh arm was found to be superficially attached to the iliococcygeus muscle and extending through the left wall of the rectum. The mesh body was mobilized as it was dissected from the anterior surface of the rectum. After the mesh arms were transected, there were two distinct rectal defects. There was a 1 cm left rectal defect. This was repaired with interrupted 2-0 polyglactin suture. The second defect was a 3 cm hole within the right lateral wall of the rectum. This was also repaired with interrupted 2-0 polyglactin sutures. Of note, both rectal defects were primarily repaired and did not require a bowel resection. A resection in this portion of the bowel would have decreased the patient's quality of life due to more frequent bowel movements, fecal incontinence, and urgency. After all visible rectal injuries were repaired, watertight closure was confirmed. After an aminal pedicle flap was placed over the rectal repair to decrease the risk of fistula formation, a diverting loop ileostomy was placed in the right lower quadrant. Six weeks after her mesh removal surgery, a barium enema was confirmed as normal, and she returned to the OR for a takedown of her ileostomy. She is currently doing well with improvement of bowel function, continence of feces, improvement of her pain, and no recurrence of vaginal prolapse. We believe that the patient's rectal injury occurred due to inadequate medial retraction of the rectum. This illustration depicts proper placement of mesh after sacrospinous ligament fixation. The body of the mesh lies between the posterior vaginal wall and the rectum with the two mesh arms fixed to the sacrospinous ligaments. It is important to displace the rectum immediately at the time of mesh arm placement during sacrospinous ligament fixation, as demonstrated by this illustration. In conclusion, penetrating rectal injury at the time of synthetic mesh placement in the posterior compartment is a rare complication. This complication is typically avoided by medial displacement of the rectum during sacrospinous mesh arm placement and confirmatory rectal exam after the procedure.

rectal mesh injury

pelvic organ prolapse repair

severe pain

rectal lumen

rectovaginal fistula