Video Summary

Laparoscopic ventral mesh rectopexy (LVMR) is a well-established surgical approach for rectal prolapse repair. Hundreds of videos show this approach on the Web. However, other LVMR indications, such as enterocele, are lacking iconography. To address this, we show in this video an LVMR procedure to repair a large and isolated enterocele, explaining the technique and pointing out some particular findings in the anatomy in this case.

Video

Teaching Points

Patient preparation

• Vaginal estrogen application for 6 weeks preoperatively
• Prophylactic dose of low molecular weight heparin the afternoon before the procedure
• Preoperative bowel preparation: 1 enema the night before and 1 enema the morning of the procedure
• Antibiotic prophylaxis: 2 g of amoxicillin/clavulanic acid intravenously 1 hour before surgery
• Foley catheter insertion before surgery that is removed once the procedure is completed
• Mechanical venous thromboembolism prophylaxis with graduated compression stockings and intermittent pneumatic compression device during the procedure

Patient position

• Lloyd–Davies position

Critical steps

• Hernia sac reduction and transection
• Fixation of a titanized lightweight polypropylene mesh with interrupted sutures to the anterior wall of the inferior rectum just above the perineal body
• Fixation of the mesh to the sacral promontory
• Closure of the rectovaginal septum defect with interrupted sutures from the posterior vaginal fornix to the mesh
• Peritoneum closure

Technical pearls/tips

• There is no rectovaginal septum dissection (commonly performed in rectal prolapse repair) because of the complete septum defect
• We strongly recommend the closure of the rectovaginal septum by suturing the posterior vaginal fornix to the mesh

Potential areas for injury/complication

• Take care not to open the posterior vagina wall during the dissection of the hernia sac because they are firmly attached.