Video Summary

The following video demonstrates a concomitant robotic ventral mesh rectopexy and sacrocolopexy for a female patient with pelvic floor prolapse. This video demonstrates the critical steps for rectal dissection and rectal mesh fixation. It also demonstrates the important parts of vaginal dissection and sacrocolpopexy mesh fixation. This combined approach allows for better support of the pelvic floor, safely performed in one operation for the patient.

Video

Teaching Points

As part of our enhanced recovery pathway, the patient receives 1000 mg of acetaminophen and 600 mg of gabapentin before surgery. The patient is allowed to have clear liquids up until 2 hours before surgery. The patient receives an enema the night before surgery and the morning of surgery before the operation. The patient is placed in the lithotomy position on the operating room table. The patient’s abdomen is prepped with a chlorhexidine-based preparation and the perineum prepped with betadine. The Foley catheter is placed in a sterile fashion following prepping and draping.

There are nine critical steps to the operation:

1. Port placement
2. Restore normal anatomy
3. Clear the sacral promontory for mesh fixation
4. Develop a plane along the rectum down to the pelvic floor
5. Clear the anterior rectum of and remove the rectal fat pad
6. Secure the mesh to the rectum and presacral fascia
7. Develop a plane between the bladder and vagina
8. Secure the mesh to the vagina and presacral fascia
9. Close the peritoneum overlying the mesh

There are a few technical tips we recommend. For the robotic ventral mesh rectopexy, it is important to leave an adequate peritoneal flap to close over the mesh at the end of the operation, or one risks having exposed mesh. Pelvic dissection should go all the way to the pelvic floor to ensure that any prolapse can be fully reduced. It can be difficult to identify the pelvic floor visually when initially performing this operation. Some visual clues include the pelvic floor musculature coalescing toward the rectum or contraction of the pelvic floor muscles when electrocautery is applied. One can also have an assistant perform a digital exam to palpate the robotic instruments just above the anal ring. It is important to adequately clear the anterior rectum so that the mesh can lay flat across the rectum. We use an L-shaped polypropylene mesh that is 15 cm long. The base is 5 × 4 cm, and the tail of the mesh is 2 cm wide. The rectal wall should be adequately cleared so the full base of the mesh is in contact with the rectal wall. We recommend multiple (approximately 9-12) sutures, fixating the mesh to the rectum to evenly distribute tension on the rectal wall and ensure good contact between the rectum and mesh for fixation. The mesh should be on light tension as it is suspending part of the rectum, but not too much tension as to pull on the rectal wall. For the robotic sacrocolpopexy, we utilize a Y-shaped lightweight mesh. The procedure is performed with the usual surgical technique.

In cases with concomitant placement of two pieces of mesh, adequate dissection and planning for sacral fixation sutures at their attachment to the anterior longitudinal ligament of the sacrum is important. In general, the ventral rectopexy mesh is placed slightly lower to allow subsequent overlap of the sacrocolpopexy mesh. Furthermore, we recommend separate fixation of the two pieces of mesh to ensure proper tensioning of each of the pelvic floor compartments.