What are the key considerations and surgical details for an anterior mesh rectopexy procedure, including patient positioning and post-operative care?

Anterior Mesh Rectopexy: Surgical Anatomy and Technical Considerations

Anterior mesh rectopexy is a safe and effective surgical approach for treating rectal prolapse with a low complication rate of approximately 1.4% for mesh-related issues, making it an appropriate option for improving patient morbidity, mortality, and quality of life. 1

Patient Positioning and Setup

• Patient should be placed in modified lithotomy position with steep Trendelenburg tilt
• Arms tucked at sides to allow surgeon access to perineum if needed
• Legs in Allen stirrups with careful padding of pressure points
• Pneumoperitoneum established using Veress needle or open Hasson technique
• Standard laparoscopic port placement:
  • Camera port at umbilicus
  • Right and left lower quadrant working ports
  • Optional suprapubic port for retraction

Key Anatomical Considerations

Anterior Dissection

• Dissection begins by opening the peritoneum over the anterior rectal wall
• Denonvilliers' fascia must be identified and preserved
• For female patients, the rectovaginal septum requires careful dissection
• Dissection should extend distally to the pelvic floor muscles
• Avoid injury to lateral stalks containing middle rectal arteries

Posterior Dissection

• Minimal posterior mobilization is required in anterior mesh rectopexy
• Preserve the lateral ligaments to reduce risk of postoperative constipation 2
• Avoid injury to hypogastric nerves which lie posterolaterally

Mesh Placement

• Mesh should be secured to the anterior rectal wall with non-absorbable sutures
• Bilateral anterior mesh fixation provides symmetrical suspension 3
• Mesh should extend from the sacral promontory to the pelvic floor
• Create a mesorectal window for proper mesh positioning 3

Technical Tips and Important Points

1. Mesh Selection: Both biological and synthetic meshes show similar complication rates of approximately 1% 1. However, avoid polyester mesh which is associated with increased morbidity 4.

2. Mesh Fixation: Use non-absorbable sutures for securing mesh to the rectum and sacral promontory. Proper fixation reduces recurrence rates 5.

3. Nerve Preservation: Careful identification and preservation of autonomic nerves is essential to prevent postoperative sexual and urinary dysfunction.

4. Limited Rectal Mobilization: Minimize posterior rectal mobilization to reduce postoperative constipation while achieving adequate prolapse correction 2.

5. Symmetrical Suspension: Ensure the rectum is symmetrically suspended to the sacral promontory through a mesorectal window 3.

6. Multidisciplinary Approach: Procedures should be performed by adequately trained surgeons working within a multidisciplinary team framework 4.

Potential Complications and Prevention

• Mesh Erosion: Most common mesh-related complication (64.8% of mesh complications) 1

  • Prevention: Proper mesh placement without tension, adequate tissue coverage

• Mesh Fistula: Accounts for 11.4% of mesh-related complications 1

  • Prevention: Avoid full-thickness rectal wall injury during dissection

• Recurrence: Lower recurrence rates compared to conventional suture techniques 5

  • Prevention: Adequate mesh fixation and appropriate patient selection

• Constipation: Better functional outcomes with anterior mesh rectopexy compared to conventional techniques 5

  • Prevention: Preserve lateral ligaments, avoid extensive posterior mobilization

Postoperative Considerations

• Early mobilization to reduce risk of venous thromboembolism 2
• Careful fluid management to avoid overhydration 2
• Removal of transurethral catheter on postoperative day 1 if low risk of urinary retention 2
• Early enteral nutrition if gastrointestinal tract is functional 2
• Monitor for signs of anastomotic leakage if resection was performed 2

Special Considerations

• In patients with rectocele, laparoscopic ventral mesh rectopexy shows better anatomic correction and greater improvement in constipation and quality of life compared to transvaginal approaches 6

• For emergency cases with signs of shock, gangrene, or perforation of prolapsed bowel, immediate surgical treatment is recommended with an open abdominal approach rather than laparoscopic 2

• In elderly or high-risk patients, consider perineal approaches (Delorme's or Altemeier's procedures) instead of abdominal approaches 7

By following these technical considerations and anatomical principles, anterior mesh rectopexy can be performed safely with excellent functional outcomes and low recurrence rates.