Detailed Surgical Steps for Anterior Mesh Rectopexy
Anterior mesh rectopexy should be performed with minimal posterior mobilization, bilateral anterior mesh fixation, and symmetrical suspension of the rectum to the sacral promontory through a mesorectal window to ensure optimal outcomes. 1
Patient Positioning and Setup
- Patient in modified lithotomy position with arms tucked
- Steep Trendelenburg position to displace small bowel from pelvis
- Standard laparoscopic port placement (typically umbilical camera port and 2-3 working ports)
Key Surgical Steps
1. Initial Access and Exploration
- Establish pneumoperitoneum
- Perform thorough abdominal exploration
- Place patient in steep Trendelenburg position
2. Pelvic Dissection
- Identify and retract sigmoid colon superiorly
- Open peritoneum at sacral promontory
- Create mesorectal window by minimal dissection of the right side of the rectum
- Preserve hypogastric and autonomic nerves to prevent postoperative sexual and urinary dysfunction 2
- Perform limited posterior rectal mobilization to reduce risk of postoperative constipation 2
3. Anterior Rectal Dissection
- Dissect rectovaginal septum (in females) or rectovesical space (in males)
- Extend dissection distally to the level of pelvic floor
- Preserve lateral ligaments when possible
4. Mesh Preparation and Placement
- Select appropriate mesh (typically macroporous monofilament polypropylene for synthetic mesh) 2
- Cut mesh to appropriate dimensions (typically 3-5 cm wide, 12-15 cm long)
- Position mesh anteriorly on the rectum
- Ensure symmetrical placement for balanced suspension 2
5. Mesh Fixation
- Secure mesh to anterior rectal wall with non-absorbable sutures
- Avoid full-thickness rectal wall sutures to prevent fistula formation
6. Sacral Fixation
- Stretch mesh to appropriate tension
- Secure proximal end of mesh to sacral promontory (S1-S2 level)
- Use non-absorbable sutures or tacks for fixation
- Ensure mesh is taut but not under excessive tension
7. Peritoneal Closure
- Close peritoneum over mesh to prevent adhesions and mesh exposure
- Use continuous absorbable suture
8. Documentation
- Document type of mesh used, method of fixation, extent of rectal mobilization 2
- Consider intraoperative photography with clear visibility of anatomical landmarks 2
Special Considerations
Laparoscopic vs. Open Approach
- Laparoscopic approach offers benefits of less blood loss, shorter hospital stays, and quicker return of bowel function 4
- Consider open approach in cases of hemodynamic instability or peritonitis 4
Mesh Selection
- Document mesh characteristics in operative report 2
- In contaminated fields, consider biological mesh or additional preventive measures 2
Elderly or High-Risk Patients
- Consider perineal approaches (Delorme's or Altemeier's procedures) instead of abdominal approaches in high-risk patients 4, 2
Postoperative Care
- Early mobilization to reduce risk of venous thromboembolism 2
- Careful fluid management to avoid overhydration 2
- Remove transurethral catheter on postoperative day 1 if low risk of urinary retention 2
- Early enteral nutrition if gastrointestinal tract is functional 2
Common Pitfalls to Avoid
- Excessive posterior rectal mobilization (can lead to constipation)
- Injury to autonomic nerves (can cause sexual and urinary dysfunction)
- Inadequate mesh fixation (can lead to recurrence)
- Excessive mesh tension (can cause pain and mesh erosion)
- Full-thickness rectal wall sutures (risk of fistula formation)
Anterior mesh rectopexy has shown significant improvement in both obstructive defecation symptoms and fecal incontinence without inducing new-onset constipation 5, 6. When performed correctly with proper technique, it has demonstrated lower recurrence rates compared to conventional suture rectopexy 6.