Equipment

A Foley catheter is inserted for the duration of the case but is removed before extubation. Clippers are used to remove abdominal wall hair.

The authors routinely use a 30° laparoscope to enter the abdominal cavity with the Hasson technique. Three 5-mm ports are required. The pexy is supported with polypropylene mesh. For robotic cases, the da Vinci surgical system is used.

Commonly used synthetic meshes are associated with a risk of erosion into adjacent pelvic organs with consequent complications. A study by Alemrajabi et al found polyvinylidene fluoride (PVDF) mesh to be a safe, effective, and cheaper alternative to more commonly used synthetic meshes for laparoscopic ventral mesh rectopexy (LVMR) in patients with obstructive defecation syndrome (ODS).^[27]

A 2022 systematic review and meta-analysis of 32 studies by van der Schans et al, intended to compare the use of synthetic and biologic meshes in LVMR, was unable to determine whether one type was superior to the other in this setting.^[28]

Patient Preparation

In preparation for the procedure, the patient is kept on NPO (nil per os) status, beginning the night before surgery. The authors do not perform bowel preparation in these patients. Prophylactic antibiotics are given per Surgical Care Improvement Project (SCIP) criteria.

Anesthesia

The procedure is performed with general anesthesia to allow abdominal muscle paralysis and thereby to optimize pneumoperitoneum.

Positioning

The authors position the patient in the lithotomy position with the arms tucked bilaterally. The patient is secured to the bed, as a steep Trendelenburg position will be required. Special attention is given to the legs, avoiding excessive posterior or lateral compression, so as to reduce the risk of any injuries to the calf muscle and lateral superficial peroneal nerve.

Monitoring & Follow-up

As per protocol in the authors’ institution, patients are started on a clear liquid diet after the procedure and advanced as tolerated. Patients may be discharged home the same day after meeting standard discharge criteria (diet tolerance, adequate urination, adequate pain control). Frail patients are observed overnight and discharged home on the first postoperative morning. Patients are discharged with standard wound care instructions, a stool softener, and nutritional instructions for a high-fiber diet and ample fluid intake.

Follow-up visits occur in the office 1 week, 1 month, and 3 months postoperatively. Questions regarding continence, the presence of prolapse, and constipation are reviewed.

Technique

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