Laparoscopic ventral mesh rectopexy for internal rectal prolapse

Evidence-based recommendations on laparoscopic ventral mesh rectopexy for internal rectal prolapse in adults. This involves using a piece of sterile material (mesh) to attach the rectum to the lower back bone using keyhole surgery.

# Recommendations
Current evidence on the safety of laparoscopic ventral mesh rectopexy for internal rectal prolapse shows there are wellrecognised, serious but infrequent complications. The evidence on efficacy and safety is limited in quality. Therefore, this procedure should only be used with special arrangements for clinical governance, consent and audit or research. Find out what special arrangements mean on the NICE interventional procedures guidance page.
Clinicians wishing to do laparoscopic ventral mesh rectopexy for internal rectal prolapse should:
Inform the clinical governance leads in their NHS trusts.
Ensure that patients understand the uncertainty about the procedure's efficacy and safety and that there are different types of mesh available, which may have different efficacies and complications. Patients should be provided with clear written information. In addition, the use of NICE's information for the public on laparoscopic ventral mesh rectopexy is recommended.
Patient selection should be done by a pelvic floor multidisciplinary team. This should typically include a surgeon, an urogynaecologist, a radiologist, a nurse specialist, a physiotherapist, a pelvic floor physiologist and, when appropriate, a gastroenterologist.
This procedure should only be done by surgeons who are trained and experienced in laparoscopic pelvic floor surgery, who have done their initial procedures with an experienced mentor.
Clinicians should enter details about all patients having laparoscopic ventral mesh rectopexy for internal rectal prolapse onto an appropriate registry (for example, the British Pelvic Floor Society database). The results of the registry should be published.
Clinicians are encouraged to collect data on patient selection, patientreported outcomes, meshrelated complications, the type of mesh used, the attachment method and longterm followup. NICE may update the guidance on publication of further evidence.
All adverse events involving the medical devices (including the mesh) used in this procedure should be reported to the Medicines and Healthcare products Regulatory Agency.# The condition, current treatments and procedure

# The condition
Internal rectal prolapse is when the lowest part of the bowel (rectum) telescopes on itself. It is more common in women who have had children but also happens in nulliparous women and in men. Factors related to the development of the condition are age, childbirth, constipation and straining. It may be associated with prolapse of other pelvic organs and some people may have a predisposition because of abnormalities in collagen. It is not life threatening but it can be a distressing and demoralising condition, with negative effects on quality of life. Symptoms include discomfort, pain, constipation, difficult evacuation (obstructed defaecation syndrome), faecal incontinence and discharge of mucus or blood. In women it can be associated with vaginal bulge (rectocele), painful intercourse, lower back pain, urinary dysfunction, and vaginal prolapse and enterocele.

# Current treatments
Conservative treatment of internal rectal prolapse may include pelvic floor exercises and advice to improve defaecatory habits, reduce constipation and improve incontinence. These are often termed biofeedback or pelvic floor retraining. Surgical treatment of internal rectal prolapse is classified into perineal (Delorme's operation) and abdominal procedures. Open abdominal surgery and laparoscopic procedures, with or without robotic assistance, use mesh or direct suturing and may involve resection of the sigmoid colon.

# The procedure
Laparoscopic ventral mesh rectopexy (LVMR) is done under general anaesthesia using keyhole surgery, in which 3 to 4 small incisions are made in the abdomen. The peritoneum over the rectum is dissected, exposing the muscle coat which is mobilised into the rectovaginal septum in females and the level of the seminal vesicles in males. The mesh is secured to the rectum anteriorly, as low as possible in the fascia, using sutures, and fixed to the sacral promontory with permanent sutures or small metal tacks. The peritoneum is closed over the mesh to prevent the bowel becoming trapped or adhering to the mesh. In women, LVMR may help control rectocele or enterocele associated with rectal prolapse.