meigs syndrome is defined as the coexistence of benign ovarian fibroma , hydrothorax , and ascites . by contrast , pseudomeigs syndrome is limited to other ovarian or pelvic tumors associated with hydrothorax and ascites 1 . both are treated by resectioning of the tumors , which could control the fluid accumulation in the thorax and abdomen 2 . although many different types of operative methods are chosen to treat rectal prolapse , rectopexy is considered the most appropriate in terms of curability , but its use is limited because of its invasiveness . laparoscopic rectopexy is expected to expand its indication even to elderly patients ; however , it is unclear whether patients with a large volume of ascites due to pseudomeigs syndrome would be candidates for laparoscopic rectopexy . we herein report a case of rectal prolapse caused by ascites from pseudomeigs syndrome that was successfully managed with laparoscopic surgery . a 64yearold female presented to our surgical outpatient department complaining of discomfort caused by rectal prolapse and abdominal distension attributable to ascites . she had been receiving outpatient chemotherapy to treat breast cancer with metastasis for 13 years , which she had commenced after a leftsided mastectomy , and her survival prognosis was estimated to be more than 1 year according to previous reports 3 , 4 , 5 . computed tomography ( ct ) revealed complete rectal prolapse ; disseminated masses , including an ovarian metastasis ; pleural effusion ; and large amounts of ascitic fluid ( especially in the pelvic cavity ) ( fig . approximately 3500 ml of slightly yellow transparent ascitic fluid was aspirated . as large ovarian metastases covered the pelvic cavity and impeded the procedure , we first performed a bilateral oophorectomy . the rectum was then dissected in the mesorectal plane to the level of the levators and subsequently stapled to the sacral bone around the region of the promontory ( fig . the patient was discharged on day 10 after surgery with no apparent complications and continued to receive outpatient chemotherapy . pathological examination revealed that the ovarian tumors were compatible with breast cancer metastases . at the 1year followup , no relapse was evident in terms of abdominal or thoracic fluid or rectal prolapse ( fig . 1 ) . thus , laparoscopic surgery was useful to treat both the rectal prolapse and pseudomeigs syndrome . ( left ) preoperative computed tomography ( ct ) scan : enlarged bilateral ovaries ( white arrows ) and a large amount of ascites fluid are evident in the pelvic cavity . ( right ) postoperative ct scan taken 2 months after surgery : both ovaries have been resected and the ascites has disappeared . ( a ) both ovaries were enlarged within the pelvic cavity and covered the rectum . ( b ) the ovarian artery and vein were ligated , and both ovaries were then resected using an ultrasonic coagulation device . ( c ) the rectum was completely mobilized down to the level of the levators . this case emphasizes that laparoscopic rectopexy can be used to treat rectal prolapse in the presence of comorbidities and that treatment of pseudomeigs syndrome improves quality of life and reduces the rectal prolapse relapse rate . a comparative study demonstrated that laparoscopic suture rectopexy is a safe and feasible procedure and has comparable results with regard to operative time , morbidity , bowel function , and recurrence ; it even has slightly better results than mesh rectopexy . furthermore , the cost of the mesh used in mesh rectopexy is absent in suture rectopexy 8 , and it is unclear whether mesh rectopexy might be safe and feasible for patients with multiple peritoneal dissemination . a recent systematic review showed that laparoscopic colorectal surgery in the elderly afforded significant advantages in terms of shortterm outcomes 9 . as the incidence of rectal prolapse increases with age , the use of laparoscopic methods might be able to extend surgical indications to elderly , fragile patients . one small randomized clinical trial showed that laparoscopic rectopexy was associated with less postoperative pain , an earlier return to alimentation , an earlier discharge from the hospital , and lowerlevel relapse , at the expense of needing a longer operation time compared to open methods 10 , 11 , 12 . additionally , laparoscopy permits visualization of the entire abdominal cavity , facilitating simultaneous treatment of several pathological lesions . in our present case , laparoscopic management was chosen not only to reduce the relapse rate but also to prevent the development of an abdominal incisional hernia attributable to increased intraabdominal pressure from ascites . as large ovarian metastases covered the pelvic cavity and impeded the procedure , we first performed a bilateral oophorectomy . this effectively treated the pseudomeigs syndrome . additionally , mitigation of the ascites prevented prolapse recurrence . palliative treatment ( i.e. , the miwagant procedure ) would not be expected to prevent early relapse because of the abundant ascites associated with pseudomeigs syndrome . in this case , neither pleural effusion nor ascites were clinically evident ; therefore , they did not affect the decision to perform the oophorectomy . if the patient were obese , it may have impeded the ability to clinically identify the presence of large ascites . however , the ascites contributed to the rectal prolapse , and the oophorectomy was thus useful . to the best of our knowledge , this is the first case in which rectal prolapse and pseudomeigs syndrome have been simultaneously treated and successfully managed by laparoscopic surgery . such surgery may thus be considered as the first choice when treating patients with rectal prolapse and pseudomeigs syndrome . tk , mt , hh , ko , ks and yk : designed the research ; tk , mt , and th : collected clinical information ; tk and mt : wrote the paper .
key clinical messagewe report a rare case of rectal prolapse with pseudomeigs syndrome in which laparoscopic bilateral oophorectomy and rectopexy were performed simultaneously and resulted in improved quality of life due to the loss of ascites and the repair of rectal prolapse . 
 laparoscopic surgery is feasible for rectal prolapse with pseudomeigs syndrome .