Ilaria Capuano

Modified laparoscopic ventral mesh rectopexy

We present a modified laparoscopic ventral mesh rectopexy procedure using biological mesh and bilateral anterior mesh fixation. The rectopexy is anterior with a minimal posterior mobilization. The rectum is symmetrically suspended to the sacral promontory through a mesorectal window.

Small-Bowel Obstruction Secondary to Adhesions After Open or Laparoscopic Colorectal Surgery

Background and Objectives: Small-bowel obstruction (SBO) is a common surgical emergency that occurs in 9% of patients after abdominal surgery. Up to 73% are caused by peritoneal adhesions. The primary purpose of this study was to compare the rate of SBOs between patients who underwent laparoscopic (LPS) and those who had open (OPS) colorectal surgery. The secondary reasons were to evaluate the rate of adhesive SBO in a cohort of patients who underwent a range of colorectal resections and to assess risk factors for the development of SBO. Method: This was a retrospective observational cohort study. Data were analyzed from a prospectively collected database and cross checked with operating theater records and hospital patient management systems. Results: During the study period, 707 patients underwent colorectal resection, 350 of whom (49.5%) were male. Median follow-up was 48.3 months. Of the patients included, 178 (25.2%) underwent LPS, whereas 529 (74.8%) had OPS. SBO occurred in 72 patients (10.2%): 20 (11.2%) in the LPS group and 52 (9.8%) in the OPS group [P = .16; hazards ratio (HR) 1.4 95% CI 0.82–2.48] within the study period. Conversion to an open procedure was associated with increased risk of SBO (P = .039; HR 2.82; 95% CI 0.78–8.51). Stoma formation was an independent risk factor for development of SBO (P = .049; HR, 0.63; 95% CI 0.39–1.03). The presence of an incisional hernia in the OPS group was associated with SBO (P = .0003; HR, 2.85; 95% CI 1.44–5.283). There was no difference in SBO between different types of procedures: right colon, left colon, and rectal surgery. Patients who developed early small-bowel obstruction (ESBO) were more often treated surgically compared to late SBO (P = .0001). Conclusion: The use of laparoscopy does not influence the rate of SBO, but conversion from laparoscopic to open surgery is associated with an increased risk of SBO. Stoma formation is associated with a 2-fold increase in SBO. Development of ESBO is highly associated with a need for further surgical intervention.

Epidemiology and Prevalence of Pelvic Floor Disorders

Pelvic floor disorders (PFDs) manifest with a variable spectrum of symptoms and can involve anterior, middle and posterior compartments. PFDs represent an important aspect of global healthcare, with about 28 million women affected by these diseases worldwide. This number is expected to reach 44 million in the next 40 years. In the literature, the incidence and prevalence of PFDs are often reported inconsistently, depending on the definitions used, the measures considered to assess the stages, the gender and age of the patient, and the severity of the pathology. The etiology of these disorders is multifactorial and it is important to identify the risk factors, because avoiding them or reducing exposure to them can change the natural history of PFDs, allowing physicians to make an earlier diagnosis and use more effective therapy.

Minimally Invasive Surgery for Rectal Prolapse: Laparoscopic Procedures

Surgical treatment of external rectal prolapse, internal intussusception (or internal rectal prolapse), and rectocele is still a challenging clinical problem in the field of colorectal surgery [1, 2]. These conditions may be associated with various pelvic floor disorders, including motility and morphological/functional disorders, ranging from constipation to fecal incontinence, thus significantly affecting the patients’ quality of life [3, 4]. A large variety of surgical procedures exists. The literature offers abundant publications, the main problem for an informed decision on the perfect surgical technique being an often large variability of patients’ selection, diagnostic assessment and variation within the same surgical technique and materials. As a consequence, the colorectal surgeon still lacks a standardized diagnostic assessment as well as a clear ideal surgical technique [5]. Perineal procedures, such as Delorme’s or perineal rectosigmoidectomy or stapled transanal rectal prolapse resection, are indicated for elderly and frail patients, who are not fit for an intervention under general anesthesia, but they have poor efficacy in terms of functional outcomes and recurrence, which may be up to 26 % [6], and also an increasing risk for postoperative incontinence [7]. Abdominal procedures, on the other side, either open or laparoscopic, employing rectal mobilization and fixation, colonic resection or a combination of both, show lower recurrence rates and better functional results, but may cause postoperative worsening of constipation, mostly due to the full rectal mobilization and the consequent possible autonomic nerve injury, which is responsible for dysmotility and impaired evacuation [8]. Laparoscopic ventral mesh recto(colpo)pexy has been introduced in order to obtain good results in terms of functional outcome of the abdominal procedures while avoiding postoperative constipation and incontinence, offering the advantages of anterolateral mobilization, mesh repair and of the laparoscopic approach compared to the open [9].

Erosion after laparoscopic ventral mesh rectopexy with a biological mesh

Today, laparoscopic ventral mesh rectopexy (LVMR) is the most commonly used transabdominal surgical technique for the treatment of full-thickness rectal prolapse. High success rates, as well as low complication rates, explain the rapid spread of this approach which seems to be the ideal approach for rectocele associate with obstructed defecation syndrome, external and internal rectal prolapse, and solitary rectal ulcer. Recent evidence suggested that mesh-related complications are uncommon for both synthetic and biological meshes; however, mesh-related erosions were found to be more commonly associated with synthetics, with the incidence reported to be 1.87% for synthetic mesh and 0.22%, for biological mesh [1]. We present a case of erosion that occurred 23 months after LVMR using a biological mesh. Briefly, a 26-yearold female underwent LVMR 7 years after a TRANSTAR performed for external full-thickness rectal prolapse. She presented with a grade V rectal prolapse according to the Oxford Prolapse Grading System. LVMR was performed with the use of A 3 × 18 strip of biological mesh (PermacolTM; Medtronic, Medtronic Parkway Minneapolis, MN, USA). Our technique has been described before [2]. Briefly, the dissection started at the sacral promontory on the right side of the rectum. The peritoneum of the Douglas pouch is opened and a very superficial dissection is carried on laterally. The dissection continues anteriorly between the rectum and vagina deep to the level of the levator ani muscle. The mesh was placed between the rectum and the vagina. The mesh was then sutured to the rectum starting distally with 2 parallel rows of interrupted TiCronTM sutures (Medtronic, Medtronic Parkway Minneapolis, MN, USA), and proximally secured to the sacral promontory with the Pro TackTM fixation device (Medtronic, Medtronic Parkway Minneapolis, MN, USA). A new pouch of Douglas was created by closure of the peritoneum with interrupted VicrylTM 2-0 sutures (Ethicon US, LLC., Cincinnati, OH, USA). The postoperative course was uneventful with good functional results. After 23 months, the patient experienced discharge of mucous and pus through the anus with no associated symptoms. A flexible colonoscopy was performed which revealed a sinus on the anterior wall of the rectum containing a TiCronTM suture previously used for the mesh fixation to the rectum. The suture was removed in the same sitting using the endoknife (Fig. 1). After 1 month, follow-up magnetic resonance imaging and examination with flexible colonoscopy were negative. Data on biological mesh-related complications are scarce. We have reported a case of biological mesh-related complications, but this was a case of complete extrusion through the vagina [3]. Evans et al. [4] in a study with a total of 2203 patients who underwent LVMR reported that erosion occurred in 2.4% of patients with synthetic meshes and 0.7% of those with biological meshes. In 1 case, the biological mesh erosion was secondary to the stitch sinus, with minor morbidity. It is likely that surgical technical errors, such as unrecognized rectal or vaginal injury or excessively deep placement of fixation sutures, may be responsible for such erosion. Nonetheless, this suture erosion could be avoided by the use of absorbable sutures such as polydioxanone (PDS) instead of non-absorbable sutures as recommended by Mercer-Jones et al. [5] in a consensus on ventral mesh rectopexy. In conclusion, erosions after use of biological mesh are very rare and could be attributed to non-absorbable sutures which may create a sinus secondary to a chronic * P. Sileri piersileri@yahoo.com

Full Thickness Local Excision of Large Rectal Tumour Using A Megawindows 36 Millimetres Circular Stapler

Colorectal adenomas are frequent in the western countries. The estimated lifetime risk is approximately 40% [1]. One third of these lesions will develop in the rectum and about 10% will become malignant [2]. Moreover, the widespread of colorectal cancer screening will necessarily lead to increased detection of adenomas and early rectal cancer. Therefore, more rectal lesions will probably undergo endoscopic or surgical management in the next years.