patients (45 women) median age 54 (range 24-71 years were referred with early
symptomatic failure (n=27) or major complications arising post LVMR (n=23). Their median length of stay was 1 day
(range 1-4). There were no
conversions or postoperative complications.
Early symptomatic failure following a
deficient LVMR [Table 1]
men, (median BMI 33Kg/m2) were referred following an inability of
the referring surgeon to perform the LVMR. Three women had undergone two attempted LVMRs; in each case
there was no evidence of a ventral dissection, the mesh “lying free” on the
pelvic brim. 11 women had undergone
LVMR using PermacolTM(Covidien,
Gosport, UK) within 4-26 months (median 11). Apart from staples and a flimsy fibrous band at the sacral
promontory there was no structural support or sutures within a fat laden rectovaginal
full thickness prolapse within one year; in seven (two PermacolTMmeshes) this followed de-attachment
from the promonontory (n=5) and wrongly positioned staples to the upper sacrum
(n=2). In each case only two staples
had been used. The remaining mesh
had been sutured to the right lateral rectal wall allowing the formation of a
large left sided peritonealocele with enterocele. Two men with continuing ODS had an inadequate strip of mesh
sutured to the right side of the upper rectum with no recto-vesicle dissection.
Management of major mesh complications [Table
were referred with recurrent ODS and new onset pelvic pain secondary to a
stricture in the mid rectum (n=3) and recto-sigmoid; all strictures were associated
with the tail of the mesh which had been stapled to the mid sacrum rather than
the promontory. There were two erosions into the rectum. Each revision was effective in relieving
the pelvic pain. Nine women were
referred with mesh erosion into the vault (n=7), mid vagina (1) and bladder
(n=1); all had undergone a previous hysterectomy and were postmenopausal.
patients were referred with chronic pelvic pain and localised vaginal tenderness
unresponsive to epidurals and poly-pharmacy. One was associated with pudendal
nerve irritation, which had started in the recovery room following the original
surgery. Each mesh was associated
with excessive chronic inflammation; replacement with Teflon coated polypropylene
lead to symptom improvement sufficient for two to withdraw their oral
medications. One developed recurrent ODS requiring the addition of a symptom relieving
posterior STARR. The same patient
has since had a transgluteal pudendal nerve release with a 50% reduction in
patient reported symptom severity and an ability to sit for longer periods of
time. In the remaining patient we
used a lightweight multifilament VyproTM mesh (Ethicon, Edinburgh, UK).
Although this improved the dyspareunia, recurrent ODS developed over a
two-year period as the mesh “stretched”.
The patient is now requesting a further revision.
Revisional surgery was
associated with significant improvements in median postoperative OD and Wexner
FI scores at one year (two tailed t test; p < 0.0001) (Figures 1 & 2). Significant
improvements in QoL scores and linear VAS for bowel symptom severity were seen
at 3 and 12 months, improvements that were then maintained over the following
year (Figure 3 & 4).
Table 1. Causes
of early failure post LVMR (n=26)
Unable to perform LVMR 3
Recurrent external prolapse within 6/12 8
LVMR x 2 3
Recurrent ODS/RI 13
Table 2. Referrals
with major complications post LVMR (n=23)
Rectal strictures 4
Rectovaginal fistula 3
Surgery for rectal prolapse and ODS should be
safe, effective, long lasting, and free of morbidity with patient satisfaction. LVMR has a relatively low risk of
laparoscopy-related complications such as port site hernias, port site
haematoma and inadvertent enterotomy and procedure specific mesh related
complications, which have been reported in around 2% and have serious
consequences1, 2, 13 The
technique requires that the surgeon must have substantial experience in
laparoscopic colorectal surgery and be able to carry out the ventral rectal
dissection down to the pelvic floor but even then there is a continuing learning
curve1,2,13. Although it has not been reported we would suggest the
learning curve might influence the functional outcome and as this paper
demonstrates the complication rate.
most serious complications inherent to the LVMR are mesh related (infection,
erosion and extrusion) and failure. The 2008 NICE review14 of
surgery for pelvic organ prolapse (POP) demonstrates that these two
complications relate to the type of mesh used and are a function of
time/follow-up. Although erosion
rates were 0% for biologic (Xenografts), 14% for combined synthetic and 7% for
synthetic meshes, the overall failure rate for biologic’s was substantially
higher at 23% vs. 9% for synthetic mesh.
complications as this paper shows are amenable to corrective surgery, which at
times can be complex and that this invariable leads to an improvement in
overall function (OD and FI scores) and quality of life which seems to be
maintained over a two year follow-up.
Unless the sepsis has made the mesh freely mobile within the
rectovaginal septum, it is our experience that it is impossible to remove and
correct from below without serious risk to potentially causing a rectovaginal
fistula, particularly if the erosion is at the vault or posterior fornix. Laparoscopic removal whilst being a
technical challenge is feasible and usually without complication.
after PermacolTM LVMR defined as recurrence of symptoms and or of
prolapse has been reported in 12% and 21% of patients at a median follow-up of
1 and 2 years15, 16. Two studies 17,18
of rectocele repair using the same Xenograft report a 41% anatomical recurrence
at 3 years, the majority of these patients reporting persisting ODS. These failures may however simply
reflect the underlying collagen disorder that predisposed the patients to
getting POP/ODS in the first instance.
mesh has the advantage of high tensile strength, immediate availability, and
cost-effectiveness19and tissue integration20. A study of 446 patients21
undergoing laparoscopic sacral colpopexy with polypropylene reported a 1% risk
of mesh extrusion.
LVMR presents two types of challenges: anatomical and technical. For trainee surgeons the anatomy and
dissection planes must be learned.
For experienced surgeons, transitioning to laparoscopy requires
adjusting to a new perspective on pelvic and abdominal anatomy. Cognitive and
technical skills modulated by judgment are the components of competency,
particularly “difficult” operations like LVMR. However, it
is these innate technical abilities (visual hand response, visual information
processing, visual spatial memory etc.,) that represent the limiting factor in
determining the ultimate level of operator skill and are aspects of performance
that do not always improve with practice22. Trainees need to develop their skills
through23 mentorship and practice outside the operating
theatre. Human cadavers offer
realistic anatomy and tissue haptics.
However, they are expensive, restricted and lack objective assessment. Performance feedback helps improvement
and performance improvement reinforces trainees24. Objective
assessment of surgical performance (including judgment) can only be obtained by
reviewing unedited videotapes of surgical procedures for errors and quality of
performance by at least two unbiased experts. Within
the current Lapco programme, 30% of “trained” consultants fail this type of
study highlights the importance of achieving the required competencies and
specialist experience in LVMR and implies the need for interested surgeons to
have undertaken a relevant supervised training programme and be willing to
submit data to a national prospective clinical audit scheme so that the
outcomes and complications can be established. However, the reality is that the
adoption of new procedures like LVMR tends to occur without thought to a
careful assessment and credentialing of the surgeon’s technical proficiency. Given the complexity of benign
pelvic floor disease, the latter needs more robust examination. Revisional surgery as this report
demonstrates is appropriate and can improve both functional outcomes and QoL but
should, because of the potential high rate of complications, only be undertaken
in specialist centers by surgeons with extensive experience.
conclusion, revisional surgery by specialist units post LVMR failure or for the
development of complications is appropriate and can improve function and QoL. Choice of mesh used is a balance between
recurrence with xenografts and mesh infection and extrusion with synthetics. We
advise caution on the widespread uptake of expensive xenografts in what is
probably a cohort of patients with an underlying collagen disorder. RCTs with long-term follow-up would
offer great insights into the ideal mesh for LVMR and method of attachment. This sub-set of patients highlights the
potential problems of uncontrolled-uptake of new interventional procedures and
the need for guidelines on training, service provision and service
commissioning in support of this fledgling discipline as well as the need for a
network of tertiary centers to provide help with difficult cases, especially
Figure 1. Pre vs. Postoperative ODS scores (n=50) at 1 year (two
tailed t test; p< 0.0001). The horizontal bars indicate the median values.
Figure 2. Pre & post-operative Wexner Faecal Incontinence (FI)
scores at 1 year (n=50) (two tailed t test; p < 0.0001). The horizontal bars
indicate the median values (if not visible this indicates that the median is
pairs 50 50
33 17 5
Figure 3. QOL (BBUSQ-22)
scores. The horizontal bars
indicate the median values: pre-operatively
v 3/12 (two tailed t test; p<0.0001); 3/12 v 1 year (p=0.015); 1 and 2 years
pairs 50 50
33 17 5
Figure 4. Linear Analogue Score for severity of bowel symptoms.
Pre-operative v 3/12 (Two tailed t test; p < 0.0001), 3/12 v 1 year (p =
0.0151); 1 vs. 2 years NS. The horizontal bars indicate the median values (if
not visible this indicates that the median is 0).
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