Complications - Ventral mesh rectopexy according to D'Hoore, laparoscopic

1. Complications due to Positioning

To improve organ exposure, patients are often placed in extreme positions during laparoscopic procedures, which can compromise superficially running, long nerves. Particularly at risk are:

• N. peroneus
• N. ulnaris
• N. radialis right

Prophylaxis

• Padded shoulder supports in anticipation of a head-down position.
• In the lithotomy position, the leg holders should be particularly well padded in the area of the fibular heads.
• When using a vacuum mattress, damage to the N. radialis right is largely excluded. The vacuum mattress should definitely be preferred over side supports!
• Position extended arms on a padded splint and do not abduct more than 90°.

2. Complications due to Trocar Insertion

Inserting the trocars, especially the first trocar, can lead to injuries of hollow organs and vessels.

3. Organ-specific Complications

• Injuries to the intestine
• Thermal damage using bipolar scissors or ultrasonic dissector
• Vascular injury
• Ureter injury: In cases of superficial injuries, a laparoscopic suture can be attempted; otherwise, a small laparotomy is recommended directly over the injury site to openly suture the ureter under vision. In any case, the placement of a ureteral stent is indicated.
• Injury to the sacral venous plexus
• Vaginal perforation
• Rectal perforation

Postoperative Bleeding

Mesh Complications

Mesh complications such as mesh erosion into the rectum or vagina are rare, occurring in 0–3.9% of cases, and can appear over a wide time range from 2 to 78 months postoperatively. Erosions into the vagina are significantly more common, while those into the rectum are extremely rare.

They can lead to challenging abdominal revisions, which in rare situations may necessitate an ultra-low rectal resection with stoma protection. In some cases, it is sufficient to simply trim the mesh protruding into the vagina. This can even be done on an outpatient basis in individual cases.

Prolapse Recurrence (approx. 10%)

An optimal procedure for recurrent prolapse has not been described. We usually perform a dorsal mesh rectopexy according to Wells. However, the decision rests with the treating physician.

Persistence or Recurrence of Obstructive Defecation Syndrome

Anal irrigation, biofeedback therapy, possibly re-operation with a transanal procedure

Fecal Incontinence

Persistent or newly developed postoperative incontinence. → The longer the bowel prolapse has existed, the lower the chances that the sphincter will fully regain its function, possibly requiring the additional application of SNS (sacral nerve stimulation). In individual cases, a stoma placement must also be discussed. Some patients are more satisfied with this.

Rectovaginal Fistula

A very unlikely complication. Interval fistula closure possibly with gracilis flap and protective stoma.

Rectal Perforation

Protective stoma, Endo-VAC, followed by suturing of the defect.

Urinary Tract Infection; Urinary Retention

A Spondylodiscitis is often not recognized or recognized very late. It is difficult to treat because it lies in deeper layers. It is very unlikely with suture fixation, but has been described with fixation using staples.