Firstly described by D’Hoore in 2004, laparoscopic ventral mesh rectopexy (LVR) is effective in treating rectal prolapse associated with obstructed defecation syndrome (ODS) and fecal incontinence (FI) [9, 40], improving respectively in 37–86 % and 4–91 % of the patients [41]. LVR shows good results also on dyspareunia and sexual dysfunction, which improve in 39 % of patients [42].

Literature data show that LVR can be the treatment of choice for elderly. It also treats the middle as well as posterior pelvic compartment (Colpo-recto sacropexy), rectocele, enterocoele, and sigmoidocoles, if present. Usually it is performed with synthetic meshes which allows stable results but can be associated to a mesh erosion risk close to 3 % during follow-up.

The few reports on LVR using biological mesh show 82–95 % improvement of ODS symptoms and 73–95 % improvement of FI [43] with a significantly reduced risk of erosion. However, new and more data are necessary to establish the superiority of one mesh over the other, in terms of short- and longer-term functional outcomes [44].

Using a four trocar technique and a 30° scope, an anterolateral dissection is carried out between the rectum and the vagina starting from the sacral promontory, down to the levator ani muscle (Fig. 12.3). A 3 × 18 cm tailored strip of biological mesh is positioned at the level of the levator ani muscle and sutured to the anterior wall of the rectum using two parallel rows of non-absorbable 2-0 sutures (Fig. 12.4).

During this stage, the rectum is retracted cranially in order to visualize the levator ani muscle and the position of the first two distal sutures, which are confirmed to be approximately at 2–3 cm above the dentate line by rectal examination or proctoscopy (Figs. 12.5 and 12.6). The mesh is then sutured to the sacral promontory using non absorbable  sutures or the ProTack™ device (Autosuture, Covidien, UK) and the vaginal vault (or cervix) is fixed to the mesh without traction using two additional absorbable sutures (vicryl 2-0), while a retractor is positioned and pulled into the vagina, in order to completely distend the posterior vaginal wall. The surgery is concluded with the closure of the peritoneal incision using a running absorbable 2-0 sutures (Fig. 12.7).

Recently, Formijne Jonkers published a paper about an international survey filled in by the European and American colorectal surgeons regarding evaluation, treatment, and follow-up of patients with internal and external rectal prolapse: LVR is the most popular treatment in Europe, for both external and internal rectal prolapse, while laparoscopic resection-rectopexy (LRR) is the most used technique in North America [45]. The authors concluded that both LVR and LRR are effective for the treatment of rectal prolapse. Although both techniques offer significant improvement in functional symptoms, continence may be better after LRR. However, LRR also has a higher complication rate than LVR.

The Ripstein technique , initially described by Ripstein in 1965, was the most diffuse approach to treat rectal prolapse in USA before the introduction of sutured posterior rectopexy. It involves a complete mobilization of the rectum and its fixation at the hollow of the sacrum using a sling of Teflon, Marlex, or Gore-Tex to place around the anterior surface of it and bilaterally anchored on the sacrum. The mesh is trimmed before positioning and sutured on the seromuscular of the rectum with the rectum under cranial retraction. The suturing is started usually in the right aspect of the sacrum and ended on the left side leaving a centimeter behind the mesh to avoid tension and stricture at this level. Three to five non-absorbable sutures are used (Fig. 12.8). The laparoscopic approach is carried on similarly to the open. However, the results in terms of constipation are disappointing with a persistence rate of preoperative constipation as high as 57 % (compared to 17 % after resection-rectopexy, p = 0.03). Moreover, in 12 % of patients a new onset of constipation was described, reason why this procedure should be avoided in case of rectal prolapse with constipation [46].

The Wells technique consists of the opening of the pararectal peritoneum on both sides to the holy plane, with a dissection of the mesorectum down to the level of the levator ani plane, avoiding any injuries of the presacral nerve plexi. The peritoneum is entered at the ombelicus with three additional trocars placed in the right lower quadrant on the anterior axillary line, at the level of the iliac crest, and the last in the lower left quadrant. If necessary, an additional trocar is placed suprapubically. Dissection is initiated opening the right-sided parietal peritoneum lateral to the rectum. A retro-rectal window is created anteriorly to the sympathetic plexus. The dissection is conducted down to the levator ani muscle. Then the sacral promontory is completely exposed reaching the iliac common vessels on the right side. A non-absorbable mesh is tailored in a T shape and oriented with the long limb of the ‘T’ along the hollow of the sacrum and the short arm behind and perpendicular to the rectum at the level of the sacral promontory. The mesh is then fixed to the sacrum and its lateral wings are fixed laterally to both sides of the rectum [47]. Using this technique, constipation improvement is achieved in 36 % of cases, while there is an 18 % new onset constipation [48]. Laparoscopy has also been successfully applied to this technique, with no major intraoperative or postoperative complications. In a series of 37 patients who had undergone laparoscopic Wells technique, incontinence was cured in 92 % of patients, while a not acceptable  38 % rate of postoperative constipation was described [49].

This is a new technique developed by Longo which aims to address not only the posterior but also the middle and anterior pelvic compartments prolapse. Using a three-trocars technique the operation starts with an exploration of the peritoneal cavity. The patient is then positioned in Trendelenburg. A vaginal flat retractor is positioned into the anterior fornix. A 30 × 30 cm prolene mesh is tailored in a V-shaped 25-cm length strips and 2 cm wide and introduced into the abdominal cavity through the 10-mm trocar. A 2-cm incision of the peritoneum is performed at the level of the apex of the anterior vaginal fornix, where the mesh is fixed using a 0 prolene stitch. Then, 2-cm bilateral cutaneous incisions are performed 2 cm above and 2 cm posteriorly to the anterior superior iliac spine and a subperitoneal plane is reached. Through this incision, a forceps is introduced and, under laparoscopic vision, a subperitoneal tunnel is created until reaching the anterior fornix of the vagina. At this point, the tip of the clamp is forced out of the peritoneal incision previously performed and one end of the V-mesh is pulled out through the subperitoneal tunnel, bilaterally. Pelvic organ suspension is achieved by making symmetrical tractions on both mesh strips. Finally, 5 cm of excess mesh strip is fixed to the muscles’ fascia using vicryl 2/0 stitches. At the end of the procedure, a circular anal dilator (CAD) is positioned and an evaluation of the rectal prolapse is performed. If a residual recto-anal prolapse and/or an anterior rectocele is still evident, a STARR (Stapled TransAnal Rectal Resection) procedure is performed.

The overall rate of surgical complications was 14.3 %. The Longo’s ODS score fell from an average of 14.55 to an average of 3.03 [50]. F. Ceci et al. evaluated the preliminary results of laparoscopic POPs + STARR in 54 women with a mean age of 55.2 and a BMI of 28.3. The authors had no relapses and the preliminary results were excellent (rectocele treated in 83 %, rectal prolapse treated in 76 %, enterocele-treated in 57 %); there were no cases of de novo dyspareunia, and all patients with this preoperative affliction reported cure or significant improvement at 1 year of follow-up [51]. However larger series with data and longer-term follow-up are needed.

Robotic assistance in laparoscopic surgery may help in shortening operating times and the surgeon’s learning curve in some laparoscopic tasks. Several studies demonstrated that robotic rectopexy is safe and feasible, leading to high-definition stereoscopic vision and intuitive tremor-free movements of instruments, excellent ergonomics, and motion scaling. However, significantly longer operating times compared to the laparoscopic technique have been described, probably due to the limited experience in robotic surgery at this moment and to the laborious difficulty in changing robotic instruments [52]. In a series of 44 patients who had undergone robotic-assisted ventral mesh rectopexy compared to 74 patients who had undergone laparoscopic ventral mesh rectopexy, early complications were significantly lower following the robotic approach. Also, ODS scores demonstrated a significantly better effect on constipation with the robotic-assisted approach, probably due to several technical advantages of robotic-assisted surgery, such as improved autonomic nerve-sparing, deeper mesh placement, and major reduction of rectococeles. There were no differences in recurrence rates and postoperative sexual function between the two groups [53].

The procedure is the same as in the laparoscopic procedures previously described, and performed with the aid of the four-armed Da Vinci-S surgical system (Intuitive Surgical Inc., Sunnyvale, California, USA). Deep access and dissection in the pelvis is easier with the robotic arms, with the possibility of suturing the mesh to the lateral stalks of the rectum [51].

Robotic-assisted rectopexy may be performed also in elderly patients, with no differences in terms of recurrence, short- and long-term function for both young and old patients [54].

Robotic surgery has higher costs than the laparoscopic approach, but it is likely that in the future newer, portable, and cheaper robotic systems will be developed. In combination with the clinical advantage of improved function the somewhat higher costs may be outweighed [55].