Rectal perforation at the time of vaginal mesh placement and subsequent abdominal mesh removal

Patrick Lang, Sallie Oliphant, Jason Mizell, Becca Austin, Susan Barr

We present an uncommon complication of vaginally placed synthetic prolapse mesh and demonstrate repair of rectal mesh perforation. A 41-year-old was referred with multiple complaints following rectocele repair using a posterior vaginal mesh kit 5 months earlier. In the immediate postoperative period, she experienced severe pain radiating down her right leg, pelvic pain, dyspareunia, dyschezia, diarrhea, and new onset fecal incontinence. Our examination revealed tight, tender mesh arms palpable at the vaginal apex with no evidence of erosion or rectovaginal fistula. Rectal examination revealed intrarectal mesh traversing the rectal lumen 6 cm from the anal verge. Pelvic MRI demonstrated a possible rectovaginal fistula with inflammation surrounding the right sciatic nerve plexus. The patient underwent exploratory laparotomy, removal of the mesh, primary repair of two perforating rectal defects and diverting loop ileostomy. Postoperatively she experienced immediate improvement in pain and later underwent successful take-down of her ileostomy. She did well with improvement of bowel function, continence of feces, improvement of pain, and no recurrence of prolapse. Our video shows an abdominal approach for mesh removal and repair of rectal mesh injury occurring from vaginal mesh placement. We discuss the rationale for the abdominal approach and review techniques for proper placement of posterior vaginal mesh.