Pelvic Floor Surgery Treatments

Pelvic Floor Services:

The Pelvic Floor Centre is a highly specialized, state-of-the-art facility. We offer a multi-disciplinary approach to patient care and the diagnosis of Pelvic Floor Disorders. By establishing ourselves as a leading research centre and referral site, we can offer advanced treatment options and an individualized, comprehensive treatment approach to every person we see.

The Pelvic Floor Centre provides diagnosis, consultation and innovative care options for:

• Accidental Bowel Leakage
• Urinary incontinence
• Urinary retention and other voiding dysfunctions
• Chronic constipation
• Pelvic organ prolapse
• Rectal cancer

Although most of these disorders are not life threatening, these health issues affect a broad range of patients and can have a devastating effect on quality of life.

We offer the following diagnostic testing:

Anal Manometry – Measures the strength of the internal and external sphincters, coordination of the muscles of the pelvic floor, and assesses sensations in the rectum. Used to assess constipation, faecal incontinence, to rule out Hirschsprung’s and many other pelvic floor conditions.

EMG recruitment – Assess patient’s ability to voluntarily contract and relax the pelvic floor muscles.  Used to assess relaxation of the pelvic floor in constipation.

Pudendal nerve EMG – Assesses conduction of the pudendal nerve.  Used primarily in diagnosis of cause of accidental bowel leakage but also in rectal prolapse and enterocele.

Rectal ultrasound – Images the layers of the rectal wall.  Used for staging of rectal tumours and also enlarged nodes.  Is also used for follow-up surveillance after treatment.  Advanced 3-D Ultrasound technology is also available.

Anal ultrasound – Images sphincters and tissues surrounding the anal canal.  Used to assess accidental bowel leakage, fistula, abscess, sphincter injury (postdelivery/surgery), and pain.

Cine Defecography – A test using fluoroscopy that evaluates rectal emptying and relaxation of the pelvic floor.  Visualizes rectocele, enterocele, and rectal prolapse.

Urodynamics/Video Urodynamics – Bladder testing used to assess causes of urinary problems including incontinence, urgency and difficulty emptying. May be done with or without fluoroscopy.

PNE (Peripheral Nerve Evaluation) – Determines whether sacral nerve stimulation for the control of accidental bowel leakage or lower urinary tract dysfunction is appropriate for a given patient. A temporary device is used and, if successful, surgery to implant a permanent device would be the next option.

Biofeedback – (Pelvic Floor Muscle retraining) – can treat accidental leakage (faecal and urinary) as well as constipation caused by non-relaxation of the pelvic floor.  Sensors are used while a nurse coaches the patient to correctly exercise and relax the pelvic floor muscles.

Pelvic Floor Disorders: Frequently Asked Questions

Q: What is the pelvic floor?

A: Both men and women have a pelvic floor. In women, the pelvic floor is the muscles, ligaments, connective tissues and nerves that support the bladder, uterus, vagina and rectum and help these pelvic organs function. In men, the pelvic floor includes the muscles, tissues and nerves that support the bladder, rectum and other pelvic organs. The pelvic floor muscle layer has hole for passages to pass through. There are two passages in men (the anus and urethra) and three passages in women (the anus, urethra, and vagina). The pelvic floor muscles normally wrap quite firmly around these holes to help keep the passages shut. There is also an extra circular muscle around the anus (the anal sphincter) and around the urethra (the urethral sphincter).

Q: What are pelvic floor disorders?

A: Pelvic floor disorders occur when the “trampoline” that supports the pelvic organs becomes weak or damaged. The three main types of pelvic floor disorders are:

• Faecal incontinence, or lack of bowel control.
• Pelvic organ prolapse: rectal prolapse, a condition in which the bowel can bulge through the anus.
• Obstructive defecation, or the inability to pass stool through the digestive tract out the anus.

Q: What are the symptoms of pelvic floor disorders?

A: People with pelvic floor disorders may experience:

• Constipation, straining or pain during bowel movements.
• Pain or pressure in the rectum.
• A heavy feeling in the pelvis or a bulge in the rectum.
• Muscle spasms in the pelvis.

Q: Are pelvic floor disorders a normal part of aging?

A: While pelvic floor disorders become more common as women get older, they are not a normal or acceptable part of aging. These problems can have a significant impact on a person’s quality of life. Fortunately, these disorders often can be reversed with treatment.

Q: What causes pelvic floor disorders?

A: Common causes of a weakened pelvic floor include childbirth, obesity, heavy lifting and the associated straining of chronic constipation.

• Childbirth is one of the main causes of pelvic floor disorders. A woman’s risk tends to increase the more times she has given birth.
• Having pelvic surgery or radiation treatments also can cause these disorders.
• Women who are overweight or obese also have a greater risk for pelvic floor disorders.
• Other factors that can increase the risk include repeated heavy lifting or even genes.

Q: When should I seek help for pelvic floor disorders?

A: Many people don’t feel comfortable talking about personal topics like pelvic floor disorders and symptoms such as incontinence. But these are actually very common medical problems that can be treated successfully.  If you have a pelvic health issue, don’t hesitate to learn more about your treatment options.

Q: What is faecal incontinence?

A: Faecal incontinence, also called bowel or anal incontinence, is the inability to control your bowels. It is the second most common pelvic floor disorder. People with faecal incontinence may feel the urge to have a bowel movement but may not be able to hold it until they reach the toilet. Or they may leak stool from the rectum. Faecal incontinence is not normal at any age and can be treated successfully. This can lead to a significant improvement in a person’s quality of life.

Q: How is faecal incontinence diagnosed?

A: Your physician will start by asking questions about your medical history. Then he or she will conduct a physical exam and order some tests.

Physicians have several tools to understand the cause of faecal incontinence. These include:

• Anorectal manometry, which checks the anal sphincter muscles that keep stool inside. This test also checks how well the rectum works.
• Defecography, which shows how much stool the rectum can hold, how well it can hold it and how well it can empty it.
• Magnetic resonance imaging (MRI), which is sometimes used to examine the sphincter.
• Other tests may be ordered to look inside the rectum or colon for signs of disease or damage that could cause faecal incontinence.

Q: How is faecal incontinence treated?

A: Treatment can improve or restore bowel control for most people with faecal incontinence. Often, a treatment plan includes many approaches, depending on the cause of the problem. These may include:

• Diet changes, such as eating smaller meals and avoiding caffeine, which relaxes the sphincter muscles and can make incontinence worse.
• Medication, which may be appropriate for some people to help slow down the bowel.
• Biofeedback, which helps people learn to strengthen their pelvic muscles so they can control their bowel movements.
• Surgery, which may help people whose faecal incontinence is caused by damage to the pelvic floor or anal sphincter. Surgeons can repair the anal sphincter using advanced techniques that restore bowel function. Surgeons also can improve bowel control by injecting bulking agents into the anus or stimulating the nerves in the lower pelvis.

Q: What is pelvic organ prolapse?

A: Pelvic prolapse is the third most common pelvic floor disorder. A prolapse occurs when the pelvic muscles and other supporting tissues becomes weak, which causes the organs in the pelvis to fall out of place. Rectal prolapse occurs when part or all of the wall of the rectum slides out of place, sometimes sticking out of the anus. Rectocele occurs when the lower wall of the vagina loses support and the rectum bulges upward into the vagina.

While these conditions are usually not associated with serious health risks, they can cause symptoms such as:

• A heavy feeling or discomfort from something that feels like it is “falling out” of the vagina.
• A pulling or “bulge” in the lower abdomen or pelvis.
• Frequent urinary infections, caused by a reduced ability to release urine from the urethra.

Q: How do you treat prolapse?

A: There are several nonsurgical treatment options for pelvic organ prolapse. These include:

• Kegel exercises and other pelvic floor exercises that can help strengthen the muscles that support the pelvic organs.
• To repair rectal and multi-organ pelvic organ prolapse, surgery may be the best option for some women. Often, these procedures can be done using minimally invasive techniques.

Q: What is pelvic floor dysfunction, and what are the symptoms?

A: Pelvic floor dysfunction is when you are unable to control the muscles that help you have a complete bowel movement. It can affect women and men. The symptoms include:

• Constipation, straining and pain with bowel movements.
• Unexplained pain in the lower back, pelvis, genitals or rectum.
• Pelvic muscle spasms.
• A frequent need to urinate.
• Painful intercourse for women.

Q: How is pelvic floor dysfunction treated?

A: Treatment can have a dramatic effect on pelvic floor dysfunction. For most people, this usually involves:

• Behavior changes, such as avoiding pushing or straining when urinating and having a bowel movement. This also might include learning how to relax the muscles in the pelvic floor area. For example, warm baths and yoga can help relax these muscles.
• Medicines, such as low doses of muscle relaxants like diazepam.
• Physical therapy and biofeedback, which can help you learn how to relax and coordinate the movement of your pelvic floor muscles.

Anal Sphincter Repair

Anal incontinence can be a distressing condition. One cause of this is damage to the anal sphincter muscle resulting in a gap in the normal ring of muscle. The damage has usually been caused by childbirth. Anal sphincter repair is an operation performed on the back passage to repair the gap in the damaged anal sphincter muscle.

What does the operation involve?

An enema is usually given an hour or so before the operation to clear the lower part of the bowel. The operation is performed under a general anaesthetic. During the operation an incision is made in the tissues between the vagina and anus. The damaged muscle is identified and freed up from any scar tissue. The healthy muscle is then overlapped (double breasted) and held together with stitches. The wound is closed with dissolvable stitches. The operation takes around 60 minutes to complete.

What are the risks?

There are small risks associated with any operation. Pre-operative assessments are made of any heart or lung conditions, as well as any coexisting medical condition. During the hospital admission patients wear stockings and are given some regular tiny injections to prevent thrombosis (blood clots). Bleeding is very rare in this type of surgery; most patients will notice small amounts of blood draining from the wound. This usually settles in the first week. Occasionally the external wound may separate at the stitch line. This rarely causes a problem, but patients may notice that they continue to pass a little blood for longer than normal after the procedure. Sometimes the wounds may become infected. If this happens a course of antibiotics is required.

What happens after the operation?

A sphincter repair operation doesn’t usually cause much pain afterwards. Most patients will need only simple oral painkillers after the first 24 hours. A drip is normally in place for 24 hours after the operation. Patients are allowed to eat and drink as soon as they feel able after the operation, usually the same day. A catheter (tube passed into the bladder) if required during the procedure is usually removed the day after surgery. Hospital stay is usually 3-5 days. After the operation patients are given as regular stool softener to take for 4-6 weeks and are advised to avoid straining. Patients are encouraged to keep mobile after the procedure. They should avoid heavy lifting or increased physical activities for about 6 weeks. Patients can normally resume driving after about 2 weeks, but this may vary. It may take several weeks to find out if the operation has been successful. We may recommend some pelvic floor physiotherapy to help strengthen the muscles afterwards.

Anorectal Physiology Studies:

What are anorectal studies?

They are a series of tests to study the function of the rectum, anus and pelvic floor. The goal of these studies is to provide your physicians with objective data for the appropriate medical and surgical treatment of your condition.

How many tests does it involve?

This depends on the types of questions that your physician wants answered. The tests currently performed are manometry (ARM), anal sensory electromyography (EMG), pudendal nerve terminal motor latency (PNTML), and endorectal ultrasound (ERUS). A cystodefecography may also be ordered and this study will be performed in the radiology department.

What is manometry (ARM)?

This is a test to study the anal sphincters and rectal wall function. It enables us to examine the coordination and strength of the muscles of the anus and rectum. The test is done by placing a small tube with a balloon at the end of it, into the anal canal and measuring the pressure changes at various locations along the length of the anal and rectal canal.

What is anal sensory electromyography (EMG)?

This study uses a sensory probe placed at the anal opening to detect the voltage activity of the anus during rest, squeeze and push. It enables us to see how well you are able to coordinate your anal sphincter relaxation and evacuation.

What is pudendal nerve terminal motor latency study?

This study enables us to evaluate the integrity of the pudendal nerve, which is one of the two important pelvic nerves responsible for the innervation and coordination of anal sphincter activity and helps maintain continence. A nerve probe is placed at the end of the examiner’s index finger and placed in the anal canal, where the pudendal nerve is stimulated at various regions adjacent to the anorectum, and the activity of the anal sphincter muscle is then recorded.

What is endorectal ultrasound?

This is an imaging tool using sound waves to look at the muscles of the anal sphincters, tumors and infections in the rectum. A probe (about the size of a thumb) with a balloon or cap at the end of the probe is passed into the rectum. The wall of the rectum and anus is scanned to look for defects, depth of tumor invasion and extent of infections.

What can I expect?

There is mild discomfort with the procedures, but they are not painful. You may need to receive two enemas prior to the procedure. This helps clean out the rectum in preparation for the study.  In order to get an accurate evaluation of the anorectal function, these tests are done without pain meds or sedation. You may therefore drive home after the procedures.

How long is the examination?

In general, the process of coming in and leaving the test center is about 2-3 hours. The procedure itself usually takes about 20-40 minutes. The number of tests and the need for sedation may affect the time to complete the study.

What is cystodefecography?

This is a test completed in the radiology department. It demonstrates how well the various pelvic organs (anus rectum, vagina, uterus, and bladder) are supported. The test involves the placement of contrast in the rectum, vagina, and bladder, in addition to the consumption of oral contrast to fill the small bowel.  After the contrast is placed, you are then asked to sit on a commode. Under radiologic evaluation, you will be asked to do a series of maneuvers to allow the visualization your pelvic organs. Their overall support and function will be assessed.

Biofeedback:

What is biofeedback for pelvic floor muscle retraining?

Biofeedback for pelvic floor muscle retraining is a treatment to help patients learn to strengthen or relax their pelvic floor muscles in order to improve bowel or bladder function and decrease some types of pelvic floor pain.  It is a painless process that uses special sensors and a computer monitor to display information about muscle activity.  This information or “feedback” is used to gain sensitivity, and with practice, control over pelvic floor muscle function. An important part of pelvic floor biofeedback therapy is consistent practice of the pelvic floor muscle exercises at home.  With biofeedback, an individual can learn to stop using the incorrect muscles and start using the correct ones.

Who can benefit?

Conditions that can be improved with pelvic muscle retraining include: accidental bowel leakage, urinary incontinence, constipation, that involves difficult or painful evacuation and some types of pelvic floor pain.

How is biofeedback performed?

Biofeedback is done in an office setting with a registered nurse who is specially trained in this type of therapy.  During the session you will be sitting in a comfortable chair in your regular clothes.  Two sensors are used.  One is placed on the abdomen and another small sensor is placed in the anal canal.  These sensors are designed to measure the electrical activity of the muscles that control bowel and bladder function. As you tighten or relax the muscles, changes are seen on the computer monitor.  Visualizing this information with the aid of the nurse, helps you to identify the correct muscles and learn to make changes that are needed. A session usually lasts one hour.  Initially a series of four weekly sessions are scheduled.  More sessions are scheduled if needed.  During the initial session the intake questionnaire and bowel diary are reviewed.  An assessment of lifestyle factors is completed.  At the end of the session you will be given instructions for your home exercise program.  Other recommendations regarding diet, fluid and exercise may be made in order for you to achieve the best results.  Your active participation is very important to your success.

How do I know if biofeedback is the right treatment for me?

It is important to consult a qualified physician when considering treatment options. A thorough assessment of the muscles and nerves in the pelvic floor needs to be done. One or more of a variety of diagnostic tests may be necessary.  Biofeedback may be a treatment recommended as a result of the evaluation.

Endoanal Ultrasound:

This involves taking ultrasound pictures of the muscles around your back passage. This test is frequently recommended to investigate patients who are complaining of faecal incontinence, rectal prolapse, constipation or symptoms of obstructed defaecation.

Do I need any preparation before-hand?

These are quick and simple tests. They are painless and do not require any sedation or anaesthetic. You do not need to take any laxatives before these tests.

What does the test involve?

You will be asked to lie on an examination couch on your left side with your knees bent. The ultrasound probe is about the same size as a finger and is inserted into the anus. This is not a painful test. Pictures can be taken which can show muscle damage or thinning. Ultrasound scans are also used to look for abscesses and fistulae. The latest equipment allows us to create three-dimensional images of the anal muscles. The endoanal ultrasound scan is often carried out at the same time as anorectal physiological tests.

What happens afterwards?

The whole testing procedure including the scan takes around 30 minutes. You will be able to go home straight afterwards and you can continue with all normal activities. The physiologist will analyse the results and a full report will be sent to your consultant.

Rectal Ultrasound scan:

An ultrasound is an examination using high-frequency sound waves to create images of tissue layers beneath the surface. Ultrasound examination involves no radiation and is a very safe procedure. It provides additional information about rectal polyps, rectal cancer, perianal infection and sphincter muscle injuries. The examination is performed by a physician who has special training in ultrasound.

What is an anal ultrasound?

An examination using high frequency sound waves to create images of tissue layers beneath the surface of the anal canal. A smooth probe the size of a finger is placed in the anus. This test is used to map out anal fistulas before surgery, and to look for lesions, tears, or scarring in the sphincter muscles. It is a safe, painless procedure and no radiation is used.

What is a rectal ultrasound?

An examination using high-frequency sound waves to create images of tissue layer beneath the surface of the rectum. A probe is put into the rectum through the anal opening. A small amount of fluid is put into the tip of the probe so that the surface of the probe is touching the inside of the rectum. This allows for better visualization of the tissue. It is a safe painless procedure and no radiation is used.

Preparation for Ultrasound:

The preparation necessary is two enemas thirty minutes apart beginning two hours prior to the procedure. These enemas will empty the rectum. You need to arrive thirty minutes before the scheduled appointment to allow time for registration and to prepare for the exam.

The Examination:

The doctor and assistant will explain the exam to you and answer any questions you have. A nurse will ask you about your medical history and your current medications and have you sign a consent form for the procedure. You will be asked to lay on your left side. The doctor will begin by doing a rectal exam. Depending on the reason for the ultrasound exam, an instrument called a proctoscope may be inserted into the rectum. The ultrasound transducer is then inserted either through the proctoscope or by itself. A transducer sends and receives sound waves that are used to create images on the screen. An additional screen is usually available so that you may watch as the doctor carefully examines the area. The doctor may decide to do a biopsy (taking small pieces of tissue) by using a small needle that passes through the transducer. The doctor is able to accurately locate and biopsy any suspicious areas with the ultrasound transducer. You may have slight discomfort for a short time during the biopsy, and an antibiotic may be prescribed for 24 hours following a biopsy.

After an Ultrasound:

Your doctor will explain the findings to you before you leave. If biopsies were taken, these will be sent to the laboratory and you will be told how to obtain the results. Doctors involved in your care will also receive the results. You will be given instructions to follow at home. If you had a biopsy, you may be given antibiotics. Usually, there are no restrictions on activity.

Rectocele Repair

This is an operation that is performed in female patients who have a bulge between the rectum (back passage) and the vagina. Often these women have difficulty emptying their bowel completely and are left with a sensation that there is more to pass symptoms of obstructive defaecation syndrome. Often they have learned to press on the back of the vagina to help them empty the bowel. The operation involves operating through the back passage (anus)  or the vagina.

 What does the operation involve?

An enema is usually given an hour or so before the operation to clear the lower part of the bowel. During the operation itself the lining of the front of the back passage is lifted up. The bulgy muscle underneath is then repaired with stitches. The lining of the back passage is then trimmed and stitched back to cover the repair. The operation involves a general anaesthetic and takes around 45 minutes to complete.

What are the risks?

There are small risks associated with any operation. Pre-operative assessments are made of any heart or lung conditions, as well as any coexisting medical condition. During the hospital admission patients wear stockings and are given regular tiny injections to prevent thrombosis (blood clots). Bleeding if very rare in this type of surgery, most patients will notice small amounts of blood on the stools when they open their bowels soon after the operation. This usually settles in the first week. Occasionally the lining of the bowel may separate at the stitch line. This rarely causes a problem but patients may notice that they continue to pass a little blood for longer than normal after the procedure. If the woman has problems with bowel control further tests may be required before surgery. The tests that would be required would be anorectal physiology and endo anal ultrasound scan as this can occasionally worsen after surgery. In some cases the operation, whilst correcting the rectocele, may not improve bowel symptoms. The surgeon will discuss this with you.

What happens after the operation?

Trans anal repair doesn’t usually cause much pain afterwards. Most women will need only simple oral painkillers after the first 24 hours. A drip is normally in place for 24 hours after the operation. Patients are allowed to eat and drink as soon as they feel able after the operation (usually the same day). A catheter (tube passed into the bladder) if required during the procedure is usually removed the day after surgery. Hospital stay is usually 2-3 days. After the operation patients are given as regular stool softener to take for 4-6 weeks and are advised to avoid straining. Patients are encouraged to keep mobile after the procedure. They should avoid heavy lifting or increased physical activities for about 6 weeks. Patients can normally resume driving after about 2 weeks but this may vary.

Surgery for rectal prolapse:

What is rectal prolapse:

Rectal prolapse is a condition in which the rectum (the last part of the large intestine before it exits the anus) loses its normal attachments inside the body, allowing it to telescope out through the anus, thereby turning it “inside out”.

Surgery for rectal prolapse:

There are two general approaches to surgery for rectal prolapse – abdominal operations (through the belly) and perineal operations (through “the bottom”).  Both approaches aim to stop the prolapse from occurring again and usually result in a significant improvement in quality of life. The choice of surgery type depends on both patient factors and procedural factors.  Patient factors include the patient’s age, sex, bowel function, continence, prior operations, and severity of associated medical problems.  Procedural factors include extent of prolapse, what effect the procedure might have on bowel function and incontinence, complication rates of the procedure, recurrence rates of the procedure and the individual surgeon’s experience. Most surgeons would agree that if a patient is medically fit for surgery, an abdominal approach may offer the best chance for a long-term successful repair of rectal prolapse.  Perineal approaches are often better choices for very elderly patients or patients with very severe medical conditions in addition to rectal prolapse. Consideration can also be given to a perineal approach in younger males, as there is a small chance (1-2%) of causing sexual dysfunction due to

nerve injury during the pelvic dissection that occurs during an abdominal approach.

Abdominal approaches:

Abdominal rectopexy with possible bowel resection:

Most abdominal techniques involve making an incision in the lower abdomen and dividing the loose rectal attachments from the pelvic walls all the way to the floor of the pelvis.  A rectopexy is then performed, whereby the rectum is pulled upwards and secured to the sacrum (back wall of the pelvis). Depending on the surgeon’s preference, the rectum may be sutured directly to the sacrum with stitches or a prosthetic material (mesh) may be included.  Regardless of the specific technique used, the intent is to hold the rectum in the appropriate position until such a time as scarring occurs to fix the rectum in place.  When patients complain of a long history of constipation, removal of a portion of the colon may be included in an attempt to improve bowel function.

Minimally invasive rectopexy with possible bowel resection:

Minimally invasive techniques such as laparoscopy or robotically, are used in some centres with equivalent success to traditional abdominal procedures.  Laparoscopy refers to the use of small incisions through which the surgeon may place a camera and surgical instruments, allowing them to perform the same procedures described above for abdominal approaches.

Perineal approaches:

It is generally believed that the perineal approach results in fewer complications and pain, with a reduced length of hospital stay. These advantages have, until recently, been considered to be offset by a higher recurrence rate. 

Perineal rectosigmodectomy:

The most common perineal approach is often referred to as a perineal rectosigmoidectomy or an “Altemeier procedure”. This approach to the surgical repair of rectal prolapse is done through the anus, with no abdominal incision.  The excess rectum and colon is pulled down and out of the body.  A full-thickness excision is done, with the remaining colon pulled down and sewn or stapled to the anus.  

Mucosal sleeve resection (Delorme procedure):

Occasionally, a surgeon may choose to do a perineal procedure slightly less extensive than a perineal rectosigmoidectomy.  A Delorme procedure does not involve a full thickness resection, as described in the perineal rectosigmoidectomy.  Instead, the inner lining of the rectum is stripped away from the muscle and removed.  The muscles of the rectum are then folded and sewn to themselves (plicate) to reduce the prolapse.  This particular procedure may be recommended in the setting of a small prolapse or if the prolapse is full-thickness but limited to partial circumference, where a perineal rectosigmoidectomy may be difficult to accomplish.  Incontinence is improved in 40-50% of patients after this procedure.

Ventral rectopexy

This is a keyhole operation performed for patients with external rectal prolapse, it is also used for patients with symptoms of obstructive defaecation or who have an internal prolapse (also known as rectal intussusception). Patients with internal external prolapse with a rectocele and faecal incontinence may also benefit from the procedure

What does the operation involve?

In most cases ventral mesh rectopexy is performed as a laparoscopic procedure. During the operation the lowest part of the bowel (rectum) mobilised on one side. A mesh made of polypropylene is fastened to the front of the rectum using stitches. The mesh is then fixed using special tacks to the bone at the back of the pelvis known as the sacrum. This has the effect of pulling up the bowel and preventing it prolapsing downwards. The operation usually involves only 3 or 4 small incisions, no larger than 1cm. Occasionally the operation cannot be done as a key-hole procedure and an open operation is required.

What are the risks?

There are small risks associated with any abdominal operation. Pre-operative assessment of heart and lung conditions are made, as well as any coexisting medical conditions. During the hospital admission patients wear stockings and are given regular tiny injections to prevent thrombosis (blood clots). Bleeding if very rare in this type of surgery and wound infections are uncommon. Sometimes during the operation the surgeon discovers that it is not possible to carry out the procedure using a wholly key-hole approach. In this situation a cut is made and the operation is done as an open procedure. This is known as conversion. In some cases the operation, whilst correcting the prolapse, may not improve bowel symptoms. The surgeon will discuss this with you. Rarely the mesh used to pull up the bowel can erode into it. If this happens the mesh or part of the mesh may need removing.

What happens after the operation?

After the operation a drip is normally in place for 24 hours.

Patients are allowed to eat and drink as soon as they feel able after the operation (usually the same day). A catheter (tube passed into the bladder) is required during the procedure and is usually removed the day after surgery. Hospital stay is usually 2-5 days. After the operation patients are given as regular stool softener to take for 4-6 weeks and are advised to avoid straining. Patients are encouraged to keep mobile after the procedure. They should avoid heavy lifting or increased physical activities for about 6 weeks. Patients can normally resume driving after about 2 weeks, but this may vary particularly if the operation is done as an open procedure.