Robotic repair of bilateral levator ani eventration

This video demonstrates a robotic approach for the repair of bilateral levator ani eventration with associated perineal hernia and obstructive defecation symptoms, including pelvic floor reinforcement and concomitant ventral mesh rectopexy.

A surgical video (available online at XXX) demonstrates the technique step by step. A 71-year-old woman with a remote history of pelvic trauma and 4 prior vaginal deliveries presented with progressive bilateral perineal bulging and obstructive defecation. Computed tomography showed a chronic right pubic/superior ramus fracture with persistent fracture lines, bowel-containing bilateral levator ani eventration (right greater than left), and a 1.5-cm left levator plate defect.

A robotic repair using a 4-arm configuration was performed. Key operative steps included: (i) abdominal access and pelvic exposure with identification of the ureters; (ii) dissection from the sacral promontory to the anterior reflection with preservation of the hypogastric nerves and development of the rectovaginal plane to the perineal body; (iii) bilateral levator plate dissection and identification of an approximately 1-cm left levator defect; (iv) bilateral onlay synthetic mesh reinforcement secured with sutures and fibrin glue; (v) ventral mesh rectopexy using bioresorbable mesh secured to the anterior rectum with partial-thickness absorbable sutures and to the sacral promontory with permanent sutures; (vi) intraoperative flexible sigmoidoscopy to exclude mucosal injury; and (vii) peritoneal closure with a running barbed absorbable suture, transversus abdominis plane block, and port-site closure.

Robotic pelvic floor reinforcement with concomitant ventral mesh rectopexy is a feasible approach for symptomatic levator ani eventration with perineal hernia, enabling precise pelvic dissection, restoration of levator plate integrity, and correction of associated posterior compartment dysfunction.