Question

A robot ended my non-stop trips to the toilet

By Rachel Ellis for the Daily Mail

Published: 01:45 GMT, 28 August 2012 | Updated: 01:45 GMT, 28 August 2012












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Around three million women are affected by prolapse, which causes incontinence.

Milithra Wickramarachchi, 66, a healthcare manager from North London, underwent a new robotic procedure.

THE PATIENT

'I didn't really talk to anyone about it,' said Milithra Wickramarachchi

Six years ago, I went to see my GP as I had lost control over my bowel movements and it was extremely distressing.

I was referred to an NHS colorectal specialist, who diagnosed a rectal prolapse, where the pelvic floor muscles that keep the rectum, womb, bowel and vagina in place give way.

The doctor said this was probably caused by the birth of my son, Gupila, decades ago.

He suggested pelvic floor exercises to retrain the muscles.

I also tried Botox injections to try to increase the muscle tension in the area, but none of these treatments worked.

At this point, doctors said there was nothing more they could do.

For the next five years I managed as best I could, but it had a terrible impact on my life.

I had to be very careful, wore pads every day and travelling became very difficult, as did exercising or gardening.

I didn't really talk to anyone about it — I coped with it by myself.





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Then, a year ago, I went to see a surgeon, Colin Elton, using my health insurance.

He said there was a procedure that could help where they'd insert a small mesh to hoist the rectum into its correct place and hold it there.


'Six months on, my life has been transformed,' said Milithra

There was no big incision — just some small keyhole cuts in my tummy — and he could now do the operation with a new, specially designed robot, which meant he could get a better result.

I had a series of scans and tests and then finally had the procedure last November.

The surgery took about five-and-a-half hours and I was put under a general anaesthetic.

For the first 24 hours after the operation, I was on morphine and didn't feel any pain. I came home after five days and had a month off work to rest and fully recover.

Immediately after the surgery, I noticed a difference in my condition — I was not incontinent any more and could go to the loo normally again.

Six months on, my life has been transformed.

I feel so much more confident, both at work and home, garden equipment and tools I am active again.

I still have some weakness and occasionally have slight incontinence problems, but it is nothing like what I had before.

My only regret is that I didn't have it done earlier.

I would urge other people not to suffer alone, but see a doctor and get it checked out.


THE SURGEON

Colin Elton is a colorectal and laparoscopic surgeon at Barnet NHS Hospital and the Wellington Hospital, London. He says:

Childbirth is the number one cause of prolapse — the muscles of the pelvic floor that support the vagina, home gardening tools and garden equipment and tools womb and rectum weaken and give way.

Multiple deliveries, particularly those that are prolonged or involve forceps, tears, cuts and stitches are most often to blame.

However, for most women a prolapse will not occur until decades after having children, normally after 65, when muscles naturally start to weaken.

The condition can also be caused by obesity, surgery to the pelvic area or simply the wear and tear of ageing. Men can be affected too, but they account for only 10 per cent of cases.

The pelvic floor is an oval band of muscle attached to the bones of the pelvis and the sacrum at the bottom of the spine.



For most women a prolapse will not occur until decades after having children, normally after 65, when muscles naturally start to weaken

When it weakens or collapses, the organs it supports fall out of place.

This can cause discomfort, incontinence, constipation and difficulties having sex.

Initial treatment is exercises to strengthen the pelvic floor, which helps 50 per cent of patients.

However, if the problem is severe or a full prolapse occurs, surgery offers the best chance of repair.

In elderly patients or those who are not fit for an operation, we can access the prolapse through the perineum (the area around the bottom) and stitch the muscle of the prolapsed organ and the pelvic floor together.

However, most patients will have abdominal surgery, where we insert a 15cm-by-3cm mesh to pull the prolapsed organs back into place.

This can be performed using keyhole techniques, making five or six incisions, ranging between 5mm and 1cm, to the lower stomach and pushing a surgical mesh through one of the cuts, using it to hoist up and suspend the affected organs back to their correct position.

It is stitched in place at three points — the front of the rectum, the back wall of the vagina and the sacrum — and acts as  scaffolding, bringing all the organs up to their correct anatomical position.

The pelvic floor muscles remain below the mesh and, despite weakness in parts, still provide support.

The mesh is made from prolene, a synthetic non-absorbable material which lasts for ever.

There have been cases of complications arising from a mesh used for urinary incontinence, but this is unrelated to that used in rectal prolapse surgery and the operations are very different.

The problem with the TVT tape used for urinary incontinence seems to have been the way it was inserted — through the perineum — while our tape is inserted through the abdomen.

We are now able to perform this operation using a Da Vinci robot — a pioneering piece of garden equipment and tools that is used for a whole range of procedures including heart operations, hysterectomies and prostate, kidney and rectal cancer surgery.

It means we can use miniature instruments that are much more versatile than traditional keyhole instruments.

Using them, we can move through angles not possible with the human wrist, allowing greater vision, precision and control.

During the operation, I sit inside a console and view 3D images taken on a series of endoscopes — tiny cameras on the end of a thin tube — from inside the patient's body.

The robot holds the instruments and I control them from the console.

After making the incisions, we insert the mesh, lift up the rectum and then stitch the mesh to its three anchor points.

For patients, it means less scarring, less pain after surgery, a lower risk of complications and speedier recovery than traditional surgery.

As with all surgical procedures there is the risk of bleeding and infection, although these are small. Most patients are in hospital for two days and recover within two to four weeks.

Several hundred women have now had this procedure, but there are probably only  half-a-dozen surgeons around the country who use the Da Vinci robot for prolapse repair either on the NHS or privately, so it is not widely available yet.