Laparoscopic ventral mesh rectopexy (LVMR) was first described in 2004 to improve surgical outcomes in patients with external rectal prolapse operated between 1995 and 1999 [1]. The technique aims at correction of the full thickness intussusception as the leading cause. Dissection is limited to the rectovaginal septum and avoids extensive rectal mobilization. Despite a limited dissection, recurrence rates have been comparable to other more extensive techniques [2].

This autonomic nerve sparing technique that spares the rectal reservoir not only improves faecal continence but also avoids the development of rectosigmoidal inertia and secondary constipation. Even more, an improved rectal evacuation was observed. This has been attributed to some of the features of the operation: the unique position of the mesh into the rectovaginal septum impedes intussusception of the rectum and reinforces the rectovaginal septum.

In a double-blind randomized single-centre study Lundby et al. showed that functional outcome after ventral mesh rectopexy was superior to that after sutured rectopexy. Obstructed defecation score, PAC-SYM and PAC-QoL significantly favoured the ventral mesh rectopexy group [3].

Over time, LVMR gained widespread acceptance to treat total rectal prolapse and indications were broadened to complex rectoceles and patients with deep internal rectal prolapse and functional problems (faecal incontinence and/or obstructed defaecation).

The impact on faecal incontinence is significant with an overall improvement of 80–90%. Therefore, LVMR is recommended as a first step in patients with faecal incontinence and high grade internal rectal prolapse [4]. The more that PNE (percutaneous sacral nerve evaluation as part of sacral nerve stimulation (SNS) has been demonstrated to be less effective in that scenario [5].

The improvement on constipation is certainly less impressive but the development of ‘de novo’ constipation is rare. Therefore, proposing LVMR for obstructed defaecation (ODS) is a slippery slope and without solid evidence LVMR certainly has been overrated as a ‘functional’ operation [6].

ODS is often multifactorial and the finding of (high grade) internal rectal prolapse is common. This can contribute to other functional problems (motility and sensitivity dysfunction in the rectosigmoid). The knowledge gap remains to understand the relative impact of the different findings. That is the reason that only about 60–70% of patients with high grade internal prolapse and ODS functionally benefit from the operation.

The evidence for LVMR for patients with ODS remains limited to mostly single-centre large patient series. Reasons enough for a critical appraisal to understand the exact role of LVMR for ODS.

The efforts of Grossi et al. are therefore of timely importance. They propose a unique trial design (stepped-wedge RCT) and use a set of different validated constipation scores. In contrast to most previous studies the authors explored validated disease—specific quality of live scores. For different reasons their trial had poor recruitment and the presented data therefore are under-powered. But they add to the evidence that LVMR could benefit patients with ODS and internal prolapse. More data are needed to understand how to meaningfully investigate patients with ODS and to come to a validated set of selection criteria to offer LVMR surgery in a specific subgroup of patients with OD.

The main reason of poor recruitment is patient’s as well as doctor’s fear to offer a rectopexy technique that includes the use of a mesh.

The transvaginal techniques for mesh rectovaginal septum reinforcement to treat pelvic organ prolapse and stress urinary incontinence resulted in an unacceptable high risk for mesh related problems: chronic infections, bleeding, mesh erosion and chronic pelvic pain. With good reason it caused a flow of lawsuits and public awareness.

This is, however, in contrast to the mesh related problems after LVMR. Consten et al., in a large series documented a < 5% cumulative risk at 10 years [2]. There should be ongoing efforts to develop the ideal mesh (material) and sutures to further minimize this risk. The media exposure on the subject impact patients and surgeons’ perception. A major effort is needed to explain the subtle differences in surgical techniques to treat pelvic organ prolapse and to convince patients that the risk of mesh related problems after LVMR is low. Large prospective registries to document long-term outcomes are needed.

Thirty years after the introduction of LVMR Grossi et al. did a major effort to determine in a scientific sound way the effect size of surgery on ODS.

Despite 30 years of experience in LVMR determining selection criteria to offer patients a conservative treatment or surgical treatment for remains a clinical challenge.