Objective: To demonstrate the safety, feasibility and technique of laparoscopic robot assisted bilateral pararectal hernia repair with mesh.

Case: 80-year-old female with multiple medical comorbidities and previous pelvic surgery for rectocele presented to the emergency department with bilateral buttock pain and ulceration over the left glute. A CT scan was performed which demonstrated large bilateral perirectal hernias containing both large and small bowel without signs of perforation or obstruction. The hernia defects were noted to be pararectal through the levator muscles, similar to a paraoesophageal hernia and diaphragm. Patient was discharged and underwent outpatient preoperative risk stratification and optimization. During this process it was discovered that the patient had been denied surgery by five surgeons spanning three hospitals. Elective laparoscopic robot assisted bilateral pararectal hernia repair with mesh was performed by reducing the hernia contents, creating a pre-peritoneal plane, reducing the hernia sacs, closing the pararectal defects with non-absorbable V-Loc suture, inserting a ProGrip Mesh and anchoring it to Cooper's ligament bilaterally and the sacral promontory using Ethibond suture. The peritoneal flap was then closed with absorbable V-Loc suture. The patient tolerated the procedure well, was discharged home on post-operative day four and continues to thrive in follow-up.

Conclusion: Pararectal hernias are rarely described in the literature, as are the techniques to treat them. We present the first minimally invasive approach using robotic surgery to repair pararectal hernias. We conclude that laparoscopic robot assisted bilateral pararectal hernia repair with mesh is safe, feasible and should be considered for pararectal hernias.