Chapter 10.4

Chapter 10.4

Rectopexy with and Without Sigmoid Resection

Alessandro Fichera and Martin R. Weiser

Indications

Management of rectal prolapse has evolved over many centuries, but it is still generating interest and controversies involving its etiology, functional aspects, and surgical management.

A surgical approach should be carefully chosen after a thorough functional evaluation and should not be based on the surgeon’s familiarity and preference for a particular technique but rather on the fi tness of the patient and the functional disorders so often associated with rectal prolapse, among them incontinence or constipation.

The use of laparoscopic methods does not broaden or modify the indications.

We prefer a laparoscopic rectopexy with sigmoid resection in the young and fi t patient with a signifi cant history of constipation. A simple laparoscopic suture rectopexy is reserved for patients predominantly incontinent but without signifi cant constipation.

Laparoscopy has shown to have several attractive features in the surgical treatment of rectal prolapse. Laparoscopic mobilization of the rectum is feasible and safe. Magnifi ed visualization is afforded by new- generation videoscopes that facilitate precise dissection, preservation of the autonomic nerves, and avoidance of severe presacral bleeding. Even with the availability of advanced laparoscopic techniques, selection of the appropriate operation continues to be problematic for surgeons.

Perineal procedures, although less invasive, have a relatively high recurrence rate with overall acceptable short-term results and they should be offered exclusively to the high-risk elderly patients. For the younger and healthier patient population, an abdominal approach is preferred because of a lower recurrence rate. In this group, a complete evaluation of the associated symptoms is mandatory to achieve the best long-term functional results. For patients with signifi cant constipation, a sigmoid resection should be considered in combination with recto- pexy in order to provide signifi cant improvement of their symptoms.

However, in patients with severe incontinence, a suture rectopexy alone is suffi cient and a resection may worsen their continence issues.

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326 A. Fichera and M.R. Weiser

Patient Positioning and Operating Room Setup

After an epidural catheter is activated and general anesthesia attained, a Foley catheter and a nasogastric tube are inserted. Venous compres- sion devices in the lower extremities are routinely used. The patient is placed in modifi ed low lithotomy position, which allows an assistant to stand between the patient’s legs for transanal insertion of a stapling

Figure 10.4.1. Positions of the equipment and the surgical team for laparo-

scopic rectopexy.

device when a sigmoid resection is performed. Early epidural activa- tion is advantageous because it affords sympathetic blockade, which preserves intestinal peristalsis, prevents distension, and facilitates small bowel retraction and pelvic visualization. When a rectal resection and anastomosis is planned, the rectum and colon are irrigated with at least 1000 cc of warm saline or water until clear before draping the patient. Some surgeons also use diluted Betadine irrigation to theoreti- cally prevent local septic complications if microscopic spillage occurs during the construction of the anastomosis.

After adequate venous access has been established, both upper extremities are secured at the patient’s side, the abdomen is prepped and draped in the usual sterile manner, and the patient is then placed in slight Trendelenburg position. At least two monitors are necessary for laparoscopic rectal dissection, resection, and/or anastomosis and they should be placed at the foot of the table, so that both the surgeon and the assistants can maintain online visualization. Also, suction and electrosurgical devices are placed at the foot of the table (Figure 10.4.1).

Instruments

Specifi c instruments recommended for laparoscopic rectopexy with resection are listed in Table 10.4.1.

Cannula Positioning

A 5- or 10-mm cannula is initially inserted using the open technique just below the umbilicus. Additional 5-mm cannulae are inserted just lateral to the rectus abdominis muscles in the left upper and right upper quadrants. A 12-mm cannula is placed in the right lower quad- rant just lateral to the rectus abdominis muscles over McBurney’s line for the endoscopic stapler to be used for bowel resection. A 5- or 10-mm cannula is placed in the left lower quadrant depending on instrumenta- tion. The left lower cannula or umbilical site can be used for specimen extraction by enlarging it to 3–4 cm (Figure 10.4.2).

Table 10.4.1. Specifi c instruments recommended for laparoscopic rectopexy with resection

5 Cannulae (1 ¥ 12 mm, 1 ¥ 10 mm, 3 ¥ 5 mm)

1 Dissecting device (i.e., Ligasure V

or Ultrasonic Shears

or electrosurgery)

1 Laparoscopic scissors

1 Laparoscopic dissector

2 Laparoscopic graspers

1 Laparoscopic needle holder

1 Laparoscopic knot pusher

1 Endoscopic paddle

1 Endoscopic stapler

328 A. Fichera and M.R. Weiser

Technique

When the pneumoperitoneum is established at 15 mm Hg and ports are placed, full evaluation of the abdominal cavity is performed, as the majority of these patients are elderly. The patient is placed in Tren- delenburg position with the left side tilted up. The small bowel is gently retracted out of the operating fi eld using atraumatic bowel graspers. The combination of sympathetic blockade afforded by the epidural administration of local anesthetics, gravity from the Tren- delenburg position, and gentle manipulation of the small bowel allows visualization of the sigmoid mesentery and pelvis. The rectum, sigmoid, and descending colon are evaluated. Typically, there is a signifi cant redundancy of the rectosigmoid with a very low peritoneal cul-de-sac.

Figure 10.4.2. Positions of the cannulae for laparoscopic rectopexy.

Rectopexy Without Sigmoid Resection

Using a bowel grasper, the rectum and colon are gently retracted up and out of the pelvis to allow for visualization of the sacral promontory and the vascular anatomy of the rectosigmoid area. Dissecting from the right side, the peritoneum over the sacral promontory is incised (Figure 10.4.3) and the superior hemorrhoidal pedicle is identifi ed and retracted superiorly. The left ureter must be clearly visualized through the submesenteric window to avoid injuring it (Figure 10.4.4). When these two important structures are clearly visualized, the peritoneal incision is extended, fi rst cephalad to the aortic bifurcation and the hypogastric nerves are swept dorsally away from the superior hemorrhoidal artery and vein, then caudally in the pelvis for several centimeters. The assis- tant at this time with the atraumatic bowel grasper is grasping the cut edge of the peritoneum and retracting the rectum anteriorly and to the left to allow safe mobilization of the rectum in the presacral space.

This plane is avascular allowing for a bloodless dissection down to Waldeyer’s fascia at the third sacral vertebra. This fascia is sharply incised and the dissection is continued distally down to the pelvic fl oor (Figure 10.4.5).

Next, the left lateral sigmoid attachments are incised and the rectum and sigmoid colon are retracted by the assistant to the patient’s right side. The peritoneum to the left of the rectum is incised to allow com- plete mobilization of the rectosigmoid (Figure 10.4.6). The dissection is extended posteriorly to join the plane previously dissected on the right

Figure 10.4.3. From the patient’s right side, the peritoneum over the sacral promontory is incised.

330 A. Fichera and M.R. Weiser

Figure 10.4.4. The left ureter is clearly visualized through the submesenteric window.

Figure 10.4.5. After division of Waldeyer’s fascia, the dissection is continued to the pelvic fl oor

posteriorly.

side. The peritoneal refl exion is incised; however, the true lateral rectal stalks are exposed but left undisturbed.

The completeness of dissec- tion is determined visually or with the aid of a double-gloved fi nger in the rectum (Figure 10.4.7). Using a laparoscopic instrument, the surgeon’s fi nger should be palpable just above the pelvic fl oor. Further mobilization of the peritoneal refl ection is continued anteriorly at the level of the cul-de-sac if necessary. It is important again to preserve the lateral rectal stalks.

At this point, if only a rectopexy is planned, the rectum is placed under moderate tension by the assistant through the left lower quadrant port sites.

A 0 nonabsorbable suture is passed through the right lower quadrant cannula into the peritoneal cavity. The needle is grasped by the needle holder in the right lower quadrant cannula and is driven through the presacral fascia, about 1 cm below the sacral promontory and about 1 cm to the right of the midline (Figure 10.4.8). The needle is then passed through the lateral rectal stalks in a location so that the rectum will be under mild tension (Figure 10.4.9). Intra- or extracorporeal knot- tying is performed. Often, we will use extracorporeal tying in which the suture is pulled out of the abdomen and a Roeder knot is performed and slit with a knot pusher to tighten the suture. At this point, a second rectopexy suture is placed in the same manner 1 cm cephalad from the previous one on the patient’s right side.

The surgeon at this time places tension on the rectum toward the right presacrum. If this maneuver does not cause excessive angulation

Figure 10.4.6. The left lateral sigmoid attachments are incised while the assistant to the patient’s right

side retracts the rectum and sigmoid colon.

332 A. Fichera and M.R. Weiser

Figure 10.4.7. Insertion of a double-gloved fi nger into the rectum may aid in determining the complete- ness of dissection of the rectum.

Figure 10.4.8. The fi rst rectopexy suture is driven through the presacral fascia, about 1 cm below the

sacral promontory and about 1 cm to the right of the midline.

or tension, rectopexy sutures can be placed on the patient’s left side.

This is indeed a controversial point and some authors would not place rectopexy sutures bilaterally in order to avoid possible rectosigmoid angulation especially when a resection is not planned. At the comple- tion of the rectopexy, an intraoperative proctoscopy is performed past the rectopexy site to make sure that no angulation or constriction of the lumen has occurred.

Figure 10.4.9. The needle is then passed through the lateral rectal stalks in a location so that the rectum

will be under mild tension (inset: Use of the externally tied Roeder now is used, allowing for rapid

tying of the rectopexy sutures).

334 A. Fichera and M.R. Weiser

Resection Rectopexy

After performing the complete mobilization, the sigmoid colon is then retracted toward the left side of the pelvis by the assistant. It is impor- tant to have a clear understanding at this point of the vascular anatomy of the rectosigmoid as well as the location of the left ureter, which was initially identifi ed through the window underneath the superior hem- orrhoidal vessels on the left side. This procedure preserves the left colic artery, dividing only the sigmoid branches of the inferior mesenteric artery.

Viability of the distal bowel in this way presents no problem and is supplied by the middle and superior hemorrhoidal vessels. The proximal blood supply is usually adequate through the left colic artery, which is also preserved. The sigmoid branches are dissected at their takeoff from the superior hemorrhoidal artery and are sealed and divided with the LigaSure

device. Mobilization of the mesentery leading to the proximal and distal transection points is also completed from the patient’s right side. The assistant on the left side is retracting the sigmoid to the left side of the pelvis.

It is important to remember that when this operation is performed for prolapse, the rectum should be mobilized to the pelvic fl oor and laterally to the level of the lateral stalks, but the anastomosis should be performed at or just below the sacral promontory. At the distal resec- tion point, the mesorectum is divided with the LigaSure

device. The assistant retracts the rectum up and out of the pelvis and toward the left side with the surgeon completing the distal dissection from the right side.

Once this is accomplished, an endoscopic stapler is inserted through the right lower quadrant port site, placed across the upper rectum, and deployed. Because of the high level of transsection, the stapler may need to be fi red twice to completely divide the rectum at this point.

When this is accomplished, the left lower quadrant or umbilical cannula site is enlarged to 3–4 cm to allow exteriorization and proximal transec- tion of the specimen.

When the abdominal cavity is entered and the pneumoperitoneum is evacuated, a wound protector is inserted. The divided sigmoid colon is then delivered through the incision. Proximal division of the mesen- tery can be completed extracorporeally and the proximal limit of the resection is identifi ed, circumferentially freed from the mesentery and divided between clamps. At this point, a pursestring is applied over the distal stump and the center rod and anvil of a circular stapler 31 mm is inserted and secured in place.

Tension over the mesentery of the sigmoid and descending colon is evaluated at this time and further mobilization is achieved if needed.

The distal stump is inserted back into the abdominal cavity. Interrupted fascial stitches are placed to close the extraction site around a port and pneumoperitoneum is reestablished.

When that is achieved, the assistant holds the distal sigmoid colon

to allow proper orientation of the mesentery and avoid torsion. The

second assistant between the legs of the patient inserts the shaft of

the circular 31-mm stapler. A suture is placed in the spike of the stapler

to facilitate laparoscopic removal. The stapler is passed transanally and guided to the rectal staple line. The spike of the circular stapler is then advanced adjacent to the rectal staple line and removed by grasping the suture. The spike is removed through the right lower quadrant port site.

The surgeon then grasps the center rod of the circular stapler anvil and inserts it into the shaft of the stapler. Proper orientation of the mesentery is further checked. The assistant allows for retraction of the sigmoid colon for adequate visualization of the mesentery. The stapler is then closed and deployed. The stapler is released and extracted transanally. The two rings are checked. A leak test is performed by insuffl ating the rectum transanally while the pelvis is fi lled with fl uid and the descending colon is occluded to detect air leaks from the anas- tomosis. The pelvis is then copiously irrigated with warm sterile saline solution using a laparoscopic suction irrigator.

The rectopexy is then performed distal to the anastomosis as previ- ously described. Proctoscopy is performed to ensure that there is no angulation or constriction. The cannulae are removed in a routine manner and the cannula sites are closed.

Special Considerations

As described in the previous section, a clear understanding and defi ni- tion of the anatomy of the pelvis at the time of dissection and exposure are mandatory to avoid intraoperative complications.

Two major structures ought to be identifi ed and avoided intraopera- tively: The left ureter and the presacral veins. As in any sigmoid and rectal resection, the left ureter is at risk for injury if not properly visual- ized and retracted out of the operating fi eld. The left ureter should be immediately visualized upon opening the right peritoneum and creat- ing a window underneath the superior hemorrhoidal vessels. When the left ureter is identifi ed, it should be dissected downward away from the operating fi eld together with the gonadal vessels. Another area where the ureter could be injured is at the level of the left pelvic rim if the incision at the peritoneal refl exion on the left is taken too laterally.

It is mandatory when incising the peritoneum on the left side of the pelvis that the surgeon retracts the rectum to the right and the fi rst assistant incises the peritoneum medially. At that level, the ureter is usually lateral and it is critical to dissect in the correct plane.

It is our practice in any laparoscopic procedure that if the anatomy of the ureter is not clearly visualized, laparoscopy is aborted and a laparotomy is performed. Similarly, in situations of inadvertent ure- teral injury, conversion to open laparotomy is essential to assess the extent of damage. Resection of damaged tissue and repair over a stent is usually possible. Because there is no retroperitoneal infl ammation in these patients, routine use of ureteral stents is not indicated.

When performing the rectopexy over the sacral promontory, it is

important to place the sutures at least 1 cm off the midline to avoid the

presacral veins. In case of a presacral bleed, an attempt to direct pres-

336 A. Fichera and M.R. Weiser

sure should be performed and it is often indicated to tie the suture that has been placed over the injured vein and eventually add additional stitches. If the bleeding cannot be controlled with laparoscopic methods, clearly a conversion is indicated.

A specifi c complication in patients that have had only a suture rec- topexy is the angulation of the redundant sigmoid colon after place- ment of the sutures. This problem should be detected and avoided by intraoperative inspection of the lumen with a rigid proctoscope before evacuating pneumoperitoneum. If this condition is not noted intra- operatively, the patient will present with diffi culty evacuating and worsening constipation in the months after surgery. This is indeed a diffi cult problem to manage at that point and will require takedown of the previous rectopexy and possibly a sigmoid resection. Usually, these are patients with redundant sigmoid colon at the time of the initial rectopexy.

In patients who have had a resection rectopexy, anastomotic leak is always a concern. Similar to any other intestinal anastomosis, tension over the anastomosis ought to be avoided. Viability and vasculariza- tion of the stumps should be left intact by preserving the left colic artery and the superior hemorrhoidal artery as previously described. In case of a clinically evident anastomotic leak, oral intake should be immedi- ately discontinued; the patient should be started on intravenous fl uids and antibiotics, and evaluated with a Gastrografi n enema to assess the extent of the leak. Management can vary from observation to having to perform a diverting loop ileostomy and drainage of the pelvic sepsis.

If a leak is noted at the completion of the anastomosis, careful evalua- tion should be performed. This should be done before completing the rectopexy so that a 360° view of the anastomosis is possible. If the area of leakage is identifi ed, it should be reinforced with intracorporeal sutures. If the leak is not controlled by this measure, treatment options include temporary diversion, takedown and re-creation of the anasto- mosis, and conversion to an open procedure for further evaluation.

Frequent early postoperative sequelae that are not specifi c to the operations described include urinary retention and postoperative ileus.

A Foley catheter is kept in place until the epidural infusion has been discontinued. This is to prevent postoperative urinary retention, espe- cially in the older male patient population. A clear visualization of the hypogastric and the sacral nerves helps in avoiding long-term urinary and sexual dysfunction.

Return of bowel function can also be delayed especially in patients with a history of chronic constipation. Our practice is to allow the patient to have a clear liquid diet the day immediately after surgery.

We watch for progression of recovery of intestinal function. When passage of gas has been documented, at that time the patients are allowed to be advanced to a low residue diet and discharged home.

Other laparoscopic techniques for repair of complete rectal prolapse

have been described. Specifi cally, tacking of the rectum to the sacrum

using either polypropylene mesh or a sling has been described. We

believe that a rectopexy or a resection rectopexy are much simpler

procedures and as effective as those that include mesh insertion.

Further details on the long-term results of this procedure will be pro- vided in Chapter 11.6.

Conclusions

To achieve adequate long-term functional results in patients with rectal prolapse, either open or laparoscopically, a careful preoperative evaluation and the selection of the appropriate surgical technique based on the physiologic parameters of the specifi c patient are required.

If these principles are applied to laparoscopy, there is no reason to believe that our long-term results will be less optimal than those achieved in the best series of conventional open approach, while the advantages of a less invasive technique will then benefi t this patient population.

Editors’ Comments

Indications: We would consider sigmoid resection in most young and healthy patients even if not symptomatically constipated because constipation tends to worsen after simple rectopexy.

Patient positioning: We place the monitors near the knees of the patient.

Electrosurgical devices are placed lateral to the patient, and the suction device is placed near the head of the patient in our setup.

Instrumentation: We use similar instruments.

Cannula positioning: Our positioning is similar.

Technique: We strongly advocate use of the surgeon’s double-gloved hand placed into the rectum to check the level of dissection. We use a size 2–0 nonabsorbable (braided) on a ski-needle (atraumatic) for the rectopexy. We also advocate intraoperative endoscopy to check patency of the lumen after application of the rectopexy sutures. We avoid placing stitches on both sides of the rectum because they may constrict the lumen of the bowel. If conversion is required, we will consider a Pfannenstiel incision, because this heals rapidly and the resultant scar will be hidden in the suprapubic area. If bleeding is the indication for conversion, a midline incision permits entry into the abdomen more quickly.

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