Abdominal Rectopexy: Hand Assisted

Edward Borrazzo

Neil H. Hyman

INDICATIONS/CONTRAINDICATIONS

Rectal prolapse may cause considerable life-altering disability including bleeding, pain, and fecal incontinence. Numerous remedial operations have been described, with very few high-quality studies available to facilitate evidence-based recommendations.

In general, abdominal approaches have been recommended for fit patients and perineal procedures for the elderly and/or infirmed patients. Rectopexy allows for fixation of the rectum to the sacrum, thereby preventing the rectum from prolapsing outside of the anal canal. The role of/need for concomitant resection remains uncertain and controversial.

Rectopexy can be performed utilizing open, laparoscopic, robotic, or hybrid techniques, such as the hand-assisted laparoscopic approach. Laparoscopic ventral rectopexy has become a very popular option to treat rectal prolapse primarily in European centers, but has a mesh erosion rate of approximately 2%. It is our custom to perform rectopexies with or without resection using a purely laparoscopic approach and to avoid the use of mesh. However, patients with recurrent prolapse after a previous open or laparoscopic abdominal approach are often best served by the hand-assisted technique. Similarly, a hand-assisted rectopexy can be used to obviate the need for conversion to a larger laparoscopic incision when technical problems are encountered during laparoscopic rectopexy.

Extensive adhesions or previous pelvic sepsis can be considered a relative contraindication to hand-assisted rectopexy; however, it is often difficult to predict a hostile pelvis based on history alone. Laparoscopic visualization is often an appropriate first step.

As with all operative procedures, surgeons must candidly assess their skill set and decide what they can best offer the patient. Hand-assisted rectopexy may be the best and safest approach for many surgeons with which to perform an effective procedure to correct the prolapse and minimize the risk of recurrence. Whether the procedure is performed open, laparoscopically, robotically, or with hand assistance is truly a secondary consideration and should be made on a case-by-case basis by the individual surgeon based on their training, experience, and comfort level.

PREOPERATIVE PLANNING

Planning is similar to the planning for any abdominal colorectal procedure. If the patient is not suitable for laparotomy/laparoscopy, a perineal procedure should be chosen. It is important to consider why the patient has developed the prolapse and whether there are other manifestations of pelvic floor relaxation.

A careful history may elicit causative factors for the prolapse such as bulimia or a connective tissue disorder. Patients who excessively strain and/or have a defecation disorder such as a non-relaxing puborectalis can be appropriately counseled or referred for biofeedback to minimize the risk of recurrence after corrective surgery. Individuals suspected to have slow-transit constipation may be scheduled for colonic transit studies and considered for colectomy at the time of rectopexy on a highly selective basis. Women with concomitant uterine prolapse or cystocele, for example, can be treated in a multidisciplinary manner with a joint surgical approach.

Flexible endoscopy (or suitable radiologic studies) should usually be performed, especially in age-appropriate patients, to make sure that the rectal prolapse is not caused by a neoplasm that is acting as the lead point for the prolapse.

If the patient has recurrent prolapse and/or has undergone previous pelvic surgery, review of the previous operative report(s) can be invaluable. Quite often, “recurrent” prolapse actually is persistent prolapse and represents a failure to adequately mobilize the rectum by an inexperienced pelvic surgeon.

Operative Technique

Not all rectopexy cases are undertaken with hand assistance. However, hand-assisted techniques are helpful for dissection of the mid and lower rectum, especially in reoperative cases. An intracorporeal hand can facilitate identification of the ureters if stents are used and also provides countertraction for dissection of the lower third of the rectum down to the pelvic floor as desired. Tactile sensation affords assessment of the true tension on the rectum and the appropriate degree of cephalad traction when fixing the rectum to the sacral promontory. If a concomitant sigmoid resection is performed, hand assistance can allow for precise cephalad countertraction while ensuring a tension-free anastomosis.

We position the hand-assist device at the level of the umbilicus (Fig. 59-1). This position keeps the hand from obscuring the field of view as compared to more inferior placement and provides acceptable cosmesis with the subsequent incision hidden in the umbilical fold. Alternatively, a hand port placed in a Pfannenstiel incision may allow wide exposure to the pelvis as necessary without extending the incision. Ports are placed in the mid abdomen on each side. An additional working port is placed in the right lower quadrant. The camera alternates between the two lateral ports to get a view on each side of the rectum as the dissection is performed in the pelvis.

In reoperative cases, anatomic planes are often difficult to visually identify at first. Use of the hand can help define the proper plane of dissection. It is often easiest to begin along the white line of Toldt at the level of the descending colon, because this area has usually been untouched in the first operation even if a resection has been performed. The left ureter can then be inferiorly traced, while mobilizing the intact mesocolon and mesorectum from the retroperitoneum, pelvic brim, and lateral sidewall (Fig. 59-2).

In a similar manner, the right ureter may be identified. Dissection is undertaken inferiorly along the lateral aspect of the rectum (Fig. 59-3). The lateral stalks are usually divided in reoperative cases to facilitate mobilization of the distal third of the rectum and improve access to the pelvic floor. This may increase the risk of constipation, but appears likely to decrease the risk of prolapse recurrence.

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