Abdominal Rectopexy: Hand Assisted



Abdominal Rectopexy: Hand Assisted


Greta V. Bernier

Sowsan H. Rasheid





PREOPERATIVE PLANNING

As previously mentioned, there is no medical treatment that is curative for full-thickness rectal prolapse. However, patients do benefit from medical optimization with respect to their defecatory function before an operation. Persistent constipation, diarrhea, and pelvic floor dysfunction with increased straining all increase the risk of recurrence postoperatively. Constipation should be managed with high water intake, high fiber diet, and laxatives. This is particularly important in internal rectal intussusception because surgery must be reserved as a last resort owing to unpredictable and mixed outcomes, including possibly worsened constipation or incontinence with rectopexy, as previously mentioned.

A complete history should be obtained including pelvic floor history, gynecologic history, traumatic vaginal deliveries, sexual abuse or assault, and trauma. Eliciting surgical history is important both for prediction of intra-abdominal adhesions as well as location of hand port potentially within a prior surgical incision. Physical examination should focus on abdominal and pelvic examination, including commode or toilet test with pseudodefecation to provoke rectal prolapse. Digital rectal examination is performed to evaluate sphincter tone. There is little benefit to anorectal manometry or physiologic testing because this will likely be abnormal given the presence of prolapse and therefore will potentially be vastly different postoperatively and, therefore, not meaningful. Likewise, routine defecography is not necessary in the presence of clinical full-thickness prolapse. Defecography is helpful if there is concern for other occult pelvic floor disorder not evident on physical examination that may change the operative approach or for evaluation of internal rectal intussusception. The only preoperative study we routinely recommend is recent colonoscopy to evaluate for concurrent disease. A colonic transit marker study is recommended if there is concern for colonic inertia as the cause of chronic straining and resultant rectal prolapse.


OPERATIVE TECHNIQUE


Positioning and Operating Room Setup

Patients are prepped in low lithotomy position with draping such that there is access to both the abdomen and the perineum. It is important to have access to the perineum for digital rectal and vaginal examinations intraoperatively to guide dissection. Arms are bilaterally tucked to allow adequate space for both operating and assisting surgeons on either side of the patient. Monitors should be placed at the foot of the bed or off the left leg. This operation will require steep Trendelenburg position; therefore, the patient should be adequately secured to the bed and the bed tested to ensure steep Trendelenburg capability.

A bladder catheter is placed for bladder decompression and bilateral ureteric catheters may be used at the discretion of the surgeon. It is important to note that the catheter may not work as well in steep Trendelenburg position. This fact should be communicated to the anesthesia team for monitoring fluid status as well as be noted by the operating team. If bladder distension obstructs exposure to
the pelvis, the patient may need to be returned to the horizontal position momentarily to drain the bladder. Orogastric tube placement, rectal irrigation, and preoperative mechanical bowel preparation are optional and may be elected on the basis of the surgeon’s preference.


Technique

Hand-assisted rectopexy begins with open incision access to the abdomen to a length of 1 cm smaller than the surgeon’s glove size. Both low midline and Pfannenstiel incisions have been described for this technique, and the choice is largely surgeon dependent. Pfannenstiel incisions have the benefit of both decreased hernia rate as well as decreased rate of surgical site infection. In addition, a Pfannenstiel is appropriately positioned to allow access to the rectum and presacral fascia if open dissection is required. Midline incisions may be beneficial for those patients in whom a straight laparoscopic approach was started and the periumbilical port site can be extended to allow for hand port placement. Midline incision can be either periumbilical or infraumbilical based on the patient’s body habitus.

Additional working ports include a 12-mm right lower quadrant port and a 5- or 10-mm camera port in the right mid-to-upper quadrant. The right lower quadrant 12-mm size port is required to accommodate stapling and suturing devices as well as to pass needles into the abdomen for intracorporeal suturing with laparoscopic needle drivers. The hand port is primarily used for blunt dissection and retraction of the rectum and sigmoid out of the pelvis.

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May 5, 2019 | Posted by in GENERAL | Comments Off on Abdominal Rectopexy: Hand Assisted
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