Hand-Assisted Resection Rectopexy

William Timmerman

Indications/Contraindications

Rectal prolapse continues to be an interesting and challenging problem for both patients and surgeons alike. A myriad of procedures utilizing abdominal and perineal approaches have been developed, which serves as a testimony to the fact that no one procedure fits all patients, and therefore fitting the right patient to the right operation is important to obtain good results (1).

As a general rule, abdominal approaches are preferred for more healthy and fit patients, while perineal approaches are more often utilized in elderly and/or infirm patients (2).

A sigmoid resection and rectopexy offers the dual advantages of refixing the prolapsing rectum to the sacrum, and removing the usually redundant sigmoid, which not only helps prevent postoperative constipation (1,3,4,5), but also helps with prevention of recurrence by leaving the patient with a straightened left colon supported by the phrenicocolic ligament and left lateral peritoneal attachments (2,6). This anchoring in turn acts as a second point of fixation to help prevent rectal sliding and descent, and subsequent prolapse recurrence.

Sigmoid resection and rectopexy can be performed in open, pure laparoscopic, or hand-assisted laparoscopic fashion. Compared with open laparotomy, a laparoscopic approach offers the advantages of less pain, shorter hospitalization, and a faster recovery and return to work (2,3,7,8). It is our practice to perform resection/rectopexy in either pure laparoscopic or hand-assisted fashion, with the hand-assisted technique being especially useful in the more difficult patients with extensive adhesions from previous surgeries or pelvic conditions, in those patients with recurrences of prolapse following previous abdominal approaches, and when trying to avoid conversion to full open surgery when technical problems are encountered at operation. We also find it a very useful technique for those striving to obtain and improve their laparoscopic comfort, skills, and competency early in their laparoscopic careers (9,10).

Contraindications include all the usual contraindications to laparoscopic surgery, including labile cardiac disease, severe COPD, and conditions causing a general inability
to tolerate position changes during surgery. The inability to safely dissect and operate at surgery, as caused by extensive adhesions or other technical factors is the most common contraindication to laparoscopic approaches. Therefore, as a first step at surgery, placing a single camera port with an honest assessment of the intra-abdominal “lay of the land”, coupled with an honest assessment of one’s technical skills, is crucial to a good, safe outcome for both patient and surgeon.

Preoperative Planning

As a first requirement, the patient must first be a suitable candidate for laparoscopic surgery. Significant cardiac and pulmonary problems must be accurately assessed and addressed, and the patient’s previous surgical history thoroughly reviewed, especially previous pelvic or pelvic brim surgery. If the patient has had extensive previous pelvic surgery or inflammatory conditions, consider the placement of temporary ureteral catheters at the time of surgery, especially if early in one’s laparoscopic career.

Preoperative workup goes to the reasons why the patient developed prolapse in the first place (11). Patients with significant constipation merit colonic transit studies, and may be candidates for concomitant total colectomy if severe colonic inertia is discovered.

Colonoscopy should be undertaken to exclude leading points for prolapse such as tumor, as well as to discover other covert or unrelated significant colonic problems that could be appropriately addressed at the same operation (e.g., a large right-sided villous neoplasm).

Concomitant pelvic floor abnormalities should be preoperatively identified, as they may affect surgical outcomes, and may on occasion be concomitantly treated at surgery. For example, uterine prolapse and cystoceles may be simultaneously treated in a multidisciplinary fashion at the time of prolapse repair (12). Paradoxical puborectalis contractions may be a contributor to preoperative constipation, straining, and the formation of the prolapse, as well as a contributing factor to postoperative recurrence if unaddressed or unrecognized. Therefore, anal manometry and defecating proctography can play an important part of the workup.

Surgery

Operative Technique

A hand-assisted technique can offer some significant advantages. For the less experienced laparoscopic surgeon, it offers the security of retained tactile feedback, improved eye-hand coordination, and help with learning depth perception while operating through a screen monitor (9,10). For surgeons at all skill levels it can offer improved exposure by traction and countertraction, and can be especially helpful with the ability to palpate and safely identify and delineate vital structures such as ureters, ureteral catheters, adhesed loops of bowel, and other significant structures, all of which may be partially obscured by adhesions and other operative conditions. It can aide in the control of bleeding vessels, and can help develop appropriate tissue planes during dissection. The tactile feedback with hand-assistance can help to more accurately assess tension across the colorectal anastomosis, and at the point of rectal fixation to the sacrum. In addition, it can also assist with intracorporeal suturing.

Patients are placed in supine lithotomy position, with both arms tucked, and orogastric and bladder catheters in place (Fig. 56.1); the operator stands at the patient’s right side.

Placement of the hand-assisted device varies between “midline” locations (Fig. 56.2

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