Laparoscopic Rectopexy

INDICATIONS/CONTRAINDICATIONS

Laparoscopic rectopexy is an important technique for the treatment of rectal prolapse. The procedure can be combined with sigmoid resection or performed alone as a means for treating full-thickness rectal prolapse when resection is not desired. Laparoscopic rectopexy without resection is especially useful when patients have problems with fecal incontinence or when a patient or surgeon does not want to accept the risk of an anastomotic leak.

PREOPERATIVE PLANNING

Before surgery, patients should undergo a full preoperative evaluation including a thorough history of the presenting symptoms, including the presence of constipation or fecal incontinence, and a physical examination. A colonoscopy should be performed to identify possible underlying colorectal pathology. In addition, these studies can be supplemented with anoscopy for better evaluation of the anal canal, with anal manometry to determine preoperative resting anal pressure, and defecography to determine if a patient has concurrent rectocele, enterocele, or internal rectal prolapse. Colonic transit studies can be considered in patients who present with constipation to evaluate for colonic inertia. Patients should also undergo appropriate preoperative cardiac and pulmonary evaluation to establish that they can tolerate general anesthesia.

We utilize a combined oral antibiotic and mechanical bowel preparation the evening before surgery. The mechanical preparation facilitates physical manipulation of the rectum with laparoscopic and robotic instruments.

SURGERY

Laparoscopic rectopexy is a relatively easily performed technique that includes full circumferential mobilization of the rectum to the level of the pelvic floor. Surgeons should be facile with laparoscopic suturing techniques and have equipment that will permit the secure attachment of the mesorectum to the presacral fascia.

Positioning

Patients should be placed in the supine position in stirrups. The patient’s thighs should be level with the torso to enable the unencumbered motion of the surgeon’s arms. The surgeon and camera operator typically stand on the right side of the patient. The first assistant stands on the patient’s left side. Generally, a camera port is placed at the superior edge of the umbilicus and the abdomen is insufflated to 15 mm Hg. Two additional lateral 5-mm ports are placed in both the right and left lower quadrants under direct vision. A 30-degree angled laparoscope is used to facilitate lateral viewing. On each side of the patient, the most inferior port is placed two fingerbreadths medial and superior to the anterior superior iliac spine. The superior lateral port is placed four fingerbreadths superior to the lower port (Fig. 57-1). Alternatively, one 5-mm port can be placed to the left and one 5-mm port to the right at the level of the umbilicus.

FIGURE 57-1 Port placement for laparoscopic rectopexy.

Technique

The operation begins by lifting the rectum toward the abdominal wall and retracting the proximal rectum superiorly and to the left. This motion creates tension on the redundant rectal mesentery. Positioning the patient in steep Trendelenburg will help displace the small bowel from the pelvis. Tilting the operating table to the left at this time will expose the right side of the rectum. The right lateral peritoneum overlying the mesorectum is then scored with electrocautery or diathermy scissors beginning at the sacral promontory (Fig. 57-2). The retrorectal space is developed in a proximal-to-distal direction toward the pelvic floor. We mobilize the right side of the rectum, first extending distal and then to the left (Figs. 57-3 and 57-4). The right and left ureters are identified and protected. When only the peritoneum remains on the left, the rectum is retracted to the right and the left peritoneum is opened (Fig. 57-5). Inclining the table to the right at this point in the operation may help exposure.

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