Laparoscopic Resection Rectopexy

Martin A. Luchtefeld

James W. Ogilvie Jr

INDICATIONS/CONTRAINDICATIONS

There are many surgical options from which to choose when treating a patient with rectal prolapse. The sheer number and diversity of choices suggests there is no perfect answer for all circumstances. The choices can be broadly categorized into three types: (a) sigmoid resection with rectopexy (Frykman-Goldberg procedure), (b) rectopexy with or without mesh, and (c) perineal approaches including perineal rectosigmoidectomy (Altemeier procedure) or rectal mucosectomy and plication (Delorme procedure). The first two options, both abdominal procedures, can be done either via an open or a minimally invasive approach. The first consideration while selecting the appropriate operation is whether or not the patient is medically fit to undergo a major abdominal operation. Abdominal approaches are felt to have a lower recurrence rate but are associated with a greater risk of complication, especially when combined with a sigmoid resection. The perineal approaches are traditionally associated with higher recurrence rates but are usually performed on older patients with more comorbidities. Nevertheless, they are most often well tolerated with few complications.

In patients medically fit for an abdominal surgery, rectal mobilization and rectopexy with or without sigmoid resection have good perioperative outcomes with low recurrence rates. However, rectopexy alone in some series has a higher risk of postoperative constipation, even in patients with normal bowel habits before the procedure. The addition of sigmoid resection with rectopexy may mitigate the disturbed effect on rectosigmoid motility related to posterior rectal mobilization and therefore may be a better choice for the patient with constipation. Nevertheless, it carries the small but real risk of anastomotic leak that is not an issue for the patient undergoing rectopexy alone. Therefore, sigmoid resection with rectopexy is a reasonable option for the medically fit patient who already suffers from moderate constipation.

Resection rectopexy can be performed via an open or a minimally invasive approach. Early in the history of laparoscopic colon and rectal surgery, rectal prolapse surgery was thought to be an ideal disease process for the new laparoscopic approach: a benign disease, noninflammatory, and the mesentery tending to be redundant and relatively easy to address. Multiple studies have confirmed that laparoscopic-aided sigmoid resection and rectopexy have decreased perioperative complications, shorter hospital stays, and less postoperative pain. Although there are fewer studies that address long-term outcomes, they demonstrate functional outcomes and recurrence rates comparable to other approaches.

PREOPERATIVE PLANNING

Before surgery, the diagnosis of rectal prolapse must be verified during physical examination. Visualizing and identifying rectal prolapse is occasionally not straightforward. Evaluating the patient on an examining table may be insufficient to confirm rectal prolapse. If the diagnosis has not been made during the usual examination, the patient can be placed on the commode and then reexamined after several minutes of straining. Once the prolapse has been reproduced, the diagnosis is usually quite obvious. However, occasionally, it can be difficult to distinguish full-thickness rectal prolapse from mucosal prolapse or significant prolapsing hemorrhoids disease. If uncertainty remains, identification of the circular folds of the full-thickness rectal prolapse will confirm the diagnosis. Small-volume or occult prolapse in addition to patient discomfort and/or embarrassment may also limit the ability to discover a prolapse. In such circumstances, fluoroscopic- or magnetic resonance imaging-based defecography (or ultrasound-based in some centers) will often reveal the hidden prolapse.

A focused history and digital rectal examination are also important to assess the integrity of the sphincter complex and any related fecal incontinence that may alter the decision to perform a resection rectopexy. Adjunct studies such as anal manometry, endoanal ultrasound, and pudendal nerve terminal motor latency testing may be useful if there is a significant history of concomitant incontinence, but in most cases they do not alter the decision-making process. It is also important to endoscopically or radiographically evaluate the colon to ascertain whether other significant pathology that might alter the surgical plan exists.

Although the majority of patients suffer some degree of constipation in addition to the prolapse, it is a rare occasion that a total abdominal colectomy is combined with the rectopexy. In most circumstances there is a significant postoperative improvement in constipation. If severe constipation persists following surgery, then further evaluation with a colonic transit study is warranted after excluding technical complications such as an anastomotic stricture. It is the author’s opinion that only after intense multidisciplinary medical management has failed should one consider a minimally invasive resection rectopexy.

PREOPERATIVE PREPARATION

Data continue to amass regarding preoperative mechanical and oral antibiotic bowel preparation. Recent meta-analyses suggest that systemic antibiotics in addition to mechanical preparation with oral antibiotics are safe and lower the risk of surgical site infections, possibly even anastomotic leak. There is controversy surrounding the extent of the benefit, but the authors routinely implement this practice. It is also technically superior to no preparation in that it facilitates bowel handling and allows easy passage of an endoscope and of an intraluminal stapling instrument. The administration of intravenous antibiotics within 1 hour of incision time is well documented to decrease surgical site infections and should be routinely given. Resection rectopexy lends itself well to enhanced recovery; however, specific adjuncts to enhanced recovery that have been directly linked to avoiding perioperative complications have not been well elucidated.

SURGERY

Positioning

Following general endotracheal anesthesia, the patient should be placed in the dorsal lithotomy position (Fig. 61-1). The legs are arranged in stirrups that can be easily positioned and changed. An indwelling bladder catheter is placed as well as gastric decompression to decrease the chance of gastric injury. It is important to have the patient secured to the operating room table to ensure that the patient does not move during intraoperative positioning, both to avoid peripheral nerve damage and also altering the ability to access the anus for intraluminal stapling. Various commercial devices exist to safely secure the patient when in Trendelenburg position, although other methods such as taping, straps,
or wrapped sheets may be acceptable and are operating room specific. Having the ability to safely place the patient in steep Trendelenburg, reverse Trendelenburg, right side up, and right side down is essential to allow the small bowel to move out of the operative field. The right arm is carefully tucked and padded as well, allowing two surgeons to be on the right-hand side of the patient.

FIGURE 61-1 The patient is placed in a dorsal lithotomy position with the legs in adjustable stirrups. The patient should be fixed in place with a beanbag mattress or some other combination of straps or fixation devices.

Trocar Placement

The placement of trocars is an important part of the success of this operation and is essentially the same as for sigmoid colectomy or low anterior resection (Fig. 61-2). A periumbilical port is used for the camera. Although usually the camera port is placed in an infraumbilical position, in a shorter patient with less distance between the pubis and the umbilicus, moving the port site to just above the umbilicus affords a better view with the laparoscope. Additional ports are placed as illustrated. If stapling is performed via the right lower quadrant port, then it should be a 12-mm port to allow passage of an endoscopic linear staple. In this case, a left lower quadrant or lower midline incision could be used for extraction. The larger 12-mm port may also be placed in the suprapubic position allowing the larger port to double as a mini-Pfannenstiel extraction site. After pneumoperitoneum is achieved, the right lower quadrant port should be placed just lateral to the inferior epigastric vessels at a level ˜2 cm superior to the anterior superior iliac spine. An additional 5-mm port on the left side allows the assistant to provide retraction and countertraction for the primary surgeon and is best positioned at the level of the umbilicus or lower.

Vascular Division

Once the trocars are in place, the patient is placed in steep Trendelenburg and right side down positions to facilitate moving the small bowel out of the pelvis and thus optimizing the continued retraction of the small bowel. This simple maneuver will optimize visualization of the pelvic structures. The vascular division is done at the level of the superior hemorrhoidal vessels (Fig. 61-3) at the level of the sacral promontory. Dissection is most commonly undertaken in a medial-to-lateral manner. The sigmoid colon is usually very redundant and the first step is to elevate the redundant colon out of the pelvis. By doing so, the superior hemorrhoidal vessels can be identified coursing over the sacral promontory. The mesentery can then be grasped and placed on traction. The step of placing the
mesentery on tension makes the vasculature stand out even in the patient with a thick or very fatty mesentery (Fig. 61-4).