Laparoscopic Ventral Mesh Rectopexy

Andre J. L. D’Hoore

Albert M. Wolthuis

INTRODUCTION

Rectal prolapse is a full-thickness intussusception of the rectum that protrudes through the anal ring as external prolapse. Untreated rectal prolapse may lead to progressive sphincter damage and eventually fecal incontinence. Deep internal rectal prolapse as a deep intussusception into the anal canal can lead to fecal incontinence and has been linked to obstructed defecation (OD). Surgery for rectal prolapse intends to restore the anatomy and to improve function while avoiding surgery-related morbidity and functional sequellae. Laparoscopic ventral mesh rectopexy (LVR) has gained widespread acceptance, but the type of mesh used (synthetic or biologic) is of timely debate. LVR aims to preserve the rectal ampulla while correcting the leading cause: the rectal intussusception. Furthermore, it corrects a concomitant enterocele and/or rectocele. The dissection is limited to the rectovaginal septum and avoids autonomic nerve damage. More classical types of rectopexy (Ripstein procedure, Wells rectopexy, etc.) require extensive mobilization of the rectal ampulla. Such mobilization may result in autonomic neural damage leading to hindgut inertia and postoperative constipation. Therefore, the functional outcome of an abdominal suture rectopexy with sigmoid resection (Frykman-Goldberg procedure) is better. Rectal prolapse is often associated with a varying degree of middle pelvic compartment prolapse. Insufficiency of the uterosacral ligaments (level I) may lead to enterocele formation and/or vaginal vault prolapse. Structural damage to the rectovaginal septum will lead to a high rectocele (level II). The unique position of the mesh in LVR not only corrects the leading cause of the rectal prolapse (the intussusception) but also reinforces the rectovaginal septum and suspends the middle pelvic compartment (Fig. 64-1). The technique therefore should be tailored to the preoperative findings on defecation proctogram (colpo-cysto-defecography). Surgery for patients with OD and deep internal prolapse remains highly controversial. There is evidence for the role of LVR in patients with internal prolapse and fecal incontinence. Despite the presence of a mesh on the anterior aspect of the rectum, there is no impact on rectal functional volume and compliance. This is in contrast to perineal procedures (Altemeier-Delorme).

PREOPERATIVE PLANNING

In most patients with external rectal prolapse, the clinical findings will be evident. It can be important to visualize the other pelvic compartments. Therefore, a colpo-cysto-defecography or dynamic magnetic resonance scan will be indicated (Fig. 64-2). In patients with fecal incontinence, anal manometry can document residual sphincter function. In patients with OD and internal prolapse, the preoperative functional investigation should be extensive to exclude other causes of pelvic floor dyssynergia that warrant conservative treatment. It is difficult to assess the relative impact of structural (anatomic) prolapse and functional problems that contribute to outlet delay (Fig. 64-3). Preoperative anesthetic consultation is important, especially in the old and frail patient to determine whether the patient is fit for general anesthetic and a laparoscopic approach. The unfit patient should undergo a perineal procedure.

PREOPERATIVE PREPARATION

Patients are given a phosphate enema before surgery to empty the rectal ampulla. The rectal ampulla and vagina are rinsed with a Betadine solution in the operating room. Antibiotic prophylaxis is given before the start of the surgical procedure and a urinary catheter is inserted.

FIGURE 64-1 Laparoscopic ventral mesh recto-colpo-pexy. Position and fixation of the mesh: 1, Deep fixation within the rectovaginal septum reaching the level of the levator ani muscles. This allows a level II and III reinforcement of the middle pelvic compartment. 2, A colpopexy incorporating the uterosacral ligaments to the same mesh suspends level I of the middle pelvic compartment (corrects an enterocele, vaginal vault prolapse). 3, The mesh is fixed to the anterior aspect of the rectum at the level of the intussusception. 4, Fixation of the mesh to the sacral promontory.

FIGURE 64-2 Defecation proctogram: end of straining. Loops of small bowel descend into the rectovaginal septum and further protrude the intussusception. Note the important dilation of the anal canal. Prolapse is most often most pronounced in the anterior aspect.

FIGURE 64-3 Outlet delay constipation. Only the anatomic causes can be corrected with prolapse surgery.

Patient Positioning and Trocar Placement

Patients are positioned in a modified Lloyd-Davis position on a moldable bean bag with both the arms adducted. Arms are tucked along the body. Strapping should allow steep Trendelenburg position if needed. An optical trocar is positioned at the umbilical site. A 30-degree optic is preferable to facilitate deep pelvic visualization. Under direct vision, three other trocars (one 12 mm and two 5 mm) are placed. The 5-mm trocars are placed in the right flank and left iliac fossa. The 12-mm trocar is placed in the lower right iliac fossa. Care should be taken not to injure the internal orifice of the inguinal canal and the genitofemoral/ilioinguinal nerve (Fig. 64-4).

Anatomic Landmarks

A temporary uterosuspension with transcutaneous suture through the broad ligament (round ligament) can be useful to optimize the view of the pelvis (Fig. 64-5). Of interest are the rectosigmoid colon (

), the impression of the sacral promontory (1), the right ureter (2), and the right internal iliac artery (3). The left iliac vein can be close to the sacral promontory and can be injured if the dissection is too medial.