Laparoscopic Well’s Rectopexy

KEY STEPS

1. Insertion of ports: 10-mm umbilical open technique; 5-mm right iliac fossa; 5-mm right upper quadrant; 5-mm left iliac fossa.

2. Patient placed in the Trendelenburg position (slight rotation to right may be required to aid visualization of sacral promontory).

3. Laparoscopic assessment and the small bowel and omentum moved toward right upper quadrant.

4. Inferior mesenteric artery pedicle identified from medial aspect and elevated off the retroperitoneum. Left ureter is identified. No vascular division is performed.

5. Medial-to-lateral mobilization of the sigmoid colon with little dissection of the descending colon.

6. Lateral mobilization of the sigmoid colon but limited mobilization of the left colon.

7. Rectal mobilization. Dissection behind the posterior 60% of the rectum in the presacral plane.

8. Division of peritoneal attachments on the right and left sides of the rectum to the level of the lateral stalks (should be preserved).

9. Insertion of a 2- × 4-cm piece of polypropylene mesh via the umbilical trocar and positioning at the sacral promontory. Fixation of the mesh to the sacral promontory.

10. Elevation of the rectum out of the pelvis under appropriate tension and suture rectopexy of the mesorectum to the mesh.

11. Closure of the umbilical port fascia.

PATIENT POSITIONING

The patient is placed supine on the operating table on a bean bag. After induction of general anesthesia and insertion of an orogastric tube and a Foley catheter, the patient’s legs are placed in yellow fin stirrups. The arms are tucked at the patient’s side and the bean bag is aspirated. The abdomen is prepared with antiseptic solution and draped routinely (Chapter 2).

INSTRUMENT POSITIONING

The primary monitor is placed on the left side of the patient at approximately the level of the hip. The secondary monitor is placed on the right side of the patient at the same level and is primarily for the assistant during port insertion and the early phase of the operation (see Fig. 23.1). The operating nurse’s instrument table is placed between the patient’s legs. There should be sufficient space to allow the operator to move from either side of the patient to between the patient’s legs if necessary. The primary operating surgeon stands on the right side of the patient with the assistant standing on the patient’s left, and moving to the right side, caudad to the surgeon once ports have been inserted. A 0-degree camera lens is used.