Minimally Invasive Surgery for Rectal Prolapse: Robotic Procedures

Fig. 13.1

Port placement. Yellow ports are robotic ports with numbers corresponding to the robotic arm in the port. The blue ports are assistant ports. The red port is the camera port

All port placements are based on the location of the robotic camera, and this port should be placed first. After insufflation of the abdomen with a Veress needle, the 12 mm camera port is placed 15 cm cephalad to the pubis. Placement of this port too high on the abdominal wall will result in inability to reach the deep pelvis at the end of the procedure. A line is drawn from the camera port to the anterior superior iliac spines on both sides. Additional robotic ports are placed 8–10cm from the camera port along this line. An additional left lateral robotic port is placed 6 cm lateral to the left lower quadrant port for robotic Arm number 3. It may be necessary to mobilize a small portion of the sigmoid colon to place this lateral port. A 12 mm assistant port is placed in the right upper quadrant, and a 5 mm assistant port is placed in the epigastric area.

After port placement, the patient is placed in steep Trendelenburg position and the small bowel is swept out of the pelvis. The robot is docked with Arm 1 in the right lower quadrant, Arm 2 in the left lower quadrant and Arm 3 in the left lateral abdomen. The Arm 1 instrument is a monopolar scissors, the Arm 2 instrument is a fenestrated bipolar grasper, and the Arm 3 instrument is an atraumatic grasper. A 0-degree robotic camera is used in the beginning of the procedure.

Rectal Mobilization

The rectosigmoid is grasped and elevated by the assistant via the epigastric port. The peritoneum overlying the base of the rectosigmoid mesentery is sharply opened with scissors. And the upper rectal mesentery is elevated off the sacral promontory. Care should be taken to identify and preserve the hypogastric nerves during the maneuver. The entire posterior mesorectum is not mobilized. The peritoneum along the right side of the rectum is opened up to the rectovaginal septum. A 0-Prolene suture is passed through the lower abdominal wall on a straight Keith Needle and passed once through the Uterus and back through the abdominal wall. The suture is used to elevate the uterus with gentle traction to the abdominal wall during the surgery and can easily be removed prior to abdominal closure. A vaginal manipulator or sound is used to elevate the posterior vaginal and facilitate the anterior dissection. Some colon and rectal surgeons have used rectal dilators for this purpose because they are usually present in the operating room. However, we advocate the use of a flat acrylic vaginal manipulator for much better retraction.

While the vagina is elevated, the assistant pulls the rectum up and out of the pelvis with an atraumatic grasper. The surgeon enters the rectovaginal plane by incising the peritoneum at that level. This can be a challenging maneuver as the rectovaginal septum can and is usually much attenuated in rectal prolapse patients. The peritoneum incision is carried to the left lower rectum to complete an inverted “J-”shaped peritoneal incision that began at the right sacral promontory. The rectovaginal septum is opened to the pelvic floor. It is important to perform digital rectal exam as the dissection approaches the pelvic floor as it is easy to dissect up too far into the intersphincteric space with the exceptional robotic visualization. The right anterior and left anterior pelvic floor is exposed, but the lateral stalks of the rectum are completely preserved. For deep pelvic dissection, it may be necessary to change the 0-degree camera lens out for a 30-degree camera lens with an “up” view.

Mesh Placement

Unfortunately, there is little evidence to guide the surgeon as to the appropriate choice of mesh for this procedure. We have routinely used a lightweight, macroporous polypropylene mesh in our practice. The mesh is cut 18 cm long and it is 3 cm wide on the side intended to attach to the anterior rectum and tapered to 2 cm in width on the side intended to attach to the sacral promontory. The mesh is rolled and delivered through the 12 mm assistant port into the abdomen. The mesh is sutured to the anterior, extraperitoneal surface of the rectum with 2-0 Ethibond^® suture. Usually six sutures are placed (Fig. 13.2). The mesh is placed along the right side of the rectum and brought to the sacral promontory. The overlying presacral fascia is opened to expose the bare periosteum of the sacral promontory and presacral veins are avoided. The position of the right ureter and iliac vessels is confirmed prior to suture placement. Two 0-Ethibond^® sutures are placed in a mattress fashion to fix the mesh to the sacral promontory (Figs. 13.3a, b and 13.4). The peritoneum is closed over the mesh with 3-0 Vicryl^® suture and Lapra-Ty^® suture clips (Fig. 13.5). We do not routinely excise a portion of the peritoneum anteriorly as originally described by Loygue [22] as we find the cul-de-sac is adequately obliterated with suture closure.

Fig. 13.2

Polypropylene mesh sutured to anterior, extraperitoneal surface of the rectum

Fig. 13.3

(a) The periosteum of the sacral promontory is exposed in preparation for suturing. (b) The needle is passed through the periosteum of the sacrum

Fig. 13.4

Polypropylene mesh suture d to the sacrum

Fig. 13.5

Peritoneum closed over mesh. Note that the deep Pouch of Douglas has been obliterated and the enterocele repaired

Postoperative Care

Mobilization of the patent should start the following day after surgery. Diet is advanced rapidly as tolerated and the urinary catheter is removed when the patient is adequately mobile. Patients are usually discharged after resuming bowel function on the second or third day after surgery. After discharge, patients should be discouraged from lifting greater than 15 lbs for 6 weeks [34].

Possible Complications

Recurrent Prolapse

Robotic-assisted rectopexy is a safe procedure with a lower postoperative recurrence rate compared to the perineal procedures [15, 17]. Long-term recurrence of prolapse in patients with robotic surgery has been reported at 11–13 % [15, 17] and it is lower than the 25 % recurrent rate for conventional perineal procedures [35]. Among abdominal procedures, there is not any significant difference between recurrence rates in laparoscopic and robotic procedures [7, 16]. A meta-analysis of the published articles between 1995 and 2003 reported that there is no significant difference in recurrence between open and laparoscopic abdominal rectopexy [7]. If recurrence does occur, robotics can be used again in a similar fashion as pelvic adhesions are likely minimal.

Mesh Complications

The use of mesh in rectopexy has been supported as a technique which decreases recurrence of prolapse [36]; however, complications of the mesh can result in significant morbidity for patients [36]. There are multiple case reports regarding complications of rectopexy with synthetic mesh in the literature and the risk of mesh complications is noted to increase in the presence of a synchronous rectal anastomosis [37, 38]. The rate of pelvic sepsis associated with the use of prosthetic mesh in rectopexy ranges from 2 to 16 %; however, the higher rates of pelvic sepsis were associated with the use of the polyvinyl alcohol sponge, a practice that has largely been abandoned [28]. While some of these percentages seem alarming, it is important to remember that several large studies of laparoscopic ventral rectopexy show mesh erosion rates from 0 to 1 % [25, 27, 39–41]. Some of the other complications of mesh include: fistula and dyspareunia [42, 43].

The treatment of mesh complications is challenging. Mesh erosion into the vaginal or rectum has been treated with simple transvaginal or transanal excision [25, 39] without significant sequela. In the largest study of complications to date after laparoscopic ventral rectopexy, four patients presented with rectal stricture and were treated with laparoscopic resection [44]. All strictures were associated with the tail of the mesh being stapled too low to the midsacrum rather than the promontory. Mesh erosion into the rectum (2), vagina (8) and bladder (1), were treated with laparoscopic excision and primary repair.

Many authors are now evaluating biologic meshes in colorectal [45, 46] and gynecological procedures [47] for pelvic organ prolapse; however, current studies have not demonstrated any significant decrease in mesh complications with the use of biologic mesh in rectal prolapse procedures [42]. Overall, the use of mesh rectopexy in patients without resection appears to be reasonable with an acceptable rate of morbidity and without significant increase in mortality. However, some authors have noted a high rate of recurrence with biologic mesh after laparoscopic ventral rectopexy [44].

Constipation

Constipation can be found in more than 40 % of rectal prolapse patients [48]. The treatment of constipation in conjunction with rectal prolapse is an important challenge. Overall, posterior rectopexy without resection is less efficient in the treatment of constipation compared to posterior rectopexy with resection. In theory, postoperative constipation is explained by kinking the rectosigmoid junction between the redundant sigmoid colon and the rectum in patients with suture rectopexy [49]. Another theory is that denervation of the rectum during division of lateral ligaments can cause postoperative constipation [50].

Overall, there is not a significant difference between open, laparoscopic, and robotic approaches in the treatment of constipation. The effect of the surgery on constipation depends on the type of procedure rather than the technique (open vs. laparoscopic vs. robotic). Recent studies show that ventral rectopexy with limited rectal dissection and preservation of the rectal lateral ligaments leads to diminished postoperative constipation [25]. Portier, in a study of abdominal ventral rectopexy with limited dissection and preservation of rectal lateral ligaments, reported an incidence of only 5 % postoperative constipation [25]. Similar results were reported by D’Hoore [26]. In a systematic review of ventral rectopexy, Samaranayke and colleagues found that there is a greater reduction in postoperative constipation if ventral rectopexy is used without posterior rectal mobilization [51]. Therefore, robotic or laparoscopic ventral rectopexy with limited dissection and preservation of the lateral rectal stalks seems suited for patients with a history of constipation.

Fecal Incontinence

Fecal incontinence has been reported in more than 50 % of patients with rectal prolapse [28, 32]. The possible pathophysiology may be sphincter injury, pudendal neuropathy, or impaired rectal adaptation to distention in patients with chronic rectal prolapse [28, 52]. In terms of treatment of these patients, overall perineal procedures are less efficient in treatment of incontinence compared to the abdominal procedures as they can worsen the previous incontinence. Abdominal procedures have been reported to improve incontinence in more than 62 % of patients within 3 months after surgery [53, 54].

Treatment of Recurrent Rectal Prolapse

Recurrence of rectal prolapse after surgical treatment is quite frequent. The recurrence rate varies depending on the type of procedure and it may be as high as 50 % in some perineal procedures. Overall, the higher recurrence rate of perineal procedures compared to abdominal procedures has been reported [55]. Usually the first step is to evaluate the patient and review the previous operative records. Obviously, a patient who previously underwent a perineal rectosigmoidectomy, or Altemeier procedure, would not be a candidate for sigmoid colectomy as the rectal vascular supply is now dependent on the inferior mesenteric artery. Consideration of the existing blood supply is critical when planning reoperative rectal prolapse surgery. The treatment of such patients remains an unresolved problem; however, generally in patients without significant comorbidities, the treatment is the abdominal approach with or without sigmoidectomy. Recurrent rectal prolapse is not a contraindication to robotic surgery as adhesions are usually minimal.

For patients with significant comorbidities, the perineal approach is feasible but re-recurrence is as high as 39 % compared to the re-recurrence rate of 13 % in the abdominal approach [56]. Steele et al., with a study of 78 patients who presented with recurrent rectal prolapse, reported a significantly lower rate of second recurrence following abdominal procedures compared to perineal procedures (39 % vs. 13 %, p < 0.001) [56]. Among abdominal approaches to recurrent rectal prolapse, more and more studies seem to favor a laparoscopic or robotic technique [55, 57]. However, there is limited data examining such patients and a study of long-term outcomes of laparoscopic or robotic techniques is needed.

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