Robotic Rectopexy

Colette Inaba

Alessio M. Pigazzi

INDICATIONS/CONTRAINDICATIONS

Indications

Rectopexy may be indicated for full-thickness external rectal prolapse or, much less commonly, for internal rectal prolapse with significant functional complaints. Complex rectoceles causing obstructed defecation symptoms are often associated with internal rectal prolapse and can be, on rare occasions, another indication for rectopexy.

Rectal prolapse occurs most often in females 50 years and older, with a male-to-female ratio of 1:6. Other risk factors for rectal prolapse include a deep pouch of Douglas, pelvic floor dysfunction, weak anal sphincters, connective tissue disorders, or high parity. Patients with rectal prolapse typically present with complaints of fecal incontinence, rectal bleeding, tenesmus, pain, or symptoms of obstructed defecation. These symptoms can be socially debilitating and have a significant effect on quality of life.

Rectal prolapse can be repaired using an abdominal approach or a perineal approach. The abdominal approaches include primarily rectopexy with or without sigmoid resection, whereas the perineal approaches include primarily the Delorme’s procedure (mucosal sleeve resection) and Altemeier’s procedure (perineal rectosigmoidectomy). Although the abdominal approaches typically require longer operative times, they allow for simultaneous correction of other pelvic organ prolapse. Overall, the abdominal approaches also have lower risk of recurrence compared to the perineal approaches (1.6-27% vs. 4-38%, respectively). In general, an abdominal approach should be offered to all patients without truly prohibitive medical comorbidities or technical factors that preclude an abdominal operation.

The primary abdominal surgical procedure to repair rectal prolapse is rectopexy, either posterior or ventral. Posterior rectopexy involves mobilization of the rectum and posterior fixation of the mesorectum to the sacral promontory, either with mesh or with suture (Fig. 58-1). This procedure is often associated with postoperative constipation, thought to be due to autonomic denervation caused from posterior dissection or kinking from redundant sigmoid colon. The risk of postoperative constipation can be mitigated by combining sigmoid resection with suture rectopexy, but with the disadvantage of risking anastomotic leak or stricture. However, resection rectopexy continues to be a good option for patients who complain of constipation and have a redundant sigmoid colon.

Ventral rectopexy involves mobilizing the anterior rectum and attaching it to the sacral promontory using a piece of mesh. It has the advantage of avoiding posterior rectal mobilization, thus minimizing the risk of postoperative constipation and limiting the need for sigmoid resection. Given evidence for reduced postoperative constipation with good functional outcomes and low recurrence, ventral rectopexy has become the procedure of choice for rectal prolapse in some countries.

Typically, ventral rectopexy is laparoscopically performed, because this approach has multiple advantages over the open technique, including less blood loss, less postoperative pain, faster recovery, and fewer procedure-related complications. Robotic surgery builds upon the advantages of laparoscopic surgery by providing the surgeon with three-dimensional imaging and a stable camera. Use of a robot also provides tremor elimination and articulated instruments for greater surgical precision, which is particularly helpful for dissecting and suturing in the limited pelvic space. Robotic ventral rectopexy is the standard approach at the authors’ institution institution, and is the main focus of the rest of this chapter.

Contraindications

Although there are no absolute contraindications for robotic surgery, severe adhesions may limit the ability to perform any type of minimally invasive surgery in general. In addition, patients should be
considered for a perineal approach instead of an abdominal approach if they have an incarcerated prolapse or significant comorbidities precluding general anesthesia. Relative contraindications for robotic surgery are similar to those for laparoscopic rectopexy, and include pregnancy, coagulopathy, increased intracranial pressure, or compromised cardiopulmonary status.

FIGURE 58-1 Robotic posterior suture rectopexy. The posterior upper rectum (A) is sutured to the sacral promontory after colorectal anastomosis (B-D).

PREOPERATIVE PLANNING

Patients should undergo a thorough history and physical, with particular focus on history of bowel symptoms and assessment of degree of prolapse. Prolapse is typically best evaluated with the patient sitting on a commode or toilet while performing a Valsalva maneuver. A history of constipation should prompt a transit study to assess for colonic inertia. Pelvic floor dysfunction can be assessed with defecography and anal manometry. Patients should also be screened for colorectal cancer with a thorough family history and colonoscopy.

Patients are placed on a clear liquid diet the day before surgery and are instructed to perform an enema the day of surgery. Preoperative antibiotics are administered within an hour of the first incision.

SURGERY

Positioning

The patient is positioned supine directly onto a foam pad that is fixed to the operating table. The friction between the patient and pad helps to minimize any sliding during the steep Trendelenburg positioning that is required during surgery. The legs are positioned in low lithotomy using Allen stirrups
with the patient’s buttocks aligned at the edge of the table and are also wrapped in sequential compression devices for deep venous thrombosis prophylaxis. Arms are tucked and all bony prominences are padded to prevent any pressure injury. The patient is strapped to the table across the chest and a Foley catheter is placed. Any prolapsed rectum should be manually reduced at this time. Vaginal and perineal preparation is performed in addition to the standard abdominal preparation, and the patient is draped widely from just below the nipples down to the pubis.

Technique

Port Placement

The abdomen is insufflated as per routine laparoscopic cases. We prefer to use a Veress needle inserted at Palmer’s point in the left upper quadrant. A 12-mm camera port is placed first, midway between the xiphoid and pubis. The camera port should not be placed any more than 15-20 cm from the pubis, because placement too far cephalad will limit visibility of the deep pelvis. Under direct camera visualization, a port is placed bilaterally, each located 8-10 cm from the camera port along an imaginary line extending from the camera port to the anterior superior iliac spine. The right lower quadrant port is 8 mm and used for Robot Arm 1, and the left lower quadrant port is 8 mm and used for Robot Arm 2. An additional 8-mm port for Robot Arm 3 is placed laterally in the left lower quadrant, and may require sigmoid mobilization for safe insertion. A 12-mm assistant port is placed in the right upper quadrant and a 5-mm assistant port is placed in the epigastric area. Figure 58-2 depicts the final position of all ports.

Rectal Mobilization

The patient is positioned in Trendelenburg to promote displacement of the bowel out of the pelvis. If present, the uterus is retracted by a 0-polydioxanone (PDS) suture passed through the anterior abdominal wall on a straight Keith needle. The needle is passed through the uterus and out though the anterior abdominal wall, where it is tied externally under some tension to provide better exposure to the rectovaginal plane. The suture is removed before abdominal closure.

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