Pelvic pressure or heaviness
Urinary incontinence or retention
Fecal incontinence
Constipation
Protrusion or bulge from vagina and/or rectum
Pain
Rectal bleeding or mucous discharge
A thorough physical examination evaluating all the pelvic floor compartments is essential for determining what surgical treatment to recommend. It is important to note that complete rectal prolapse (rectal procidentia) is a full-thickness protrusion of the rectum through the anus (Fig. 11.1), while incomplete rectal prolapse (partial rectal procidentia) consists of internal rectal prolapse to, but not through, the anal canal. Both represent degrees of severity along the continuum of pelvic floor prolapse and should be appropriately diagnosed and treated.
Fig. 11.1
Complete rectal prolapse (rectal procidentia )
The simplest method of diagnosing complete rectal prolapse is to visualize this in the office by having the patient reproduce the prolapse while straining in the left lateral position or while sitting on a commode. Sometimes it can be difficult to reproduce, and we have found it helpful for patients to take a photograph at home. In addition, rectal examination should focus on evaluation of sphincter tone and function , as well as the presence of a patulous anus, rectocele, solitary rectal ulcer, and/or rectal mass. How do we know who should be referred for more than a sacrocolpopexy? If patients deny having a protrusion or defecation problems, we do not think any further work up is necessary. But, the right questions need to be asked. Many patients will not openly tell you unless you ask. In addition, many patients either think it is their hemorrhoids or are afraid it may be something worse such as cancer and so they don’t inform anyone.
While vaginal and rectal prolapse are diagnosed by physical examination, the presence and extent of associated pelvic floor dysfunction requires dedicated imaging studies. Fluoroscopic defecography (Fig. 11.2) or dynamic magnetic resonance imaging (MRI) (Fig. 11.3) prove critical in identifying the various anatomic defects present and ensuring the involvement of appropriate specialties in an attempt to improve surgical outcomes and decrease recurrence. There is consensus that most types of vaginal prolapse can be staged and surgery planned without imaging. In fact, most “enteroceles” that occur in the setting of high stage vaginal vault prolapse are without symptoms and are addressed by a sacrocolpopexy without formal enterocele repair. However, rectal prolapse is often caused by severe straining caused by an enterocele that protrudes between the posterior vaginal wall and the anterior rectum (usually in the setting of good apical vaginal support). In the setting of rectal prolapse, it is very important to obtain if the patient has an enterocele. A common mistake is to correct the prolapse without repairing the enterocele. This results in a very high recurrence rate. Additional preoperative studies may be warranted based on the patient’s clinical evaluation which are beyond the scope of this chapter (Table 11.2) .
Fig. 11.2
Example of flouroscopic defecography
Fig. 11.3
Dynamic magnetic resonance imaging of rectal prolapse. Note the enterocele, which results in severe straining and likely exacerbated her rectal prolapse symptoms
Table 11.2
Ancillary preoperative studies and imaging
Colonoscopy |
Anal manometry |
Urodynamics |
Cystoscopy |
Colonic Transit Marker Study |
Surgical Treatment of Multi-visceral Organ Prolapse
Although much progress has been made regarding the preoperative assessment and necessity for a combined surgical repair when addressing multi-visceral organ prolapse, the optimal procedure for treatment of this disorder is still not defined. In our practice, we approach all pelvic reconstruction surgery through a multidisciplinary approach with colorectal surgeons, urologists, and gynecologists discussing the pathology, patient selection, and approach. In our opinion, this offers the best chance for curative intervention with the aim of improving symptoms and quality of life.
Abdominal sacrocolpopexy is considered the gold standard procedure for the surgical correction of vaginal vault prolapse. Sacrohysteropexy is an option for women who wish to preserve their uterus (see Chap. 9). Simultaneous repair of rectal prolapse includes anterior or posterior rectopexy, with or without placement of mesh, and with or without sigmoid resection . Watadani and colleagues studied open sacrocolpopexy and rectopexy for combined middle and posterior compartment prolapse, demonstrating that it is a safe procedure with low risk of recurrence, improved bowel function, and improved quality of life scores [8]. Many surgeons have transitioned to performing this procedure through a minimally invasive approach, initially with laparoscopic instrumentation and, more recently, with robotic technology. This evolution of approach is born from the enhanced capabilities of robotic instrumentation for operating in the deep pelvis as compared to rigid laparoscopic instruments. For years, surgeons operating in the pelvis have had to adapt to the limitations of laparoscopic instrumentation, which include operating at an oblique angle in the cone-shaped pelvis utilizing static instrumentation . However, robotic surgery mimics the surgeon’s maneuvers and is more consistent with open surgical techniques. The da Vinci surgical system has several advantages including three-dimensional visualization, wristed instrumentation that restores seven degrees of freedom, zoom magnification, and a third working arm. The end result is finer dissection with improved exposure, visualization, and suturing (particularly anteriorly and deep to the sacral promontory). Previously, deep pelvic dissection and the required pelvic suturing proved challenging and was limited to expert laparoscopic surgeons. The learning curve for robotic surgery, especially in the pelvis, does not appear as steep as for traditional laparoscopic surgery [9].
Combined Robotic Sacrocolpopexy and Posterior Rectopexy: Techniques and Surgical Options
Rectopexy vs. sigmoid resection . There is no consensus among colorectal surgeons about the best approach for repair of rectal prolapse. Traditionally, if a patient has severe constipation associated with a redundant sigmoid colon and rectal prolapse, she is recommended to have sigmoid resection and rectopexy. If there is no evidence of a redundant sigmoid colon, then a rectopexy alone is advised. This continues to evolve as new techniques emerge such as the ventral mesh rectopexy that will be discussed later in this chapter.
Step 1. Intubation
The patient is placed directly on a thick foam pad on the operating table in order to prevent sliding with Trendelenberg position during the operation. After general endotracheal anesthesia is administered, the patient is placed in low lithotomy position in Allen stirrups. The patient’s arms are padded with foam and tucked at the sides. A urinary catheter is then placed in a sterile field.
Step 2. Port Placement
Once the abdomen and perineum are prepped and draped, a 12 mm curvilinear incision is made in the periumbilical position. A Veress needle or a Hassan technique is used to achieve trocar placement, followed by insufflation to 12–15 mmHg CO2 pneumoperitoneum. The da Vinci camera (Intuitive Surgical, Sunnyvale, CA) is introduced and a general inspection is performed. A 0° or 30° down camera can be used, based on surgeon preference. We prefer the 30° down scope because we can visualize over the sacral promontory better in the presacral space.
Under direct visualization, two 8-mm trocars are placed on each side along the mid-clavicular line just below the umbilicus. A third 8-mm trocar is placed in the left lower abdomen along the mid-axillary line. Finally, a 1-mm trocar is placed at the right lower abdomen along the mid-axillary line as an assistant port approximately 4 cm above the anterior superior iliac spine. The Si robot arms should be placed a minimum of 10 cm apart in order to avoid arm collisions; however, the robotic arms can be placed closer with the Xi robot (Fig. 11.4).
Fig. 11.4
Port placement
Step 3. Docking
The patient is placed in steep Trendelenberg position with slight left side up. The da Vinci bedside cart is side-docked in order to maintain access to the vagina and rectum during the course of the procedure (Fig. 11.5). The small bowel is retracted out of the pelvis and the relevant pelvic landmarks are identified.
