Once rectal prolapse has been diagnosed, anterior resection with or without rectopexy, or rectopexy alone with or without mesh should be considered. Anterior resection involves resection of the sigmoid colon and proximal rectum with creation of a colorectal anastomosis. Resection rectopexy involves an anterior resection with suture fixation of the rectum to the sacrum (posterior) or Cooper’s ligament (anterior). It is the preferred surgical option for patients with procidentia associated with chronic constipation, extensive diverticular disease, and excessive redundant sigmoid. Mesh is often used to help create fibrosis for pelvic support and to prevent recurrence, but only in cases of rectopexy alone. If a resection is considered, the bowel should be mechanically prepared with a polyethylene glycol or sodium phosphate solution. If a patient is unable to tolerate general anesthesia, a perineal approach should be considered which includes anal encirclement, mucosal resection, and perineal proctosigmoidectomy [15, 16].

After general endotracheal anesthesia is induced, the patient is placed supine in a modified lithotomy position with legs in adjustable stirrups and carefully secured to the table to avoid any shifting when adjusting the table. Bony prominences and pressure points are padded with both arms tucked, and the body position is secured with a vacuum-mattress device, especially laterally on the right side. A foley catheter is placed into the urinary bladder under sterile technique. An orogastric tube is placed by the anesthesiologist. The operative field is prepped and draped in standard fashion.

The abdominal cavity is entered through a 12 mm incision just 1 cm above the umbilicus using either the Hassan approach or Optiview with or without the Veress needle, whichever method is preferred by the surgeon. A camera port is inserted. The remote center or thick black band on the cannula must be at the level of the peritoneum. The abdomen is then insufflated. A 30° scope is introduced into the supraumbilical port and the peritoneal cavity is explored. A 13 mm port for the first instrument arm is then placed under direct visualization a minimum of 8 cm from the camera port, 1 cm medial to the mid-clavicular line (MCL) , and along the spinoumbilical line (SUL) . The distance to the symphysis pubis should be approximately 14–16 cm. If ileostomy is required, consider placing this port at the location of the area marked as the ostomy site. Under direct visualization, another 8 mm port for the second instrument arm is then placed a minimum of 8 cm from the camera port, 1 cm medial to the left MCL, and about 2 cm superior to the SUL. A third 8 mm port can be placed on the right or left flank to provide retraction and improve exposure. If planning to perform a resection rectopexy, a 15 mm port must be placed in the rightmost position to allow for the endoscopic stapling device. A 5 mm assistant port can be placed 8–10 cm cephalad to the first instrument arm and approximately 2 cm medial to the right MCL (Fig. 11.2). Of note, port placement and docking may vary based on patient body habitus. It is also dependent on the surgeon’s comfort and skill level. There are hybrid and dual docking instructions available through the da Vinci Surgery Online Community website. Please refer to Fig. 11.3 for port placements according to body habitus.

The patient is then tilted right side down in deep Trendelenburg (Fig. 11.4). Laparoscopic technique should be used to sweep the bowel out of the pelvis for exposure. Next, the robot is docked on the patient’s left side. The patient cart, camera arm, and endoscope port must be aligned crossing the anterior superior iliac spine. Standard robotic instrumentation includes an 8 mm or 12 mm camera, cautery hook for initial dissection, graspers, forceps, scissors, and vessel sealer. Table 11.1 presents a list of recommended robotic instruments and accessories . Additional laparoscopic graspers as well as suctioning may be available to be used by the bedside assistant.

Patient positioning and preparation is similar to that of the da Vinci Si System. The da Vinci Xi System follows universal port placement guidelines. In order to maximize workspace, ports must be placed in a straight line of at least 6–8 cm apart. They must be placed at least 2 cm away from bony prominences. The initial endoscope port must be inserted approximately 10–15 cm from the closest boundary of the target anatomy, and assistant ports must be placed at least 8 cm lateral to the adjacent ports, opposite of the patient cart. With the Xi System, the abdominal cavity is entered with assistance from the Veress needle. There is no Hassan available with this system. All ports are similar in size, except if requiring an endoscopic stapling device for colon resection, a 15 mm port must be placed. Therefore, the camera can be inserted into any of the ports.

For resection rectopexy, the initial endoscope port should be placed in the umbilicus or more superior and to the right if necessary. Using the universal port placement guidelines for the Xi system, the remaining ports should be placed in a straight line following an imaginary line from the patient’s left shoulder to the right hip as in Fig. 11.5. The system is then ready for deployment. Under anatomy selection, choose “Pelvic.” The approach should be from the patient’s left side. The operating room table should be placed as low as possible in Trendelenburg with right side down at or greater than 15°. The patient cart can then be driven to position the green laser crosshairs on the initial endoscope port. Adequate clearance must be ensured between the patient and the robotic arms. The arms should be flexed inward so that they are close together but not interfering with one another (Fig. 11.6). The boom should be centered above the initial endoscope. The arms should be docked according to the cart position. Arm 3 should be docked in the initial endoscope port if the patient cart is on the left, and Arm 2 should be docked in the initial endoscope port if the patient cart is on the right. The scope should be placed in the initial port and directed at the anatomy of interest for targeting.

After proper patient positioning, port placement, and docking, the robotic instruments are introduced into the abdominal cavity via the ports. The lateral attachments of the sigmoid colon and rectum are incised with electrocautery. Dissection is carried down into the anterior space via Denonvilliers fascia to the rectovaginal space (Fig. 11.7a). Sometimes, a hernia sac that may be associated with an enterocele is seen here. The peritoneal sac may be resected. Posterior and lateral dissection is avoided. Once the anterior space is mobilized, a polypropylene mesh is secured around the anterior aspect of the rectum at the level of the peritoneal reflection and sutured bilaterally to the presacral fascia with nonabsorbable suture. The anterior wall of the rectum is thus pulled upward and posteriorly without traction. The posterior vaginal fornix can then be lifted and sutured to the mesh anteriorly, aiding in the repair of the rectocele as well as the prolapse [15–19].

The patient setup is essentially the same as previously described, but the mesh is affixed to the posterior aspect of the rectal fascia propria and then to the presacral fascia with nonabsorbable sutures or endoscopic tacks. Dissection is started posteriorly. The posterior pelvic plane under the superior rectal artery is entered. The left ureter and hypogastric nerve plexus are identified. Dissection is carried downward all the way to the pelvic floor below the rectosacral fascia (Fig. 11.7b). Sometimes to facilitate exposure, the right lateral stalk of the rectum is mobilized. Dissection then proceeds anteriorly into the rectovaginal plane to the upper limit of the vagina careful to preserve the left lateral ligament. The rectum is pulled cephalad out of the pelvis and where the fixation will occur is assessed. A window is made on the left side of the rectum to facilitate the rectopexy. A small rectangular piece of polypropylene mesh is inserted via the right lower quadrant port and placed down into the pelvic floor and extended superiorly to the mesorectum. The mesh is affixed to the sacral promontory with either endoscopic tacks or interrupted 0 nonabsorbable sutures approximately 5 cm on each side, a centimeter apart. The lateral stalks may then be sutured and tacked to the mesh to aid in suspension [15–19].

As previously described, after proper patient positioning, port placement, and docking, the robotic instruments are introduced into the abdominal cavity through the ports. Taking a medial-to-lateral approach, the redundant sigmoid is first lifted up, placing traction on the mesentery (Fig. 11.8). The mesorectum is then opened with an energy device just in front of the sacral promontory on the right and extended in both the cephalad and caudal directions. Careful dissection through the presacral avascular space is performed to preserve the hypogastric nerves anterior and inferior to the sacral promontory. Further dissection is carried out laterally along the mesentery, and the ureters, gonadal, and iliac vessels are identified and preserved. The sigmoid vascular pedicle is then isolated and divided (Fig. 11.9). Following this, the rectum is mobilized from its attachments down to the pelvic floor while maintaining the lateral stalks. The rectum must then be pulled upward from the pelvis and the distal resection margin defined for a planned anastomosis at the level of the sacral promontory. The upper rectum is then divided with an endoscopic stapling device. The proximal resection margin at the sigmoid colon is delineated, and the proximal sigmoid colon mobilized until it can reach the rectum. The robotic instruments are then removed from all the ports under direct visualization. The robot is undocked, and the gas is then exsufflated through the ports. A 5 cm extraction incision is made either through a Pfannenstiel incision or by widening the port incision in the left lower quadrant or umbilicus. Next, the proximal sigmoid is divided and an end-to-end anastomotic stapler anvil is placed within the lumen with either a purse-string device or running 2-0 prolene suture. A tension-free anastomosis is created at the level of the sacral promontory. An air leak test is then performed. Finally, rectopexy from the lateral stalks to the presacral fasia is performed with nonabsorbable sutures (Fig. 11.10). The pelvis is irrigated and hemostasis achieved prior to standard closure [16, 20].

Intraoperative complications include hemorrhage and injury to the surrounding organs and structures such as the ureters, bladder, and vagina. General early postoperative complications include atelectasis, urinary tract infection, wound infection, deep venous thrombosis, pulmonary embolism, myocardial infarction and congestive heart failure, prolonged ileus, anastomotic leak, and deep pelvic infection. Late complications include anastomotic stricture, recurrence, bowel obstruction, incisional hernia, sexual and/or urinary dysfunction, and fecal incontinence secondary to autonomic nerve injury. Complication rates vary widely among institutions and depend on surgeon experience. The recurrence rate after robotic rectopexy has been reported to be anywhere between 0 and 23 %, depending on follow-up time. In all studies, operative time was longer, but minor complication rates similar to or less than that of the conventional laparoscopic approach. The majority of studies indicate that patient satisfaction and overall functional outcome were greater for those who underwent robotic rectopexy [21–24].