Daniel P. Geisler, Deborah S. Keller and Eric M. Haas (eds.)Operative Techniques in Single Incision Laparoscopic Colorectal Surgeryhttps://doi.org/10.1007/978-3-319-63204-9_17

17. Single-Incision Rectopexy (With and Without Resection)

Samuel Eisenstein¹ and Sonia Ramamoorthy¹

(1)

Moores Cancer Center, UC San Diego, 3855 Health Sciences Drive #0987, La Jolla, CA 92093-0987, USA

Samuel Eisenstein

Email: seisenstein@ucsd.edu

Sonia Ramamoorthy (Corresponding author)

Email: sramamoorthy@ucsd.edu

Keywords

Single-incision laparoscopyRectopexyLaparoscopic rectopexyRobotic rectopexyRectal prolapseRobotic single-incision surgery

Steps of the Operation

1.

Positioning and equipment setup.
2.

Single-incision platform is placed and accessing the abdomen with a 2.5–3 cm vertical transumbilical incision.
3.

Dissection is begun at the level of the superior rectal artery and a window is made posteriorly, the left ureter is identified.
4.

If a resection is to be performed, the rectum is separated off of the sigmoid colon using a linear stapler.
5.

Dissection is carried down through the mesorectal plane anteriorly and posteriorly to the level of the levators.
6.

If a resection is to be performed, the distal end of the colon is measured, exteriorized, and transected through the single-incision port.
7.

A purse-string suture is placed and the end-to-end anastomosis (EEA) anvil placed into the distal colon and the bowel returned into the abdomen.
8.

EEA is performed.
9.

Rectopexy is performed by suturing the lateral stalks to the sacral periosteum at the level of the sacral promontory.
10.

Abdominal wound is closed.

Tips and Tricks

For optimal cosmetic results the vertical transumbilical incision hides well in the umbilicus. The fascia can be undermined to further accommodate space with minimal external scaring.
We recommend using a robotic platform if at all possible to facilitate low pelvic dissection as well as ease of rectopexy.
The dissection must be carried down to the level of the levators or the recurrence rate significantly increases. The posterior mesorectal plane is the simplest place from which to approach.
If a resection is to be performed, ensure that there is minimal tension on the anastomosis while also minimizing redundancy. It is safer to err on the side of slight redundancy to minimize the risk of anastomotic leak. We recommend testing the length intracorporeally and marking the point at which the anastomosis will be made.
The anastomosis should be made prior to the rectopexy to ensure the EEA will not disrupt the sutures.
Rectopexy should be performed by taking generous bites of the lateral stalks and suturing to the periosteum of the sacral promontory using nonabsorbable sutures.
We recommend using 2-0 Prolene and placing 3 interrupted sutures on each side, starting on the left side, which is usually more difficult.
When suturing the rectopexy, if you encounter presacral bleeding, do not remove the suture, and tie it down to compress the bleeding vessel.
Rectopexy can be very difficult to hand-sew intracorporeally using the single-incision approach. To facilitate ease of the rectopexy, we recommend the use of a robotic or other articulating surgical platform. If this is not an option, consider tying the knots extracorporeally and using a knot-pushing device or consider absorbable tacks.

Considerations for the Procedure

When accessing the abdomen for a single-incision rectopexy, it is important to be familiar with the tenets of the surgery in advance. The goals of a rectopexy include carrying your dissection to the level of the pelvic floor and suturing the rectum up to the level of the sacral promontory. Access will need to allow exposure to the sigmoid colon as well as the rectum and pelvic floor. Our preferred approach is through a vertical transumbilical incision, which allows the surgeon to be an appropriate distance away from the rectum so they can obtain the best angle for the posterior dissection and still manage to triangulate their instruments by crossing them over themselves.

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