Ventral Rectopexy

Sherief Shawki

Sarah A. Vogler

Perioperative Considerations

Full-thickness rectal prolapse is a true intussusception of the rectum through the sphincters versus the anorectal mucosa only.
Typically, patients present with symptoms to include fecal incontinence, bulging “mass,” pain, mucous discharge, bleeding, and reduced quality of life.
Perineal approaches may be best suited for high-risk patients, given the less invasive nature of the procedure compared to traditional open approaches, and the ability to be performed under regional or local anesthesia.
With minimally invasive technology, data have shown reduced postoperative pain, decreased length of hospital stay, earlier recovery, lower surgical site infections, and similar functional results and recurrence rates with an abdominal approach.
All patients (unless contraindicated) should receive preoperative oral antibiotics (eg, metronidazole and neomycin), along with a full mechanical bowel preparation, and provided a chlorhexidine body wash for the night prior to surgery.

Patient Positioning

The patient is placed in modified lithotomy position. Legs are held in Yellowfins. Lithotomy position gives the option to the surgeon to stand between the legs when distal transverse colon mobilization is necessary.
Patient should be well secured to the operative table, body parts are well padded, and joints properly positioned as patient will be in steep Trendelenburg for the majority of the operative procedure, while the robot is docked.
An orogastric tube is inserted as well as a Foley catheter that comes out under the patient’s right leg.
The surgeon is at the robot, and the bedside assistant stands at either side.
The primary working monitor is on the patient’s right side.

Anesthesia

General anesthesia is typically utilized.
Complete muscle relaxation is necessary for effective insufflation and laparoscopic visualization.
Epidural anesthesia is unnecessary. Pain is generally well controlled using multimodal analgesia with transversus abdominis plane block, oral, and intravenous analgesia.

Technique

Port Placement

For Si Platform

A 10-mm conventional laparoscopic port at the umbilicus for the robotic camera.
Two robotic trocars (8 mm) placed 9 cm lateral and 15 degrees caudal to the umbilicus bilaterally.
A third robotic trocar corresponding to the fourth robotic arm is placed 9 cm lateral and 45 degrees cephalad on the left side.
An 8- to 10-mm conventional laparoscopic port is placed on the patient’s right lateral side for assistant. This creates a flattened “W” configuration (Fig. 48-1A).

FIGURE 48-1

da Vinci Si port placement. A. Si Port Placement. B. Xi Port Placement.

For Xi Platform

The four robotic arms are placed horizontally across the level of the umbilicus (Fig. 48-1B). The robotic camera is placed through robotic arm 3. The assistant port remains the same (Fig. 48-2).
The patient is subsequently placed in steep Trendelenburg for exposure of the pelvis and in preparation for docking.

FIGURE 48-2 Xi robot and differences in arms.
During this time, and prior to docking the robot, the surgeon may perform any needed steps, in a conventional laparoscopic manner, to assure proper pelvic exposure.
- This may include moving the redundant sigmoid colon, and or cecum out from the pelvic cavity, perform adhesiolysis, and/or tucking the uterus to the anterior abdominal wall (Fig. 48-3A-D).

FIGURE 48-3

A. Bowel in pelvic cavity that will need to be removed. B. Bowel being removed from pelvic cavity. C. Takedown of adhesions to remove the bowel from the pelvis. Inset. Lysis of adhesions is done prior to docking for optimal pelvic exposure and safe conduction of the procedure. This could also be done while the robot is docked. D. Uterus anchored to anterior abdominal wall.

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