Laparoscopic sigmoidectomy with ventral and posterior indirect rectopexy for rectal prolapse in a female patient

Rectal prolapse is an uncommon disease mainly seen in patients of advanced age. In the last few years, the laparoscopic route has been shown to be feasible and has the advantage of being a minimally invasive technique. The objective of this film is to demonstrate a technique for the repair of rectal prolapse with sigmoidectomy. This is the case of a 72-year-old woman with a previous history of hysterectomy presenting also with dyschezia and moderate incontinence and a grade III rectal prolapse. Defecography showed a prolapse of the upper rectum with an enterocele without any associated rectocele in spite of the hysterectomy.

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Laparoscopic sigmoidectomy with ventral and posterior indirect rectopexy for rectal prolapse in a female patient

Authors

J Leroy, D Mutter, F Costantino, J Marescaux

Abstract

Rectal prolapse is an uncommon disease mainly seen in patients of advanced age.
In the last few years, the laparoscopic route has been shown to be feasible and has the advantage of being a minimally invasive technique. The objective of this film is to demonstrate a technique for the repair of rectal prolapse with sigmoidectomy. This is the case of a 72-year-old woman with a previous history of hysterectomy presenting also with dyschezia and moderate incontinence and a grade III rectal prolapse. Defecography showed a prolapse of the upper rectum with an enterocele without any associated rectocele in spite of the hysterectomy.

Classification

clinical cases

Keywords

Laparoscopic sigmoidectomy, ventral posterior indirect rectopexy, rectal prolapse

Media type

Surgical video

Duration

10'03''

Publication

2009-07

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E-publication

WeBSurg.com, Jul 2009;9(07).
URL: http://www.websurg.com/doi-vd01en2485.htm

Laparoscopic sigmoidectomy with ventral and posterior indirect rectopexy for rectal prolapse in a female patient

1. Introduction 00'09''

The objective of this film is to demonstrate a technique for the repair of rectal prolapse with sigmoidectomy. This is the case of a 72-year-old woman with a previous history of hysterectomy presenting also with dyschezia and moderate incontinence and a grade III rectal prolapse. Defecography showed a prolapse of the upper rectum with an enterocele without any associated rectocele in spite of the hysterectomy.

2. Exploration of operative field 00'38''

As soon as the abdominal cavity is entered, both the sigmoid and omentum are fixed at the level of the bladder and left part of the pelvis.

3. Freeing of adhesions 00'49''

Adhesions of the sigmoid colon to the left lateral side of the pelvis are taken down. This adhesiolysis is unfortunately followed by a bleeder at the level of the rectal wall, which will necessitate resection of the sigmoid colon later on.

4. Presacral dissection 01'07''

Once the root of the sigmoid mesocolon has been exposed, the prerectal space is opened paying attention to the superior right hypogastric nerve plexus, which tends to be drawn by traction placed to the medial portion of the sacrum. The presacral dissection posterior to the fascia propria of the rectum is brought down very caudally until the posterior part of the horizontal rectum. Anteriorly, the Douglas’ pouch is opened on the posterior aspect of the vaginal wall.

5. Rectovaginal space opening 02'03''

The rectovaginal space is opened by staying as close as possible to the vaginal wall proximal to Denonvilliers’ fascia. Dissection is carried out thanks to monopolar spatulated scissors and thanks to anterior traction of the vaginal wall through a H-shaped retractor allowing for a cranial retraction (as if a valve had been introduced into the suprapubic space).

6. Double strip placement for rectopexy 02'51''

Once dissection and retraction are complete, a double strip is attached to the sacral promontory thanks to Protack® staples or stitches. The titanium staples are placed on the fibrous tissues paying attention to preserve the middle sacral vessels. This prosthesis is also fixed to the upper portion of the sacral concavity. We use a polyester prosthesis. As can be seen in the pictures here, the lateral peritoneal bridge has been preserved. And the strips are positioned posterior to the peritoneum, which will restrict peritonization and will preserve the lateral attachments of the rectum. The 12 by 15cm long, polyester prosthesis that has been fixed to the promontory, is brought to the anterior surface of the lower rectum and is anchored by polyester stitches. Here we can see how helpful it is to use an adequate retractor that allows to lift up the vagina and control the strip’s attachments to the anterior rectal wall. This is achieved through Ethibond polyester threads using a knot-pusher that ensures a blunt fixation of the polyester strip on the anterior rectal wall. Four stitches are placed. The objective is to maintain the rectum cranially enough without any excessive traction. It is also useful to fix the fascia propria of the rectum on the posterior surface of the strip, which helps maintain the posterior part of the rectum cranially without any undue traction. This helps to avoid the opening of the anorectal flexure. The objective of the fixation is to maintain the rectum cephalad in a traction-free fashion only through rectal suspension.

7. Douglasectomy 05'48''

In the present case, a Douglasectomy is performed. We must bear in mind that the Douglas’ pouch is quite deep. Anyhow, its resection will help to re-approximate the space using absorbable monofilament material. This material is easy to manipulate and avoids any trauma to tissues, and helps to place several stitches laparoscopically before placing any traction on the thread that will bring tissue edges together. This prevents any suction effect on the different stitches as can be seen here. Indeed, when the thread is pulled, the edges are brought together and the thread slides easily. The running suture is almost complete. Stitches are placed rather than resorting to techniques like the Aberdeen knot. The next to last loop is grasped as a thread to achieve a square knot.

8. Closure of peritoneal incision 07'34''

Closure of the upper portion of the peritoneal incision is carried out with monofilament Maxon 3/0 material. A running suture is performed and several stitches are placed on the strip to maintain the peritoneum fixed cranially. The strips have been completely covered by peritoneum. The strips are subperitoneal and maintain the rectum relatively cephalad but without any traction. As mentioned earlier on, given that the colon has become fragile because of the dissection, resection of the sigmoid colon is decided upon; and this especially because the patient was regularly prone to constipation. The resection is carried out while preserving as much rectal vascularization as possible. The vascular dissection is performed as proximal to the sigmoid wall as possible.

9. Distal colon resection 08'48''

The colonic extremity is divided by an application of the 45mm long Endo-GIA linear stapler, blue cartridge.

10. Suprapubic colon extraction for proximal division 08'58''

The sigmoid colon is brought out through a suprapubic plastic drape wound protector in order to achieve the proximal resection.

11. Anvil introduction 09'08''

The anvil of the 28mm DST PCEEA circular stapler is used. Then the base of the stapler is introduced into the rectum.

12. Colorectal anastomosis 09'23''

The anvil and the stapler’s shaft are connected to perform an end-to-end trans-sutural colorectal anastomosis. The anastomosis is situated above the Douglas’ pouch and therefore not in contact to the strips. The presence of leakage is ruled out. We can observe that subperitoneal gas trapped by the suture does not come out.