Laparoscopic treatment of rectal prolapse in a female patient

This video demonstrates the mesh repair of rectal prolapse using a sling mesh to suspend the rectum and vaginal vault from the sacral promontory. The mesh is covered by the peritoneum. The surgeon in this case adds a sigmoidectomy to the procedure as patient had symptoms of constipation preoperatively and was at risk of worsening after mesh repair. Addition of a resection after insertion of a mesh is controversial as many surgeons may prefer to do one or the other. This video provides a good demonstration of sling repair of rectal prolapse.

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Laparoscopic   treatment   of   rectal   prolapse   in   a   female   patient

Authors
J Leroy, J Marescaux
Abstract
This video demonstrates the mesh repair of rectal prolapse using a sling mesh to suspend the rectum and vaginal vault from the sacral promontory. The mesh is covered by the peritoneum. The surgeon in this case adds a sigmoidectomy to the procedure as patient had symptoms of constipation preoperatively and was at risk of worsening after mesh repair. Addition of a resection after insertion of a mesh is controversial as many surgeons may prefer to do one or the other.
This video provides a good demonstration of sling repair of rectal prolapse.
Classification
controversial cases
Keywords
rectum, prolapse, laparoscopy, sigmoidectomy, mesh repair
Media type
Duration
09'45''
Publication
2003-03
Popular
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, Mar 2003;3(03).
URL: http://www.websurg.com/doi-vd01en1385e.htm

Laparoscopic   treatment   of   rectal   prolapse   in   a   female   patient

2. Rectal dissection 02'00''
The 1st step of the dissection is the posterior dissection behind the rectum. Again, this is an embryologic plane between the anterior fascia of the sacrum and the fascia propria of the rectum. We have created a wide enough opening in the peritoneum such that we can work behind the rectum. The camera now is then positioned at the level of the sacral promontory and looking down deep into the pelvis. We are dissecting behind the rectum again towards the pelvic floor. It’s necessary to create the space so that we can place our prosthetic mesh. Now we mobilize all the way to the pelvic floor. This patient has had a hysterectomy. We are now grasping the cuff of the vagina. It’s necessary to fix the vagina as well as the anterior wall of the rectum. We like to preserve the lateral ligaments of the rectum in order to preserve the innervation. For that reason, we will open only the peritoneum in the pouch of Douglas. It’s necessary to do a wide opening of the peritoneum so that we may later close it, covering completely our prosthetic mesh on the left side of the rectum. We are now creating a space in Douglas’s pouch between the posterior wall of the vagina and the anterior wall of the rectum. Again this is necessary for mesh placement. With an anterior traction on the cuff of the vagina, we can create a good space here. In order to preserve the right lateral ligament of the rectum, we will create a hole in the lateral fat pad and this will serve as a space to thread our prosthesis from posterior to anterior to anchor to the anterior portion of the rectum.
3. Mesh fixation 04'30''
We have a hemostatic field as shown here. The next portion of the procedure is placement of the prosthetic mesh. We use a non-absorbable prosthetic mesh and we anchor it to the anterior surface of the sacral promontory. We use an absorbable suture, in this case, PDS. We use an external knot-pusher to create the knot. We use 2 tacking sutures to keep this in place. We notice that this is being tacked in a retroperitoneal position, that is we’ve opened our peritoneum anterior and cephalad to where the mesh is anchored so that we can cover it later. The mesh is brought down into the pelvis and then anteriorly through the hole that we’ve used. It’s then tacked to the anterior wall of the rectum again with PDS absorbable sutures. We use 2 sutures to accomplish this. It’s important that the mesh lays in the plane behind our open peritoneum so that we can cover it later. We feel that covering the mesh is necessary to minimize the chance of bowel fistulization and intraperitoneal adhesions. The lateral fat pad of the rectum is also being anchored to the prosthesis. We take the posterior cuff of the vagina; the stitch is brought through and a 2nd limb of the prosthesis is then anchored to the anterior surface of the rectum and the posterior surface of the vagina. This gives us a sort of a sling, which is suspended from the sacral promontory to the posterior wall of the vagina, and the anterior wall and posterior wall of the rectum. The excess mesh is then trimmed. Now we will begin to close the peritoneum. Again this is in an attempt to prevent any future complications. We feel there is a decrease in the likelihood of mesh infection if the peritoneum has been closed overtop of the mesh.
4. Sigmoidectomy 07'11''
Digital vaginal exam shows that we have full closure of the peritoneum and good position of the mesh. We feel that sigmoidectomy is indicated in this patient and especially in patients where they have a problem with constipation preoperatively. We begin by opening the sigmoid mesentery dividing it. This is a Ligasure device, which is high-frequency energy. Because this is not a cancer operation, we can do our division of the mesentery relatively close to the bowel wall. Rectal fixation increases constipation in patients who have it preoperatively; therefore, resection of the sigmoid decreases the likelihood of postoperative constipation as well as providing some cephalad traction on the rectum itself. We fully mobilize the colon as necessary; in this case, you’re seeing lateral mobilization along Toldt’s line. If it is necessary to mobilize the splenic flexure, we will mobilize the splenic flexure. Fortunately in this case, we have a redundant enough sigmoid that was not necessary. You can see here where our peritoneum has been opened. We will do a distal division on the distal sigmoid rather than on the rectum at the rectosigmoid junction because our anastomosis has to be intraperitoneal rather than retroperitoneal as is typical. The suprapubic port site is then opened. A wound protector is placed and the distal sigmoid is brought out through the wound. A purse-string device is placed and our proximal division is undertaken. At this point, an anvil is placed. We drop the specimen back into the peritoneal cavity and re-establish our pneumoperitoneum. The circular stapler is introduced from below into the rectum. The anvil is mated to the circular stapler. It is closed and fired and our anastomosis is then completed. You can see that we have a tension-free anastomosis and a hemostatic field. The pelvis is then rinsed and the procedure is complete.