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

The aim of surgical treatment of rectal prolapse is to anatomically restore prolapse and functionally remedy fecal incontinence and disorder of rectal emptying. There is not yet sufficient evidence-based knowledge of the advantages and disadvantages of various surgical methods. In practice, trans-abdominal surgery is recommended for patients in good conditions and perineal surgery for elderly and frail patients suffering from associated diseases. The progress of laparoscopic surgery has, however, made the trans-abdominal operation possible also for those in increasingly poor condition. With this procedure a significant improvement of defecation disorder is achieved in over 80% of patients. This video demonstrates the laparoscopic management of a rectal prolapse associated with constipation and a posterior enterocele.

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

Authors

J Leroy, J Marescaux

Abstract

The aim of surgical treatment of rectal prolapse is to anatomically restore prolapse and functionally remedy fecal incontinence and disorder of rectal emptying. There is not yet sufficient evidence-based knowledge of the advantages and disadvantages of various surgical methods. In practice, trans-abdominal surgery is recommended for patients in good conditions and perineal surgery for elderly and frail patients suffering from associated diseases. The progress of laparoscopic surgery has, however, made the trans-abdominal operation possible also for those in increasingly poor condition. With this procedure a significant improvement of defecation disorder is achieved in over 80% of patients. This video demonstrates the laparoscopic management of a rectal prolapse associated with constipation and a posterior enterocele.

Catégorie

complex cases

Mots-clés

Laparoscopic treatment, symptomatic rectal prolapse, young female patient

Type de vidéo

Vidéo chirurgicale

Durée

15'30''

Publication

2009-05

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, May 2009;9(05).
URL: http://www.websurg.com/doi-vd01en2619.htm

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

1. Introduction 00'08''

The objective of this video is to show the laparoscopic management of a rectal prolapse associated with constipation in a young woman. In addition, a voluminous posterior enterocele was found, probably secondary to a hysterectomy that had been performed several years earlier. Because the patient suffered from discomfort, the operation was decided upon. A laparoscopic exploration takes place: it demonstrates the presence of a few small bowel adhesions as well as the hysterectomy scar - procedure which had been performed using the vaginal route.

2. Pelvic exploration 01'05''

The procedure starts with the freeing of a few adhesions and with the pelvic exploration, which shows a redundant sigmoid loop and a very prominent Douglas’ pouch, which may account for the enterocele.

3. Opening the presacral space 01'21''

Following the exposure of the sigmoid mesocolon’s root, the presacral space is opened thanks to a large peritoneal incision on the right lateral aspect of the root of the sigmoid mesorectum. Only the peritoneum is opened. The retroperitoneal space is explored thanks to the pneumodissection induced by anterior traction.

4. Identification of the nervous plexus 01'47''

This allows to identify the nerve plexuses, and particularly the superior hypogastric plexus in its right branch.

5. Pelvic dissection 01'58''

The dissection is then continued either anterior to the presacral fascia, or posterior to the presacral fascia as in the present case. The anterior route helps to preserve the mesorectum’s nerve supply and its lateral attachments. Laterally, we must keep away from the nerve plexuses as well as anteriorly; a Douglasectomy is envisaged.

6. Douglasectomy 02'31''

This procedure consists in opening the peritoneum of the Douglas’ pouch just posterior to the cervix or to the posterior vaginal pouch. Dissection is continued thanks to a posterior traction placed on the peritoneum while sliding on the posterior aspect of the vaginal wall, which tends to unfold due to the existence of an anterior rectocele. Thanks to traction and counter-traction, the dissection plane is demonstrated at the limit between the posterior vaginal wall and the rectal wall. This dissection is continued as caudally as possible since a ventral rectopexy will be performed. It is critical to dissect the anterior rectal wall as caudally as possible since the prolapse essentially affects this anterior rectal wall and not the posterior rectal wall. The opening of the Douglas’ pouch is pursued to the left. In this patient presenting with constipation and hysterectomy-related sequels of adhesions (especially on the left lateral aspect of the pelvis), dissection of the sigmoid colon must be continued on its lateral aspect. Attention must be paid to avoid the ureter. Adhesions at the ovary must be identified. Indeed, it is preferable in a 41-year-old woman to preserve the ovary and avoid injuring the ovarian vessels. The preserved ovary has to remain functional. In the present case, the sigmoid colon is intimately attached to the ovary and as such, it must be freed progressively by using the monopolar scissors’ electrode as in our case, or ultrasonic scissors. They allow for a precise dissection while preserving the vascular supply.

7. Descending colon mobilization 05'46''

Because a sigmoidectomy is envisaged at the end of the procedure in order to avoid an aggravation of the constipation, and since the wounded small bowel will be resected, mobilization of the descending colon is started. This will allow for a resection and anastomosis on a compliant tension-free colon. Freeing of the descending colon is continued on its external part at the level of the parietocolic gutter. Once achieved, dissection is brought back to the pelvis where the rectum has been freed on its posterior surface, but especially on its anterior surface until the pelvic floor.

8. Introduction of the polyester strips 06'38''

Two polyester strips are then introduced (2cm wide by 15cm long) through the 12mm supraumbilical port. They are fixed to the sacral promontory either using ProTack® staples or one-two stitches of absorbable suture material.

9. Rectal fixation 07'03''

Traction is maintained on the rectum and the strip is lowered on the anterior surface of the rectum. Fixation is then achieved on the fibrotic tissues located on the anterior surface of the rectum in this patient. The 15cm long by 2cm large polyester strip is fixed on the anterior portion of the lower rectum while avoiding excessive traction on the rectum. The aim is to avoid a collapse of the rectum when pushing; the strip maintains it in the pelvic cavity, thus avoiding the prolapse of the rectum’s anterior wall. Excessive traction can lead to an opening of the anorectal angle, which in turn can cause anal incontinence. The rectum’s fixation on its anterior surface, then more cranially on its lateral and posterior surfaces, is performed with non-absorbable 2/0 Ethibond sutures tied extracorporeally. Some authors recommend to affix a second strip on the rectum’s left lateral surface, but more often than not, one large anterior strip is sufficient.

10. Colpopexy 08'25''

What is also important in these patients is to perform a repair of the vaginal prolapse, which is often associated and accounts for the rectocele. That is why posterior colpopexy with a second strip is performed; this vaginal prolapse is almost constant and can be managed by being fixed to a second strip, some authors even offering to affix it to the same strip that was applied on the rectum’s anterior wall. In order to keep the rectum in its cranial position, it is recommended to perform a colpopexy on the strip, but to also perform the amplest Douglasectomy possible to avoid a large Douglas’ pouch that would favour a new posterior enterocele.

11. Pelvic space closure 10'02''

Once the Douglasectomy has been performed, we close the pelvic space with absorbable 2/0 monopolar stitches (PDS or Maxon) while closing the peritoneum above the strip. Some stitches can eventually be supported by the strip, and by having performed a Douglasectomy, the peritoneum is maintained above the strip. The closure must be perfect. Using absorbable monopolar suture material allows to perform a running suture and to place some traction on it once the stitches have been made. It is not essential to pull on the suture after each stitch. To complete the closure, the left portion of the incision should of course be closed. We start the second running suture on the left extremity, and not in the middle because once the left running suture has been completed, both running sutures will meet on the stitch’s medial part, which will allow to tie the last knot on the middle portion. This is also made easier by the fact that the previous running suture had been started at that position and that the suture thread had been kept long enough for the last knot. The resection of the redundant sigmoid remains to be done. To do so, we perform the resection while preserving the rectum’s vascular supply as much as possible. We expose the sigmoid mesocolon and divide the sigmoid branches while preserving the marginal arteries. The resection is done caudally while preserving the colorectal junction in order to avoid a subperitoneal anastomosis and the risks of infection caused by the prosthesis if there is a problem, and to preserve as best as possible the junction to avoid the incontinence that can be caused by its disappearance.

12. Colon division and anastomosis 13'40''

The lower sigmoid colon is divided using an Endo-GIA 60mm linear stapler. Proximally we have brought the colon through a small suprapubic incision and introduced the anvil of a DST PCEEA circular stapler that will be connected to the tip of the anvil introduced trans-anally through endoscopic manipulation only. Once we have checked that there are no twists, we begin the anastomosis using the DST PCEEA circular stapler. We then check the anastomosis, in particular the donuts, before performing an air test that allows to check the airtightness of the stapling line. We can also see the airtightness of the peritoneal running suture as there are no bubbles that could have been caused by the carbon dioxide trapped subperitoneally.