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12.2 Repair of Rectal Prolapse
this operation. These results demonstrate the superiority of
transabdominal techniques over extraabdominal procedures.
Despite the simplicity and excellent results of transabdominal
correction of rectal prolapse with Wells’ rectopexy, we feel that
a less invasive procedure for correcting this benign disorder is
both desirable and advisable. Performing rectopexy or a resection procedure laparoscopically offers these advantages.
Indications
The indications for laparoscopic rectopexy are identical to those
for Well’s rectopexy by laparotomy. If the patient has undergone
a previous abdominal operation, the situation should be carefully assessed according to the location of the laparotomy scar
and the adhesions to be expected. If the patient has pronounced
preoperative constipation with demonstrated elongation of the
sigmoid colon, sigmoid diverticulitis, or if a colon transit exami-
nation shows a significant delay in a defined segment of the
colon, the surgeon should consider a rectopexy without implant
material in combination with a colon resection. The combination of sigmoid resection and rectopexy following complete
mobilization of the rectum may also be performed laparoscopically (see laparoscopic sigmoidectomy, chapter 11.3).
Contraindications
Extraabdominal procedures should be preferred for correction
of rectal prolapse in very elderly patients and/or in patients
with cardiopulmonary or other systemic risk factors contraindicating general anesthesia or a pneumoperitoneum.
Patient Positioning
(Fig. 12.2.1).
Position of the Operating Team
(Fig. 12.2.2).
Trocar Placement
(Fig. 12.2.3).
Complications
Intraoperative Complications
− Injury to hollow organs caused by inserting the Veress
needle or the laparoscope/camera trocar.
− Injury to a major vessel with resulting bleeding caused by
the Veress needle or laparoscope/camera trocar.
− Thermal damage to the large or small intestine resulting
from improper use of monopolar electrocautery.
− Iatrogenic injury to the large or small intestine from grasping
instruments.
− Subcutaneous air emphysema resulting from improper fixation of the trocar in the abdominal wall.
− Injury to a ureter.
− Bleeding from the presacral venous plexus.
− Bleeding from the mesorectum resulting from dissection in a
non-anatomical plane.
Surgical Risks and Informing the Patient
The patient should be informed of the surgeon’s degree of skill
and experience with this new surgical technique. Always discuss any possible complications of a colorectal procedure. These
include injury to the colorectal wall, bleeding, and conditions
that require creation of a stoma. Aside from these specific complications, the patient should be aware of the general risks as-
sociated with laparoscopic operations, such as bleeding, per-
foration, and subcutaneous emphysema resulting from trocar
placement. Inform the patient of the specific risk of a mesh infection and of the possibility of having to convert to an open
procedure. Possible injuries to the ureter and lesions resulting
from positioning on the operating table should be mentioned.
Specific Preparations
Administer 5−6 L of a bowel preparation with GOLYTELE. Even
elderly patients will tolerate this oral preparation well in the ab-
sence of disturbed intestinal motility. Care should be exercised
in patients with cardiac insufficiency. These patients should be
prepared using enemas in combination with oral laxative. Preoperative placement of a nasogastric tube and urinary catheter
is indicated.
Corrective action: If one of these serious complications occurs,
immediate conversion to an open procedure is indicated. Some
of the complications can be managed via laparoscopic suturing
techniques if the surgeon has sufficient experience.
Postoperative Complications
− Postoperative bleeding.
− Wound infection.
− Mesh infection.
− Thrombosis.
− Embolism.
− Peritonitis and abscess formation resulting from an untreated lesion of the large or small intestine.
Corrective action: See above.
Anesthesia
General anesthesia.
Fig. 12.2.1 Repair of rectal prolapse. Patient positioning.
Assistant holding the laparoscope
Aspirator/
irrigator set
Surgeon
Electrocautery
unit
Assistant
Instrument table
Monitor
Insufflator
Surgeon
Place the patient on an operating table for rectal surgery in an extreme
Trendelenburg position (inclined 30−40°). Shoulder and pelvis supports
should be used to restrain the patient. To minimize the risk of compart-
ment syndrome, venous thrombosis, and compressive neuropathies, en-
close the patient’s knees and calves in thick foam rubber cushions and
legs in venodyne boots.
Complications
369
Fig. 12.2.2 Repair of rectal prolapse. Position of the operating team and
equipment.
The procedure requires two equally experienced surgeons, who stand on
either side of the patient. Depending on the situation, the surgeons work
with one or both hands. The assistant holding the laparoscope stands at
the patient’s left shoulder. The patient’s head is sterilely draped, and the
left arm is positioned alongside the torso. A second assistant stands next
to the patient’s right leg, and the operating room nurse stands next to the
patient’s left leg with the instrument table. The monitor, insufflator, and
light source are located between the patient’s abducted legs. The electrocautery unit and the aspirator/irrigator set can be positioned more or less
as desired.
370
T1
T3
Fig. 12.2.3 Repair of rectal prolapse. Trocar placement.
T1 10/12-mm laparoscope/camera trocar: slightly superior to the umbilicus
and left of and lateral to the midline.
T2−5 10/12-mm instrument trocars: forming a semicircle with the laparo-
scope/camera trocar around the pelvis.
Open trocar placement is an alternative.
12.2 Repair of Rectal Prolapse
T1
T4
T5
Step-by-Step Procedure
1. Insert the trocars under laparoscopic visualization.
2. Expolore the abdomen; determine the diagnosis and operative plan.
3. Separate the sigmoid colon from any attachments in the
lateral gutter to the lateral abdominal wall (see Fig. 12.5.5,
p. 384).
4. Expose the left ureter (see Fig. 12.5.6, p. 385).
5. Dissect the mesosigmoid off Gerota’s fascia as far as the aorta
or the iliac bifurcation, respectively (see Fig. 12.5.6, p. 385).
6. Enter the posterior fascial cleavage space from the left.
7. Retract the sigmoid colon to the left and incise the lateral rectal peritoneum at the level of the promontory.
8. Open the retrorectal cleavage space to the floor of the pelvis.
9. Divide the lateral ligaments to the left and right of the rectum.
10. Cut nonabsorbable mesh material to size.
11. Introduce the rolled mesh into the abdomen through a reducing sleeve.
12. Spread the mesh out on the parietal pelvic fascia and attach it
to the fascia at the level of the promontory using staples.
13. Place interrupted laparoscopic sutures through the mesh at
the level of the promontory for additional fixation of the mesh
material.
14. For additional fixation, place interrupted sutures under laparoscopic vision in the parietal pelvic fascia in front of the
sacrum through openings cut in the mesh.
15. After placing the mobilized and extended rectum into the
mesh, suture the edges of the mesh to the lateral walls of the
rectum.
16. Where necessary, a widened pouch of Douglas may be re-
duced by placing interrupted sutures in the peritoneum.
Operative Technique
1
2
컅 Fig. 12.2.4 Repair of rectal prolapse. Elevating the uterus, fallopian
tubes, and ovaries to the abdominal wall in the female patient.
To provide broad exposure and keep the uterus from falling onto the rectum when the rectum is mobilized, suture the uterus and its appendages
to the anterior abdominal wall (1) using a straight needle introduced
through the abdominal wall (see p. 384). This exposes the pelvis and will
typically reveal an intestinal hernia that manifests itself in the widened
rectouterine peritoneum that also covers the posterior wall of the vagina
(2).
Complications
2
371
1
Fig. 12.2.5 Repair of rectal prolapse. Findings in the pelvis.
A complete prolapse of the rectal wall is regularly accompanied by patho-
logical findings in the pelvis. The rectouterine pouch is typically deepened
and the posterior vaginal and anterior rectal walls are almost completely
covered with peritoneal tissue. The anterior rectal wall forms the floor of
the abdominal cavity and can easily be pushed through the anus with a
swab. This condition will frequently be accompanied by fibrous or edematous thickening of the rectal wall as a result of chronic trauma from invagi-
nation.
Fig. 12.2.7 Repair of rectal prolapse. Opening the peritoneum at the pel-
vic inlet.
If one cannot open the retrorectal cleavage space any further from the
left, retract the sigmoid colon to the left and incise the lateral peritoneum
of the rectum at the pelvic inlet. This also provides access to the retrorec-
tal cleavage space inferior to the promontory (see Fig. 12.2.3 for key to in-
strument numbers).
Fig. 12.2.6 Repair of rectal prolapse. Entering the retrorectal cleavage
space.
The operation begins similarly to laparoscopic sigmoidectomy or laparoscopic excision of the rectum. First separate the sigmoid colon from the
peritoneal reflection to the lateral abdominal wall and expose the uterus
from the left. After completely mobilizing the sigmoid colon along
Gerota’s fascia as far as the aorta or the iliac bifurcation medial to the ureter, enter the retrorectal cleavage space. Between the mesorectum and
the parietal pelvic fascia inferior to the promontory there will only be fine
fibers of connective tissue. Divide these fibers with electrocautery or a
dissecting swab. Opening the retrorectal cleavage space reveals the
lateral ligaments, which are extended due to the prolapse of the rectum.
Lift these ligaments with a swab (see Fig. 12.2.3 for key to instrument
numbers).
1 Rectum
2 Promontory
컄
T4
T3
372
12.2 Repair of Rectal Prolapse
T5
1
2
Fig. 12.2.8 Repair of rectal prolapse. Elevating the rectum.
Once access has been gained to the opening in the retrorectal cleavage
space from the right, there will be a gap in the mesenteric attachment inferior to the vascular axis of the superior rectal artery, into which one can
insert a swab from the left. Use this swab to lift the mesosigmoid and me-
sorectum to permit dissecting the retrorectal cleavage space down to the
floor of the pelvis.
1 Left ureter
2 Promontory
Fig. 12.2.9 Repair of rectal prolapse. Mobilizing the rectum.
To achieve complete mobilization of the rectum down to the floor of the
pelvis, divide the lateral ligaments on both sides one at a time, carefully
controlling bleeding with electrocautery and clips. We do not recommend
dissecting the anterior fascial cleavage plane. The intestinal hernia will already have widened the peritoneum of the rectouterine pouch between
the posterior vaginal and anterior rectal wall (or between the rectovesical
septum and the anterior rectal wall) so that further dissection would only
damage the autonomic nerve fibers in this region. The only dissection
necessary is a peritoneal incision if elevating the rectum places tension on
the peritoneum. Sufficient elevation of the rectum may be achieved by
adequately mobilizing the posterior rectum in the presacral region and by
dividing the lateral ligaments on both sides.
T3
T4
ca. 11 cm
Fig. 12.2.10 Repair of rectal prolapse. Preparing the mesh.
Now prepare the rectopexy by cutting nonabsorbable mesh to size. Cut
three openings in the center of the mesh to facilitate secure fixation to
the parietal pelvic fascia with laparoscopic sutures or staples. This reduces
the risk of bleeding from the presacral venous plexus when the mesh is attached to the parietal pelvic fascia and makes it easier to control bleeding
if it does occur.
Fig. 12.2.11 Repair of rectal prolapse. Introducing the mesh into the abdomen.
After rolling the mesh tightly, introduce it into the abdomen through a
10-mm reducing sleeve (T3). Retract the mobilized rectum anteriorly and
to the left with a swab (T4) so that the mesh can be spread out in front of
the sacrum, inferior to the promontory.
T3
Complications
373
T3
Fig. 12.2.12 Repair of rectal prolapse. Attaching the mesh with clips.
After spreading out the mesh in front of the sacrum and inferior to the
promontory, attach its wide margin to the posterior parietal pelvic fascia
at the promontory with a hernia stapler (T3). Place the staples so that
they engage the edges of the mesh on one side and the fascia on the
other. Stapling through the mesh has not produced good results.
T3
Fig. 12.2.13 Repair of rectal prolapse. Attaching the mesh with sutures.
If it is not possible to attach the wide margin of the mesh to the posterior
parietal pelvic fascia at the promontory with the stapler alone, one can
place laparoscopic sutures (T3). Good results have been achieved with extracorporeal sutures and tying introduced into the abdomen with a knot
pusher.
T3
Fig. 12.2.14 Repair of rectal prolapse. Attaching the mesh with sutures.
After attaching the margin of the mesh, attach it further to the parietal
presacral pelvic fascia by placing laparoscopic interrupted sutures at the
openings in the middle of the mesh (T3). These openings permit con-
trolled suturing and help minimize the risk of bleeding from the presacral
venous plexus. Place as many sutures as are required to securely attach
the mesh to the presacral pelvic fascia.
Fig. 12.2.15 Repair of
rectal prolapse. Attaching the rectum to the
mesh.
After the nonabsorbable mesh has
T4
and place it in the mesh. Do not use a grasper to elevate the rectum; use
swabs (T4).Theyare atraumaticandminimize theriskof damagingtherectal wall.After extendingthe rectum andplacing thedesired upward tension
on it, place laparoscopic sutures to attach the lateral edges of the mesh to
the rectum (T3). Place three to four interrupted sutures on both sides,
taking care to ensure that at least one-fourth of the circumference of the
rectal wall is free to minimize the risk of stenosis. The sutures should not
penetrate the rectal lumen, as this could lead to a mesh infection.
been securely anchored
to the presacral pelvic
fascia, elevate the mobilized rectum upwards
374
12.2 Repair of Rectal Prolapse
Fig. 12.2.16 Repair of rectal prolapse. Internal pelvic findings following
rectopexy.
Mobilizing and stretching the rectum upwards and suturing it to the mesh
attached to the presacral parietal pelvic fascia reduces the size of the peritoneum and the widened rectouterine pouch. Further corrections can be
made to the pelvic peritoneum by placing additional interrupted sutures.
Bibliography
Delemare JBVM, Gooszen HG, Kruyt RH, Soebhag R, Maas Geesteranus A. The
effect of posterior rectopexy on fecal continence. Dis. Colon Rect. 1991;
311 .
Duthie GS, Bartolo DCC. Abdominal rectopexy for rectal prolapse: a compari-
son of techniques. Brit. J. Surg. 1992; 79:107.
Encke A, Doertenbach JG. Der Rektum- und Analprolaps. In Bünte H,
Junginger T. Jahrbuch der Chirurgie. Biermann 1990; 115.
Frykam HM, Goldberg SM. The surgical treatment of rectal procidentia. Surg.
Gynecol. Obstet. 1996; 1225.
Gemlo BT, Madorr RD. Suture rectopexy with colon resection for rectal pro-
lapse. Semin. Colon Rect. Surg. 1991; 193.
Gemsenjäger E. Rektumprolaps, solitäres Rektumulkussyndrom und Syn-
drom des deszendierenden Perineums. In Marti MC, Givel JC. Chirurgie anorektaler Krankheiten, p. 229. Berlin: Springer; 1990.
Köckerling F, Gastinger I, Gall CW, Schneider B, Kraus W, Gall FP. La-
paroskopische Rektopexie. MIC 1992; 1:68.
Köckerling F, Gastinger I, Reck T, Schneider B. Laparoskopische Eingriffe am
Rektum. Langenbecks Arch. Chir. Kongreßband 1993; 111.
Fig. 12.2.17 Repair of rectal prolapse. Reducing the size of the rectouterine pouch.
The sagittal section through the pelvis shows how elevating the rectum
and shifting it superiorly reduces the size of the widened rectouterine
pouch. After the rectum has been shifted and extended superiorly, it no
longer fills the floor of the pelvis.
Mann CV, Hoffmann C. Complete rectal prolapse: the anatomical and
functional results of treatment by an extended abdominal rectopexy. Brit.
J. Surg. 1988; 75:34.
McCue JL, Thomson JPS. Rectopexy for internal rectal intussusception. Brit. J.
Surg. 1990; 77:632.
Nicholls RJ, Simson JNL. Anteroposterior rectopexy in the treatment of soli-
tary rectal ulcer syndrome without overt rectal prolapse. Brit. J. Surg.
1986; 73:222.
Reck T, Köckerling F, Gastinger I, Gall CW, Schneider B, Gall FP. La-
paroskopische Rektopexie. In Brune IB, Schönleben K. Laparoendoskopische Chirurgie, p. 249. München: Marseille; 1993.
Speakman CTM, Madden MV, Nicholls RJ, Kamm MA. Lateral ligament divi-
sion during rectopexy causes constipation but prevents recurrence: results of a prospective randomized study. Brit J. Surg. 1991; 78:1431.
Watts JD, Rothenberger DA, Buls JG, Goldberg SM, Nivatvongs S. The man-
agement of procidentia. Dis. Col. & Rect. 1985; 97.
Wolff BG, Dietzen CD. Abdominal resectional procedures for rectal prolapse.
Semin. Colon Rect. Surg. 1991; 184.
12.3 Laparoscopic Second Stage Hartmann Procedure
12.3 Laparoscopic Second Stage Hartmann Procedure
S. D. Potter , C. A. Schneider , J. C. Jrací, V.A. Marrero
375
Introduction
A two stage Hartmann procedure is an established treatment
option when dealing with complicated acute diverticulitis or
distal sigmoid and rectal perforation. The laparoscopic approach to the second stage of this procedure offers many advan-
tages over the traditional open approach. Patients usually experience less pain and therefore better comply with postopera-
tive instructions. Additionally, there is usually a shorter post-
operative ileus, reduced hospital stay, and a more rapid return
to daily activities.
Indications
A laparoscopic second stage Hartmann procedure can be performed on any patient requiring reconstruction of continuity
between a diverting end colostomy of the proximal colon segment and the closed colo-rectal stump (the original Hartmann
procedure) or a distal colo-rectal mucus fistula.
Contraindications
A rectal pouch longer than the shaft of a circular stapler.
Instrumentation
− General purpose laparoscopic setup
− 3 10/11 mm ports
− 2 Laparoscopic Babcock clamps
− 1 Linear stapling device
− Circular stapler sizers
− 1 Circular stapler
Anesthesia
General endotracheal.
Positioning
Lithotomy position with reverse Trendelenberg (see Fig. 12.2.1).
Complications
Complications are the same as for an open second stage Hartmann procedure and any laparoscopic surgical procedure.
Step-by-Step Procedure
(Figs. 12.3.9 to 12.3.11)
1. A mechanical and chemical preoperative bowel preparation is
performed.
2. The patient is placed on the operating room table in the
lithotomy position with the abdomen and the perineum exposed
in the operative field.
3. A circular incision is made around the colostomy staying as close
to the bowel as possible. This incision is extended downward
through the subcutaneous tissues and toward the fascia and peritoneum, fully mobilizing the bowel into the abdominal cavity
(Fig. 12.3.1).
4. The bowel is sized using the circular stapler sizers.
5. A suture leash is attached to the spike of the anvil rod of the
selected stapler, which is then placed through the colostomy and
into the descending colon (Fig. 12.3.2).
6. A linear stapler and scalpel are used to close and transect the
colostomy scar, taking care not to cut the “leash” which exits
from the bowel through the middle of the staple line (Fig. 12.3.2).
7. The leash is pulled so that the spike of the anvil protrudes fully
through the staple line (Fig. 12.3.3).
8. The descending colon with the anvil and attached leash are re-
turned to the abdominal cavity and placed in the lateral gutter
(Fig. 12.3.4).
9. A finger is placed through the old colostomy site to sweep adhe-
sions off the anterior abdominal wall at least past the midline. If
necessary the dissection can be done sharply and under direct vi-
sion by elevating the borders of the colostomy site (Fig. 12.3.4).
10. A 10-mm port is placed in the old colostomy site and a
pneumoperitoneum established (Fig. 12.3.5).
11. Under direct visualization two additional ports are placed. A 10mm port in the infraumbilical position and another 10 mm port
just lateral to the right rectus muscle and in the same line as the
old colostomy site (Fig. 12.3.5).
12. Using a Babcock clamp and laparoscopic scissors, further lysis of
adhesions is performed in the pelvis, identifying and freeing Hart-
mann’s pouch (Fig. 12.3.6).
13. The anvil and descending colon are retrieved from the lateral gut-
ter and are brought down into the pelvis. (If tension is noted as
the descending colon is brought into the pelvis, this can be relieved by sharp mobilization along the white line of Toldt and
possibly the splenic flexure. An additional 10-mm port in the left
upper quadrant can aid in the splenic flexure mobilization).
14. The cartridge of the stapler chosen for anastomosis is placed
transanally and is advanced into the blind end of the rectal pouch
(Fig. 12.3.7).
15. The trocar of the cartridge shaft is advanced fully through the
midportion of the staple line of the pouch. The trocar is removed
leaving only the hollow central rod protruding fully through the
rectal pouch. The trocar is removed through one of the working
ports (Fig. 12.3.7).
16. The anvil rod is joined with the hollow central rod of the cartridge
taking care not to twist the bowel (Fig. 12.3.8).
17. Once properly positioned the stapler is closed, fired and withdrawn (Fig. 12.3.13).
18. The integrity of the anastomosis is checked.
19. The pneumoperitoneum is released and the ports are removed.
20. The fascial defects of all the 10 mm port sites are closed.
376
12.3 Laparoscopic Second Stage Hartmann Procedure
Operative Technique
1
2
Fig. 12.3.1 Second stage Hartmann operation.
A circular incision is made around the site of the proximal colostomy.
Circular dissection is continued in depth until the entire colostomy is freed
and mobile. An adequate length of colon is then pulled out through the
opening onto the abdominal wall.
Fig. 12.3.3 Second stage Hartmann operation. 컄
The suture is then pulled, bringing the pointed central rod of the anvil up
through the middle of the staple line.
3
Fig. 12.3.2 Second stage Hartmann operation.
A heavy gauge suture “leash” is tied to the trocar of the anvil portion of
the circular stapler, which is then placed through the colostomy and into
the proximal descending colon with the suture extending out the
colostomy orifice. A linear stapler is placed around the bowel just proximal to the colostomy scar and fired. A scalpel is used to transect the
colostomy scar while taking care not to cut the suture exiting through the
middle of the staple line.
1 Suture (“leash”) attached to the anvil trocar
2 Colon pulled out through opening in abdominal wall. Anvil inserted in-
traluminally before stapled closure of bowel.
3 Anvil of circular stapler
12.3 Laparoscopic Second Stage Hartmann Procedure
3
1
377
1
2
Fig. 12.3.4 Second stage Hartmann operation.
The suture is left in place to aid in the subsequent recovery of the anvil
and colon, which are then placed in the abdominal cavity and stored in
the lateral gutter. Through the old colostomy site the index finger is swept
along the peritoneum, lysing any adhesions within reach and clearing the
undersurface of the umbilicus. This can also be done by sharp dissection
under direct vision, by elevating the edges of the colostomy site.
1 Rectal stump
2 Colon with anvil stored in lateral gutter
3 Lysis of adhesions with index finger or scissors.
5
2
3
Fig. 12.3.5 Second stage Hartmann operation.
Stay sutures are placed in the fascia and a 10/11-mm Hassan blunt port is
inserted through the old colostomy site. If the fascial defect of the old
colostomy site is too large for the Hassan port, it should be closed around
the port with a pursestring suture. A pneumoperitoneum is then established and two additional 10/11-mm ports are placed as shown in the
above diagram.
Using a laparoscopic Babcock clamp and scissors through the lateral ports
further lysis of adhesions into the pelvis is then performed. Mobilization of
the descending colon along the white line of Toldt and possible splenic
flexure mobilization may be necessary in order to bring the stump of the
descending colon tension free into the pelvis. An additional 10/11-mm
port in the left upper quadrant may be necessary for retraction during the
splenic flexure mobilization.
1 10/11-mm port
2 Proximal colon stored in left lateral gutter
3 Additional port if splenic flexure mobilization is necessary
4 Blunt port in umbilicus
5 10/11-mm port
4
Fig. 12.3.6 Second stage Hartmann operation.
Hartmann’s pouch is then cleaned free of surrounding tissue using a laparoscopic Babcock clamp and scissors. Identification of the rectal stump
can be aided by transanal insertion of a rectal probe or the cartridge head
of the circular stapler for longer stumps.
Note: A pouch longer than the length of a circular stapler shaft is a con-
traindication for this procedure. The foresight to create a pouch con-
sisting essentially of rectum during the first stage of a Hartmann pro-
cedure is essential to the success of a laparoscopic second stage.