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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_841_Библиотеки_им_академика_М_И_Перельмана.pdf
Pelvic Autonomic Nerve Preservation
403
50
Funktionsprüfung autonomer Beckennerven bei TME
wegen Rektumkarzinom. In: Haas NP, Neugebauer E,
Bauer H (Pub.) Chirurgisches Forum 2003 für experimentelle und klinische Forschung. Forumband, 32.
Heidelberg: Springer; 2003, p. 203–5.
11. Stelzner F. Der vergessene Sphincter ani internus im Mittelpunkt des anorektalen Kontinenzorgans. In: Stelzner F
(Pub.) Chirurgie an viszeralen Abschlußsystemen. Stuttgart: Thieme; 1998, p. 188–96.
12. Stelzner F, Fleischhauer K, Holstein AF. Die Bedeutung
des Sphincter internus für die Analkontinenz. Langenbecks Arch Chir. 1966;314:132–6.
Individual Surgery for Rectal Prolapse
Contents
Chapter 51 Introduction – 405
MichaelKorenkov, Christoph-omasGermer,
andHaukeLang
Chapter 52 Surgical Technique and Dicult
Situations from Karl-Hermann Fuchs
(Laparoscopic Resection Rectopexy) – 409
Karl-HermannFuchs, W.Breithaupt, andB.Babic
405
XI
Chapter 53 Surgical Technique and Dicult
Situations from David Jayne
(Laparoscopic Ventral Rectopexie) – 413
JimTiernan andDavidJayne
Chapter 54 Surgical Technique and Dicult
Situations from Antonio Longo
(Dierent Techniques) – 419
AntonioLongo
407
Introduction
MichaelKorenkov, Christoph-omasGermer, andHaukeLang
51.1 The Length ofProlapse – 408
51.2 Combination ofRectal Prolapse
with Other Forms ofPelvic Floor
Disorders – 408
51.3 Special Constellation oftheRectal
Anatomy – 408
51.4 Previous Pelvic andPerineum Surgery – 408
51.5 Classication ofIntraoperative Diculties – 409
51
© Springer-Verlag Berlin Heidelberg 2017
M. Korenkov et al. (eds.), Gastrointestinal Operations and Technical Variations,
DOI10.1007/978-3-662-49878-1_51
M. Korenkov et al.
408
51
Patients undergoing surgical treatment of rectal
prolapse can be divided in following groups:
5 Patients undergoing surgery via a perineal
approach
5 Patients undergoing surgery via an abdominal
approach
Because of the numerous varieties of surgical
procedures and technical modications, situations requiring dicult decisions can occur
prior to choosing the proper surgical approach.
ese diculties are rooted in generic and local
patient factors. e local factors include the
length of prolapse, combination of rectal prolapse with other forms of pelvic oor descending
(genital prolapse, rectocele, cystocele, descending perineum syndrome, etc.), special constellation of the rectal anatomy (very thick rectal wall;
very dilated rectum with a big caliber dierence
between rectum and sigmoid colon), as well
as previous pelvic surgery, and anal mucosal
prolapse.
51.1 The Length ofProlapse
For external rectal prolapse shorter than 10cm,
we recommend an abdominal approach for
elderly patients (personal preference). We believe
that such constellation is not appropriate for the
Altemeier procedure (. Fig.51.1).
e ideal condition for the Altemeier procedure is the so-called rectosigmoidal prolapse,
which consists of the inner cylinder from intact
or diverticulum but not a swelled sigmoid colon
wall. Under such conditions will be creation a
sigmoidoanal anastomosis and postoperative
healing mostly uneventful. For an external rectal
prolapse shorter than 10 cm consist the outer and
the inner cylinders from a swelled fragile rectal
wall; that is why the creation of a rectoanal anastomosis is more dicult compared with the rectosigmoidal prolapse. Accordingly, it increases
the risk of postoperative complications such as
postoperative bleeding, pelvic hematoma, or
abscess.
51.2 Combination ofRectal
Prolapse withOther Forms
ofPelvic Floor Disorders
A combined rectal and vaginal prolapse will in
many cases be operated on simultaneous with a
gynecologist. In the event an Altemeier procedure is chosen, the extent of cul-de-sac resection should be discussed with the gynecologist
prior to surgery, otherwise resectioning the
cul-de-sac too extensively can lead to deficiency of peritoneal tissue for the posterior colpor rhaphy.
51.3 Special Constellation
oftheRectal Anatomy
Technical problems and situations requiring difcult decisions can occur in patients with a pronounced dilated rectum and thick rectal wall.
Both of these situations can increase the risk of a
stapler line leak. Additionally, using cartridges
with longer staple heights (4.5 mm, green cartridge) may not be sucient for adequate closing.
In some cases of where the rectal wall is thick, it is
better to perform a “pure” rectopexy instead of
using resectioning procedures.
. Fig. 51.1 Rectal prolapse <5cm– not appropriate for
the Altemeier procedure
51.4 Previous Pelvic andPerineum
Surgery
For patients who have undergone previous pelvic
and perineum surgery can have an inuence on
the choice of surgical procedure. Such situations
always require an individual decision.
Introduction
409
51.5 Classication ofIntraoperative Diculties
e surgical diculty for an Altemeier procedure can be classied as summarized in . Table51.1.
. Table 51.1 Operative diculties for an Altemeier procedure
Grading Case type
51
I (ideal cases)
It is easy to operate; every surgical technique is
technically unproblematic
II (not quite ideal)
Some minor technical diculties may occur; some
surgical techniques can be more dicult than others
III (problematic)
Dicult to operate, some surgical techniques are
considerably more dicult than others
IV (very problematic)
Every surgical step is dicult
Prolapse longer than 10cm
No anal stenosis
2
Moderate obese patient (BMI around 35kg/m
otherwise similar to grade I
2
Overweight patient (BMI >35kg/m
combination with other forms of pelvic oor disorders
Anal stenosis
Recurrent rectal prolapse
Extreme form of grade III factors
),
),
411
Surgical Technique
and Difficult Situations
from Karl-Hermann Fuchs
(Laparoscopic Resection
Rectopexy)
Karl-HermannFuchs, W.Breithaupt, andB.Babic
52.1 Introduction – 412
52.2 The Concept of NOTES – 412
52
52.3 Patient Preparation – 412
52.4 Operative Technique – 412
© Springer-Verlag Berlin Heidelberg 2017
M. Korenkov et al. (eds.), Gastrointestinal Operations and Technical Variations,
DOI 10.1007/978-3-662-49878-1_52
K.-H. Fuchs et al.
412
52
52.1 Introduction
A frequent problem in pelvic oor disorders is
internal or external rectal prolapse situation. e
operative treatment for these functional anatomic changes has been established by laparoscopic resection rectopexy. e selection of
patients for these operations requires an extensive diagnostic workup to verify the indication
for surgery precisely. e diagnostic workup
should consist of a proctologic investigation;
endosonography; to verify the status of the anal
sphincter system, an anorectal manometry; a
Hinton test; and, to verify a possible coexistence
of a slow-transit constipation, dynamic MR
defecography.
e traditional laparoscopic rectal resection
rectopexy has the following operative steps:
5 Dissection and mobilization of the rectum
under preservation of the rectal peritoneal tissue
5 Deep mobilization and dissection of the retro-
vaginal area toward a possible rectocele in
order to lengthen and fully mobilize the scar
tissue, which has been created by the rectal
prolapse over the years
5 Dissection of the redundant sigmoid colon for
resection
5 Traditional laparoscopic sigmoid resection and
circular stapling for the descend rectostomy
5 Pexy of the pararectal peritoneum at the
promontorium using non-resorbable suture
material and peritoneal adaptation
52.2 The Concept of NOTES
Since pure NOTES procedures are currently
rather unfeasible because of lacking adequate
instruments and endoscopes, Hybrid-NOTES
procedures could provide the necessary bridging
between traditional laparoscopic techniques and
NOTES procedures.
e principle of NOTES is the use of a natural
orice as entry port into the abdominal cavity and
prevent additional access trauma through the
abdominal wall. Since endoscopic technology is
not available to perform complex operations such
as a colon resection inside the abdomen exclusively via a natural orice such as the mouth or
the anus, a Hybrid solution has emerged.
is Hybrid technique uses the natural orice
for instruments and tasks, which need a larger
diameter of access (>5mm) to the abdominal cavity and at the same time allows for a laparoscopic
assistance via limited-sized ports in order to avoid
access trauma and morbidity.
The transanal approach, initially limited to
rectal disease, can be used today for NOTES
Hybrid colorectal surgery. From TEM via TEO,
the technique has been moved to transanal
minimally invasive surgery (TAMIS), as it is
called in the USA recently, or Transanal
HybridMinimal Access Natural Orifice Surgery
(ta-MANOS).
As a consequence alternative instruments
were tested with smaller diameter to evaluate the
possibility of reducing the size of the “transanal
trocar.” e passage of specimens as well as stapler
and instruments was tested, and the transanal
endoscopic applicator (TEA) was developed rst
as a prototype and evaluated. Finally, it became
clinical evident that a diameter of 3cm is enough
to use the device for the assistance in Transanal
Hybrid Colon Resections.
52.3 Patient Preparation
e patients underwent a preoperative bowel
preparation in order to have a clean bowel during
the operation, when intra-abdominal opening
and manipulation of the bowel were necessary.
Prior to surgery, prophylactic IV antibiotics
(cephalosporin and metronidazole) were given.
General anesthesia was performed, and the
patient was brought in supine position for the
operation.
52.4 Operative Technique
Aer establishing a capnoperitoneum via a
Veress needle and aer necessary safety tests, a
periumbilical port was introduced in the abdominal cavity. Two additional 5 mm ports were
brought in the right lower quadrant for dissection of the colon and rectum. Via these ports also,
the dissection of the anastomotic site, all necessary hemostasis, and all energy delivery were
applied. e dissection of the mesentery was
stepwise performed under careful laparoscopic
Surgical Technique and Difficult Situations from Karl-Hermann Fuchs
413
52
control to ensure that the pelvic nerve plexus was
not in danger and the dissection planes could be
followed.
In case of sigmoid resection for prolapse
surgery, the colon lumen was clamped at the level
of the descending segment, and a sigmoidoscopy
was performed to make sure that this bowel segment was clean, which was claried by rinsing of
the rectum and colon. Aer removal of the scope,
bougies of the sizes 25, 28, and 33 were introduced into the anus, rectum, and sigmoid colon.
A careful bougienage of the rectum facilitates the
following maneuvers.
en the anvil of a 28mm circular stapler
was introduced into the TEA and rectum with a
special grasper and maneuvered more proximal
up to the descending colon to the future anastomotic site.
e next step was the transanal introduction
of a transanal endoscopic applicator (TEA), which
allows for safe introduction of endoscopes, linear
staplers, grasping devices, and specimen removal.
is was followed by an incision of the colon–
usually the distal sigmoid– at the distal anastomotic site. Here, a transanally introduced linear
stapler can exit the colon into the abdominal cavity and was used to transect the proximal end of
the sigmoid segment, which needs to be resected
. Fig. 52.1).
(
Via the transanal-positioned TEA instrument,
the application, removal, and change of stapling
. Fig. 52.1 The transanal endoscopic applicator (TEA),
a multifunctional transanal trocar, is used to get access
with larger instruments into the abdominal cavity
cartridges were technically rather easy to be performed. At the proximal colon stump, the intraluminal anvil was grasped through the bowel wall
and stabilized. e central pin of the anvil was
penetrated through the bowel wall at the stapled
line to be available for later anastomosis. e penetration of the pin was facilitated by performing a
small hole at the stapled line with the ultrasound
cutting device.
Once the sigmoid segment was resected and
free of detachments, a grasper was advanced via
the TEA to reach for the specimen in the abdomen. en the specimen was pulled through the
luminal opening at the distal rectosigmoid stump,
via the rectal lumen and via the TEA transanally
to the outside.
Aer removal of the specimen transanally, a
purse-string suture was placed at the distal rectosigmoid stump in order to complete the anastomosis with the circular stapling device. e TEA
was removed, and a circular stapler was inserted
transanally and advanced to the distal rectosigmoid opening, carrying the purse-string suture.
e central pin was opened, and the purse-string
suture was tied down around the central pin.
Furthermore, the anvil was connected to the stapler, followed by approximating and ring the
device in the usual manner under laparoscopic
visual control. us the actual anastomosis could
be performed under the same optimal conditions
that laparoscopic surgery can provide.
In case of a rectal prolapse, a rectopexy was
added in the usual technique with nonabsorbable
sutures between the peritoneal, the pararectal tissue, and the sacral bone at the promontorium
using the 5mm ports, straight needles, and miniinstruments.
In case of slow-transit constipation, subtotal
colon resection was performed by dissection and
severing of the complete colon mesentery with the
5mm energy device usually via two 5mm ports,
occasionally added by another 3mm grasper without trocar for assisting and better exposure. e
ileum as well as the sigmoid colon was transected
via a transanal linear stapler. en the complete
colon was removed transanally. e anvil was
advanced transanally to the distal ileum and
inserted into the lumen, followed by penetration
of the central pin through the antimesenteric ileal
wall for later anastomosis. e ileum was closed
via a transanal linear stapler. e tissue remnant
K.-H. Fuchs et al.
414
52
was removed transanally. e ileosigmoidostomy
was performed similar as described above.
Aer the control of hemostasis, inspection of
the anastomosis, leak test with air and water, as
well as placement of a drainage, the procedure
was nished by removal of the three ports.
e patients could drink water and tea on the
evening of the operation and were given uids
including protein drinks on the rst postoperative
days. Usually on the third postoperative day,
enteral feeding started with soup, semisolid food,
and, if they tolerated it well, subsequently also
solid food.
e initial clinical experience of the past years
shows a safe introduction of this NOTESassociated technique into clinical practice.
Surgical Technique
and Difficult Situations
from David Jayne
(Laparoscopic Ventral
Rectopexy)
JimTiernan andDavidJayne
53.1 Introduction – 416
53.2 Technique – 416
53.2.1 Patient Selection – 416
53.2.2 Preparation – 416
53.2.3 Operative Technique – 416
53.2.4 Postoperative Care – 418
415
53
53.3 Difficult Situations and Intraoperative
Complications – 418
References – 419
© Springer-Verlag Berlin Heidelberg 2017
M. Korenkov et al. (eds.), Gastrointestinal Operations and Technical Variations,
DOI 10.1007/978-3-662-49878-1_53