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416
J. Tiernan and D. Jayne
53
53.1 Introduction
is chapter describes the authors’ approach to
laparoscopic ventral rectopexy along with technical tips to avoid diculties and complications. For
the sake of clarity, the below description assumes
a female patient.
53.2 Technique
53.2.1 Patient Selection
5 All patients with full-thickness rectal prolapse
are suitable for laparoscopic ventral rectopexy
except for the very old and inrm in whom
the risk of general anaesthetic is considered to
be too great.
5 ere is an argument for avoiding pelvic dis-
section in the young male, in whom injury to
the autonomic nerves carries the theoretical
risk of erectile and ejaculatory dysfunction.
5 e presence of full-thickness prolapse
should be elicited on history and conrmed,if possible, by clinical examination.
Preoperative workup should include a exible sigmoidoscopy as a minimum to exclude
a colorectal lesion. Anorectal physiology and
proctography are performed at the surgeon’s
discretion.
53.2.2 Preparation
5 No preoperative bowel preparation is neces-
sar y.
5 Prophylactic broad-spectrum antibiotics are
administered at induction of anaesthesia.
5 General anaesthesia is employed and the
patient placed securely on the operating table
in the reverse Trendelenburg position.
5 A urethral catheter is placed to decompress
the bladder.
halfway between the umbilicus and the
xiphisternum and a few centimetres to the
le of the midline.
5 Further ports are placed under direct vision
and include a 5mm port medial and superior
to the right anterior superior iliac spine, a
12mm port in the right lateral position and
level with the umbilicus and a 5mm assistant
port in the le iliac fossa.
5 With the patient in a head-down position and
tilted slightly to the right, the small and large
bowel is lied out of the pelvis. If necessary, a
redundant sigmoid colon is suspended to the
lateral abdominal wall with the use of laparoscopic tacks placed through suitably bulky
appendices epiploicae, taking care not to
injure the bowel wall or any diverticulae.
5 If necessary, a bulky uterus can be suspended
ventrally by a suture placed through the anterior abdominal wall of the uterine fundus.
5 e pelvic anatomy is identied to guide dis-
section; note is made of the sacral promontory, the right ureter and the right iliac artery.
5 Dissection of the right mesorectal reection
commences at a level just above the sacral
promontory, extending down the right mesorectal gutter and across the anterior rectum at
the level of the Pouch of Douglas (
. Fig. 53.1).
Care is taken not to extend the dissection too
far posteriorly for fear of compromising the
autonomic innervation of the rectum; similarly, dissection is kept to a minimum at the
anterolateral aspect rectum at the Pouch of
Douglas.
5 e recto-vaginal septum is entered. Here,
dissection is aided with the use of a retractor
53.2.3 Operative Technique
5 Pneumoperitoneum to 15mmHg is estab-
lished using a Veress needle in the le subcostal position.
5 An Endopath® Xcel® Optiview® (Ethicon
Endosurgery, USA) 12mm port is placed
. Fig. 53.1 Dissection of the right mesorectal reflection
Laparoscopic Rectopexy: Technique and Difficulties
417
53
inserted per vagina to li the vaginal vault
ventrally. Dissection in the recto-vaginal plane
is continued as low as possible and can be
checked by insertion of a digit into the rectum
(. Fig. 53.2); a laparoscopic instrument
should be easily palpable just above the anorectal junction.
5 A 3 × 20cm strip of mesh is fashioned. It is the
authors’ preference to use a composite, semiabsorbable mesh, such as Vypro II® (Ethicon
Endosurgery, USA), which provides the initial
support necessary for repair whilst avoiding
problems with mesh erosion and migration
that has been associated with heavier prosthetic meshes.
5 e mesh is inserted into the dissected recto-
vaginal septum, as low as possible, and
sutured to the anterior rectum with ×4 nondisposable sutures, such as 3/0 Ethibond®
(Ethicon Endosurgery, USA) (. Fig. 53.3). For
convenience, the authors use an extracorporeal knot-pushing technique.
5 X2 sutures are next inserted to secure the
mesh to the posterior vaginal vault.
5 e mesh is then pulled loosely up to the
sacral promontory, where it is either secured
to the sacral promontory with ProTack®
(Covidien, USA) or 3/0 Ethibond® sutures.
Any excess length of mesh is trimmed and
removed (. Fig. 53.4).
5 Haemostasis is checked and the Pouch of
Douglas and pelvic peritoneum reconstructed with a continuous dissolvable
suture (. Fig. 53.5).
5 e operation is completed by releasing the
sigmoid colon (if suspended), deating the
abdomen and closing the fascial defects at the
12mm port sites (. Table 53.1).
. Fig. 53.2 Dissection of the recto-vaginal septum
. Fig. 53.3 The mesh is inserted into the dissected
recto-vaginal septum and sutured to the anterior rectum
with four non-absorbable sutures
. Fig. 53.4 The proximal mesh is secured to the sacral
promontory
. Fig. 53.5 The pouch of Douglas and pelvic peritoneum
are reconstructed with a continuous non-absorbable
suture
53
J. Tiernan and D. Jayne
418
. Table 53.1 Patients classified by operative difficulty: ‘ideal’ = easy to operate with no expected problems;
‘not quite ideal’ = some minor difficulties may occur; ‘problematic’ = difficult to operate, some operative steps are
considerably more difficult than others; ‘very problematic’ = every operative step is difficult
Type Description Examples
I Ideal Female
No previous hysterectomy
Virgin abdomen
Low BMI
II Not quite ideal Obesity
Large redundant sigmoid
Previous hysterectomy
Mild adhesions
III Problematic Scarred abdomen
Moderate adhesions
Previously failed rectopexy procedure
Other coexistent abdominal or pelvic pathologies
IV Very problematic Multiply scarred abdomen
Dense adhesions
Multiple failed rectopexy procedures
53.2.4 Postoperative Care
5 e patient is encouraged to drink, eat and
mobilise as soon as possible aer surgery. e
urethral catheter is removed as soon as convenient.
5 Postoperative medications include a stool so-
ener and bulking agent for 7 days to prevent constipation and straining at defaecation.
5 In the authors’ practice, around 50 % of patients
are discharged the day following surgery, with
the remainder on postoperative day 2.
53.3 Difficult Situations
and Intraoperative
Complications
5 Vascular injury: vascular injuries include possi-
ble injury to the le internal iliac vein and bleeding from the middle sacral vessels at the sacral
promontory. e le iliac vein is at risk during
the initial dissection to li the mesorectum o
the sacral promontory if the dissection is carried
too far to the le side. It is only necessary to
clear the sacral promontory such that most of
the anterior aspect is free, and if dissection is
restricted to this extent, then major vascular
injury will be avoided. Bleeding from the middle
sacral vessels during xation of the mesh to the
sacral promontory can be avoided by careful
inspection for the vessels and placement of the
xation sutures/tacks appropriately. Should
bleeding be encountered, it can usually be controlled by tying o the sutures combined with
pressure applied via a gauze swab. Other potential bleeding points include the lateral pelvic
sidewall and the posterior vagina and are
avoided by keeping the dissection in the correct
mesorectal plane.
5 Autonomic nerve injury: this is an injury
caused by the dissection straying out of the
correct mesorectal plane. Vulnerable points
include initial dissection at the sacral promontory and the anterolateral aspect of the rectum at the Pouch of Douglas.
5 Mesh complications: there are reported cases of
mesh migration and erosion into the vagina and
rectum with associated pelvic sepsis [1, 2]. is is
probably more frequent with the use of heavy,
prosthetic mesh. In the authors’ experience of
over 200 cases using lightweight, semiabsorbable mesh, this has never been experienced. Because of the concern regarding mesh
erosion with prosthetic mesh, there is an interest
in the use of biological meshes for rectopexy, and
preliminary data suggests that it is eective at
least on short-term follow-up [3, 4].
5 Small-bowel obstruction: in laparoscopic recto-
pexy this may be associated with incomplete
Laparoscopic Rectopexy: Technique and Difficulties
419
53
reconstruction of the Pouch of Douglas and pelvic peritoneum. Attention should be paid to
ensuring complete closure of the peritoneum,
without any gaps for small-bowel herniation.
5 Dyspareunia: this is reported in all proce-
dures that involve dissection of the rectovaginal septum and may be more frequent
with the use of heavy, prosthetic mesh. e
reported incidence is around 2.5 % following
laparoscopic ventral rectopexy. It is oen
dicult to treat and referral to a gynaecologist is recommended.
5 Lumbar discitis: this has been reported aer lapa-
roscopic ventral rectopexy and is presumably a
result of the xation method of the mesh to the
sacral promontory [5]. In the authors’ experience, lower back pain for a few days is not an
Case Example
Situation
A 65-year-old female presents with
full-thickness rectal prolapse,
defaecatory urgency and tendency
to faecal incontinence. Flexible
sigmoidoscopy is normal. The
patient undergoes laparoscopic
ventral rectopexy without
complication, but represents to the
clinic at 6 weeks postoperative
complaining of mucous discharge
and bleeding on defaecation.
Proctoscopy reveals obvious rectal
mucosal prolapse, but without
full-thickness prolapse.
Dilemma
How to deal with symptomatic
residual mucosal prolapse
following mesh rectopexy?
Solution
The patient underwent transanal
resection of the mucosal prolapse
uncommon complaint following mesh xation
to the sacral promontory with ProTack, but is
rarely described following sutured xation.
5 Recurrent rectal prolapse: failure of the recto-
pexy with recurrent rectal prolapse is reported
to occur in 3.4 % of cases (range, 0–15.4 %) [1].
e most frequent cause of failure is detachment of the mesh from the sacral promontory
and is usually amenable to redo procedure. In a
minority of patients (8 % in the authors’ series),
the patient may have evidence of residual
mucosal prolapse rather than full-thickness
prolapse recurrence. is may be a result of the
mesh being placed to high in the recto-vaginal
septum, but it some cases it is a reection of an
incompetent, patulous anal sphincter, when it is
largely unavoidable.
using the STARR (stapled transanal
rectal resection) technique.
Theoretical concerns regarding
incorporation of the mesh in the
transanal resection are largely
unfounded, as long as resection is
limited to the area of prolapsing
tissue.
Outcome
Resolution of symptoms
References
1. Samaranayake CB, Luo C, Plank AW, Merrie AEH, Plank
LD, Bissett IP. Systematic review on ventral rectopexy
for rectal prolapse and intussusception. Colorectal Dis.
2010;12:504–12.
2. Faucheron J-L, Voirin D, Riboud R, Waroquet P-A, Noel
J. Laparoscopic anterior rectopexy to the promontory
for full-thickness rectal prolapse in 175 consecutive
patients: short-and long-term follow-up. Dis Colon
Rectum. 2012;55:660–5.
3. Sileri P, Franceschilli L, de Luca E, Lazzaro S, Angelucci
GP, Fiaschetti V, Pasecenic C, Gaspari AL. Laparoscopic
ventral rectopexy for internal rectal prolapse using
biological mesh: postoperative and short-term functional results. J Gastrointest Surg. 2012;16:622–8.
4. Wahed S, Ahmad M, Mohiuddin K, Katory M, MercerJones M. Short-term results for laparoscopic ventral
rectopexy using biological mesh for pelvic organ prolapse. Colorectal Dis. 2012;14:1242–7.
5. Draaisma WA, van Eijck MM, Vos J, Consten ECJ. Lumbar discitis after laparoscopic ventral rectopexy for
rectal prolapse. Int J Colorectal Dis. 2011;26:255–6.
Surgical Technique
andDicult Situations
fromAntonio Longo
(Dierent Techniques)
AntonioLongo
54.1 Stapled Hemorrhoidopexy – 422
54.1.1 Description of the Technique – 422
54.2 STARR – 425
54.2.1 Description of the Technique with 2 PPH 01 – 425
54.2.2 Description of the Technique with Transtar – 426
421
54
54.3 Treatment of External Rectal Prolapse – 428
54.4 SIR Procedure – 429
54.5 POPS Technique – 429
54.5.1 Very Problematic Case – 431
54.5.2 Description of the Intervention – 432
© Springer-Verlag Berlin Heidelberg 2017
M. Korenkov et al. (eds.), Gastrointestinal Operations and Technical Variations,
DOI10.1007/978-3-662-49878-1_54
422
A. Longo
54
e rectal prolapse can be classied as internal
and external. e internal rectal prolapse can be
of the mucosal type (5–10 % of cases) or full thickness. Both types can cause hemorrhoidal prolapse. e internal rectal prolapse may occur as an
intussusception or, under straining, can dilate
forming also a rectocele or a megarectum.
e hyperdescending perineum and enterocele are frequent alterations associated with internal rectal prolapse because they are secondary to
straining induced by obstructed defecation. e
presence of an enterocele must be well assessed
preoperatively to prevent serious intraoperative
complications.
e external rectal prolapse is commonly classied according to the length that comes out compared to the anal verge: procidentia, rectal
prolapse, and rectosigmoid prolapse. We believe
this classication is inadequate because it does not
take into account anatomical and structural damage of the rectum. We have observed that oen the
rectum is stretched due to weakness of the muscular tunics resulting in obvious loss of compliance.
is could explain the high percentage of constipation aer rectopexy, with any technique
undertaken, including the so-called anterior rectopexy. For this reason and for other complications, we have abandoned traditional rectopexy.
In cases of external rectal prolapse without structural damage and lengthening, from 2007 we have
proposed a novel approach: so intraperitoneal
rectosuspension (SIR).
In the case in which the prolapsed rectum
presents elongation and thinning of muscular
tunic, we prefer to amputate it via the perineum
according to Altemeier technique but making the
anastomosis with the PPH stapler at least 4 cm
above the dentate line.
e full-thickness rectal prolapse, internal or
external, may be primary or secondary to genital
prolapse. We have demonstrated, through MRI
dynamic pelvigraphy, that a genital prolapse
always induces a rectal prolapse and that conventional techniques adopted by gynecologists, both
transvaginal and colposacropexy, do not correct
the associated rectal prolapse.
In cases of rectal prolapses, internal or external, associated with genital prolapse greater than
one degree (Baden & Walker), we perform the
POPS technique. e protocol of our surgical
choices regarding the various types of rectal prolapse is shown in . Table54.1 and . Fig.54.1.
54.1 Stapled Hemorrhoidopexy
54.1.1 Description oftheTechnique
Aer lubrication of the anal canal, the circular
anal dilator (CAD) is introduced. e introduction of the CAD causes the reduction of the hemorrhoidal prolapse and anoderma. As it is
transparent, the CAD allows visualization of the
dentate line, allowing the surgeons to check the
correct positioning. e CAD is then stitched to
the perineum with four stitches, at the cardinal
points. Aer removing the obturator, the
prolapsed mucosa falls into the lumen of the CAD
and may be evaluated through the Parks
maneuver.
. Table 54.1 Types of external rectal prolapse and related surgical indications
Types
External rectal prolapse
Primary Procidentia– not signicant enterocele Perineal resection by
Secondary to urogenital
prolapse
Clinical and structural alterations Suggested procedure
contour
Procidentia– associated to deep Douglas or enterocele Soft intraperitoneal
Rectal prolapse without structural alterations of the
muscular layer and elongation
Rectal prolapse with rectal elongation and thinned
muscular layer
Genital prolapse associated to external rectal prolapse POPS ± STARR or SIR
rectopexy (SIR)
SIR
Altemeier
Surgical Technique andDifficult Situations fromAntonio Longo (Different Techniques)
a
b
423
54
c
PROCIDENTIA RECTAL < 6 cm RECTUM-SIGMOID > 6 cm
d
. Fig. 54.1 a Stapled anopexy. Rectal mucosa pro-
lapse with hemorrhoidal prolapse. b STARR.Full thickness internal prolapse and/or rectocele with or without
hemorrhoidal prolapse. c Modified Altemeier. SIR (soft
intraperitoneal rectosuspension). d POPS ± STARR
(pelvic organ prolapse suspension). Genital prolapse
associated to external or internal rectal prolapse and/or
rectocele
424
A. Longo
54
e purse-string suture anoscope is introduced through the CAD. is instrument will
move the mucous prolapse along the rectal walls
along a 270° circumference, while the mucosa
that protrudes through the PSA window can be
easily contained in a suture that includes only
mucosa and submucosa. is suture must be carried out at least 2–3 cm above the apex of the
hemorrhoids (. Fig. 54.2a), the distance to be
increased in proportion to the extension of the
rectal prolapse. By rotating the PSA, it will be possible to complete a purse-string suture around the
entire anal circumference.
e circular stapler is opened to its maximum
position. Its anvil is introduced beyond the pursestring (. Fig. 54.2b). e PPH is slightly with-
a
b
drawn, enough to ensure the purse-string can be
visualized. e purse-string is then tied with a
single closing knot. With the help of the suture
threader, the ends of the suture are pulled through
and out of the lateral holes of the casing. e ends
of the suture are knotted externally or held by a
clamp. e casing of PPH is introduced into the
anal canal. During the introduction, it is advisable
to partially tighten the stapler.
Via a moderate traction on the purse-string,
the prolapsed mucosa is accommodated into the
casing (. Fig.54.2c). e instrument is then tightened to the end. If the patient is a woman, check
the posterior vaginal wall to be certain that it has
not been incorporated in the staple line. e stapler is then red. e PPH is slightly opened
cd
. Fig. 54.2 Steps of stapled hemorrhoidopexy a https://www.dict.cc/englisch-deutsch/purse-string.html purse-string
https://www.dict.cc/englisch-deutsch/suture.html suture must be carried out at least 2–3 cm above the apex of the haem-
orrhoids b The circular stapler is opened to its maximum position. Its anvil is introduced beyond the purse-string c Via a
moderate traction on the purse-string, the prolapsed mucosa is accommodated into the casing d nished stapler line
Surgical Technique andDicult Situations fromAntonio Longo (Dierent Techniques)
425
54
(one-half to the three-fourths revolutions) and
extracted (. Fig.54.2d). Finally, the staple line is
examined using the PSA.
Inspect the staple line for bleeding, and if necessary reinforce it with hemostatic stitches using
2-0 absorbable suture. In order to ensure four
checks for post-op bleeding, a long wet swab
(25cm), with a suture anchored at the lower end,
is completely inserted above the staple line. e
swab is normally removed aer 4–5 h. Inspect the
specimen to conrm that the technique has been
properly performed. Accessory procedures (e.g.,
tag or papilla excision ) can be performed either
before or aer stapling.
Ideal Case
Patient without previous anal surgery with internal mucosa prolapse less than 4 cm, reducible
hemorrhoidal prolapse, without skin tags.
Not Quite Ideal Cases
Patients with previous hemorrhoidectomy, with
anus not very dilatable that impedes the introduction of the CAD.
kTechnical variant
you can practice two lateral incisions on the anoderma such that the CAD may be introduced.
e incisions are sutured aer the rectal resection.
Problematic Cases
1. Anal canal with very long massive hemorrhoids
occupying the anuscopio obscures the view of
the rectal mucosa and makes it dicult to per-
form the purse-string suture.
2. Patient with voluminous skin tags that make
the hemorrhoidal prolapse not reducible.
Variation of technique: excision of skin tags
through the incisions and detach the ano-
derma from the anal sphincter to make it
mobile and reducible. At the end of the inter-
vention, the wounds can be sutured, and if
they are too many and wide, and if there is a
risk of stenosis, small sliding skin aps can be
made.
kTechnical Tip
enter in succession into the holes of the CAD a
spatula 2cm wide that goes beyond the internal
edge of the CAD; move the hemorrhoids laterally
making it possible to stitch the rectal mucosa.
Very Problematic Case
Patient, 46 years old, male, underwent hemorrhoidectomy 2 years previously. Frequent rectal
bleeding, daily use of laxatives, and enemas.
Severe anal stenosis extended the whole length
of the anal canal. e defecography, performed
with very uid barium, showed signicant rectal
mucosa prolapse.
kIntervention
patient in lithotomic position. Dilation of the stenosis by Hegar. Two lateral and longitudinal incisions are carried out on all the stenotic anal canal.
With curved scissors and dissector, the anoderma
is dissected from the anal sphincters. It is noted
that the rectal prolapse occupies the anal canal. e
anal dilatation obtained allows the introduction of
a PPH but not of the CAD.A purse-string suture is
made 8 cm from the anal verge. A node on the
purse-string is carried out without tightening. e
ends of the threads are brought outside through
the holes of the stapler. e casing stapler is
inserted up to 6cm. e stapler head is opened and
pushed just above the purse-string. Seen through
the holes that the prolapse occupies the casing, the
resection is carried out. Hemostasis is checked.
Two rotating skin aps are prepared to correct
the anal stenosis.
Postoperatively, the patient reports no more
bleeding and obstructed defecation. For about 3
months, soiling and dermatitis is reported and is
subsequently improved. e postoperative ultrasonography shows absence of smooth sphincter in the
posterior and le side replaced by brotic tissue.
54.2 STARR
54.2.1 Description oftheTechnique
with2 PPH 01
e lithotomic position is mandatory. Spinal
anesthesia is advantageous because it achieves a
constant sphincter relaxation and the patients
don’t have postoperative pain for 4–5h.
e CAD introduction maneuver is similar to
the stapled hemorrhoidopexy. e edge of the
prolapsing rectal cylinders must be captured by
three stitches passed at 10– 12– 2h. e tail end
of the central stitches are tied together with the
right and le ones. In order to avoid the inclusion
of posterior prolapse in the anterior resection, a
54
426
A. Longo
. Fig. 54.3 STARR technique: a spatula is introduced
in the posterior window of the CAD to avoid resection
of posterior rectal prolapse. PPH stapler is introduced in
maximum opening. The stitches in the edge of anterior
prolapse are passed
spatula, 2 cm large, must be carefully inserted
8–10cm through the posterior hole in the ange
of the CAD.A PPH 01 stapler head, at its maximum opening, is inserted and positioned just
beyond the sutures (. Fig. 54.3). e suture
threads are pulled through the casing holes and
knotted together. Keeping the head of the stapler
just above the stitches, start to close the stapler.
Before the complete closure, in women, a vaginal
valve is placed in the posterior fornix and with
two ngers; it is checked that the vaginal wall isn’t
trapped in the stapler. Aer having red, the stapler is removed.
Normally, two dog-ears, connected with a
mucous bridge, will be observed. Aer removing
the spatula and interrupting the mucosal bridge, one
stitch for each dog-ear is passed through and one
more in the middle of the edge of the posterior prolapse (they are the lateral end of the posterior prolapse). Having introduced the spatula in the anterior
window of the CAD ange, the posterior resection
is made as well as the anterior one. At the end of the
procedure, two small dog-ears can be observed; it
can be removed or sutured using Vicryl 00.
54.2.2 Description oftheTechnique
withTranstar
the edge of the prolapsing rectal wall, ve short
running sutures must be apposed circumferentially, like parachute cords (. Fig.54.4a), to obtain
total control of the prolapsing rectum. A stitch
must be apposed at 3o’clock involving the entire
length of the prolapse and is knotted tightly.
Keeping this stitch in traction, the stapler was
positioned transversally and the rst shot red.
is maneuver opening longitudinally the
rectal prolapse (. Fig.54.4b) allows the start of
the circumferential resection by subsequently ring cartridges stapler (. Fig.54.4c, d). Aer ring
the last shot and removing the specimen, eventual
bleeding can be stopped by stitches.
Ideal Cases
Patients without previous anorectal operations
and/or hysterectomy. Internal rectal prolapse full
thickness with rectocele but not megarectum,
normotrophic vaginal wall.
Not Quite Ideal Cases
e following conditions make surgery less simple and require special care:
1. Substenosis anal skin tags with non-reducible
hemorrhoidal prolapse
2. Prior STARR or stapled hemorrhoidopexy
3. Obesity
Problematic Cases
1. Megarectum
2. Hysterectomy with short vaginal stump
Very Problematic Cases
Technique by Two Staplers
A 43-year-old woman with severe constipation
and frequent rectal bleeding (Hb 9.2).
Defecography shows 5cm deep rectocele, rectoanal prolapse, and deformation due to retraction
of the posterior rectal ampoule.
e colonoscopy shows an ulcer 3 × 2cm on
the posterolateral rectal wall, 3cm above the hemorrhoidal apex.
Histological examination: likely solitary ulcer
of the rectum.
Patient in lithotomic position. A new device, a
rechargeable CCS-30 Contour Transtar stapler kit
(Ethicon Endo-Surgery), is the dedicated device
utilized. Aer CAD introduction and xing, on
kIntervention
Aer the insertion of the CAD, inspection of the
rectal ampoule conrms endoscopic data. esolitary ulcer covers the posterolateral edge of the