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158
M. DeBarros and S.R. Steele
Fig. 14.4 Suggested trocar and monitor placement for laparoscopic rectal prolapse repair
Table 14.1 Equipment
Head lamps for surgeon and assistant (optional)
Laparoscopic monitors
5- and 10 mm 30° laparoscope
Trocars (5 mm × 3), Hasson, 10–12 mm × 1, additional 5 or 10 mm
trocars for optional ports
Laparoscopic blunt, atraumatic graspers, and scissors
Laparoscopic needle driver
Laparoscopic retractor (i.e., fan blade retractor, optional)
Electrocautery with extender tip (i.e., Bovie)
Laparoscopic energy device (surgeon preference)
Linear cutting stapler and appropriate staple loads
Circular cutting stapler (29–33 mm based on surgeon preference)
Sizers for circular cutting stapler
Nonabsorbable suture
Prosthetic mesh (optional)
Wound protector drape (optional for resection and extracorporeal
anastomosis)
Proctoscope
• Secondary trocar placement: An additional 10–12 mm
trocar is placed in the right lower quadrant and a second
5 mm port in the right upper quadrant with emphasis on
adequate triangulation. We attempt to have a minimum of
a fi st-size distance between each of these ports. If a rectopexy alone is the procedure, the 10–12 mm port will be
changed to a 5 mm trocar.
• Optional trocars: (5 mm up to 12 mm in size) may be
placed in the left paramedian position, lateral to the edge
of the rectus in the left mid-abdomen to assist with sigmoid retraction. Additionally, a suprapubic 5 mm port
may be useful in cases where the mesh or the mesorectum
is secured to the sacrum with a tacking device.
• Optional hand-assist device placement: For surgeons who
prefer to use a hand-assist device, this may be placed in
the Pfannenstiel or midline position.
Mobilization of the Sigmoid Colon and Rectum
• Mobilization of the sigmoid colon: A medial or lateral
considered in the left upper quadrant or away from other
prior surgical fi elds.
• Establishment of pneumoperitoneum: This is achieved
through the umbilical port. Following adequate pneumoperitoneum, the 10 mm 30° camera is inserted. The abdomen is explored in all four quadrants, and any abnormalities
are noted.
approach can be utilized depending on the comfort level
and preference of the surgeon. Proximal mobilization
typically involves only the section of redundant sigmoid
and routine splenic fl exure mobilization is not required.
Further mobilization may result in more redundancy and
possible recurrence of prolapse or constipation symptoms
with a large “fl oppy” colon (see Fig. 13.4 ). The superior
14 Laparoscopic Rectopexy
159
Fig. 14.5 Takedown of the lateral attachments of the sigmoid
rectal/inferior mesenteric vessels should be preserved, if
possible.
– Lateral approach: The left colon is retracted medially
with blunt atraumatic bowel graspers, utilizing gravity
by tilting the operating table to the patient’s right and
head down. An energy device or hook-electrocautery is
then used to mobilize the sigmoid and descending
colon away from left lateral abdominal wall (Fig. 14.5 ).
– Medial approach: The sacral promontory provides a
uniform landmark to begin medial mobilization under
the inferior mesenteric artery and access the avascular
plane (Fig. 14.6 ).
• Pearl : For either lateral or medial approach, the
left ureter should be identifi ed early and protected,
typically as it courses over the bifurcation of the
iliac vessels (Fig. 14.7 ).
• Rectal mobilization: The presacral space is entered at the
sacral promontory, which is aided with anterior retraction on the rectosigmoid junction (Fig.
14.8 ). Care
should be noted here to avoid transection of the hypogastric nerves that course medially in the retroperitoneum
prior to forming two distinct trunks that course posteriorly and laterally in the pelvis (Figs.
14.9 and 14.10 ).
Distally, mobilization continues down to the pelvic fl oor
(Fig. 14.11 ). There are differing opinions regarding the
extent of the lateral and anterior dissection.
– Lateral dissection: We prefer to avoid extensive lateral
dissection and do not divide the lateral stalks.
– Anterior dissection: We dissect approximately 4 cm
until the cut edge of the peritoneal refl ection can be
easily pulled back to the level of the sacral promontory
(Fig. 14.12 ).
– Alternative dissection: Others prefer to perform a com-
plete rectal mobilization circumferentially down to the
level of the pelvic fl o o r .
Fig. 14.6 Mobilization line of dissection for a medial approach
Resection of the Redundant Sigmoid Colon
• Distal division of sigmoid colon: A point is chosen for
distal division past the point where the taenia splay using
a cutting stapler (Fig. 14.13 ).
• Extra-corporealization of distal sigmoid colon: Once the
distal portion of the bowel is transected, the bowel is
brought out at either the umbilical port site or a small
Pfannenstiel incision. The redundant sigmoid is delivered
through the wound utilizing a wound protector (Fig. 14.14 ).
• Proximal division of sigmoid colon: Transection of the
bowel with a laparoscopic linear cutting stapler is completed at a tension-free location that easily reaches the
sacral promontory without redundancy.
• Placement of anvil: A purse-string suture is placed in the
proximal bowel, and the anvil is secured. Sizers can then
be used to determine the appropriate size of the circular
stapler to be used. We almost exclusively use a 29 mm
160
M. DeBarros and S.R. Steele
Fig. 14.7 Most common location of identifi cation of the left ureter as
it crosses over the common iliac bifurcation
Fig. 14.9 Hypogastric nerves at the level of the sacral promontory
Fig. 14.8 Accessing the presacral space
end-to-end stapler; however, sizing can be done according
to surgeon preference.
– Pearl: Remember that the diameter of the sizer is
smaller than the corresponding stapler diameter
when selecting the appropriate sized stapler .
• Return of the colon to the abdomen: The descending
colon can then be returned to the abdomen in preparation
for anastomosis creation.
Anastomosis Creation
• Anastomosis creation: The circular stapler is then placed
into the anus to the level of the rectal stump. The trocar
Fig. 14.10 The right hypogastric nerve can be seen coursing posterior
and into the pelvis
portion of the stapler is carefully advanced until the anvil
is engaged. Prior to closing the stapler, the surgeon
should confi rm that there is no inclusion of extra tissue,
twisting of bowel, or mesentery. The location of both
ureters and vagina should be reconfi rmed to ensure they
are not included in the staple line. The stapler is then
fi red and tissue doughnuts should be removed and closely
inspected to confi rm circumferential integrity of the
staple line.
• Inspection of anastomosis: The newly created anastomosis
is carefully inspected for bleeding or ischemia as well as
tension (Fig. 14.15 ). An air-leak test is performed using a
proctoscope with endoluminal insuffl ation of air after the
14 Laparoscopic Rectopexy
161
Fig. 14.11 Posterior extent of mobilization down to the pelvic fl oor past the coccyx. Note that the mesh is secured to the sacral promontory
Fig. 14.12 Cut edge of the anterior peritoneal refl ection, which should
reach back to the sacral promontory to ensure appropriate mobilization
prior to rectopexy
anastomosis has been submerged in warmed normal
saline (see Fig. 10.12 ).
• Troubleshooting the anastomosis: Any leaks encountered
should be reinforced with sutures or the anastomosis redone, and the air-leak test performed again. The use of a
proctoscope also allows for endoluminal inspection of the
anastomosis. If there is any evidence of tension or ischemia after anastomosis creation, further mobilization
should be performed, and anastomosis should be taken
down and recreated.
Fig. 14.13 Extent of resection for redundant sigmoid delineated. Note
the limited sigmoid mobilization with proximal mobilization
Rectopexy
Rectopexy may be performed prior to creation of the anastomosis or after, though we prefer the latter. If the rectopexy is
completed prior to the creation of the anastomosis, then pexy
sutures should not be secured until after the creation of the
anastomosis to ensure a tension-free anastomosis.
• Performing the rectopexy: Utilizing the previously created Pfannenstiel incision or the laparoscopic ports, the
162
M. DeBarros and S.R. Steele
Fig. 14.14 The proximal transection of the sigmoid colon has completed extracorporeally with the bowel brought out through a wound
protector
Fig. 14.15 Anastomosis complete, endoscopic view
rectum is pulled posteriorly and superiorly toward the
sacrum at a site of fi xation approximately 1–2 cm below
the sacral promontory. The rectum should be suspended
without redundancy below the rectopexy sutures without
excessive tension on the anastomosis. Two to three mattress sutures of nonabsorbable suture (0-Ethibond or 2-0
Prolene) are passed in an anterior to posterior fashion
through the mesorectum adjacent to the bowel wall,
through the presacral fascia and then back through the
mesorectum in a posterior to anterior fashion approximately 1.5–2 cm form the initial bite (Figs. 14.16 and
14.17 ). Although some surgeons advocate for the bilat-
eral placement of sutures, we prefer to place all the
sutures on one side to avoid kinking at the site of
rectopexy.
Fig. 14.16 Mesorectal fi xation using three horizontal mattress sutures
unilaterally
– Troubleshooting: Care should be taken to avoid injury
in the presacral venous plexus and mesenteric vessels
during placement of the suture. If presacral bleeding is
encountered, the sutures should be tied down and
direct manual pressure applied. If bleeding persists,
more aggressive maneuvers such as thumbtacks or
fi brin sealant may be utilized (Fig. 14.18 ).
• Closure of the abdomen: Once meticulous hemostasis is
assured, then the Pfannenstiel incision is closed in layers
(if utilized) and all port sites incisions are closed in the
standard fashion. The placement of pelvic drains is not
routine. The patient is placed back in the supine position,
and the orogastric tube is removed at time of emergence
from anesthesia. The Foley catheter should remain in
place until postoperative day 1.
Laparoscopic Rectopexy
Trocar Placement (Fig. 14.4 )
If rectopexy alone is indicated, similar port sites are placed
as in the case of an additional resection.
• Trocar placement: A 5 mm trocar in the supra- or infraumbilical position (camera port) followed by two 5 mm
ports placed in each quadrant of the right hemi-abdomen
at the lateral edge of the rectus muscle (Fig. 14.19 ).
• Optional ports may be placed to allow for self-retaining
retraction instrument placement on the left side of the
abdomen and in the suprapubic position.
• Surgeon’s position is at the discretion of the operating
surgeon, though we prefer to stand on the patient’s right
side, with the assistant on the left.
Fig. 14.17 Lateral view
of the sacral fi xation
Fig. 14.18 Optional bleeding control measures of muscle fl ap/thumbtacks
164
M. DeBarros and S.R. Steele
Fig. 14.19 Trocar sites for straight laparoscopic rectopexy. The
patient’s feet are toward the top of the picture
Fig. 14.20 Rectopexy with mesh secured to the upper sacrum
Rectum Mobilization
Similar to the resection rectopexy, rectal mobilization is
carried down to differing levels (i.e., anterior vs. posterior vs.
lateral) with rectopexy alone. The extent of anterior and lateral mobilization is again somewhat less defi ned. Whether or
not the extent of anterior mobilization is effi cacious in preventing recurrence or improving functional outcome is
unknown. The argument for dividing the lateral ligaments is
improvement in incontinence and decreased recurrence
down to the level of the mid- to upper third of the vagina
in females or seminal vesicles in males; more aggressive
distal dissection especially in males can result in parasympathetic nerve injury.
• Lateral dissection: This involves the preservation or division of the lateral ligaments; however, there is a gathering
evidence in the literature that these ligaments are not true
anatomic structures.
rates; however, proponents for preservation note that there
are reports of increased postoperative constipation with their
division. A meta-analysis performed by Tou et al. found that
division, rather than preservation, of the lateral ligaments
was associated with less recurrent prolapse but more postoperative constipation [ 13 ].
• Posterior dissection: Dissection should end at the level of
the pelvic fl oor levators by continuing dissection in the
anatomic mesorectum plane. Access to this avascular
plane is reproducibly performed under the IMA at the
level of the sacral promontory. The hypogastric nerves
should be identifi ed at the level of the sacral promontory
and preserved. Injury or unintentional division of these
nerves can cause sexual and urinary dysfunction. This can
be avoided by ensuring proper identifi cation of the avascular presacral plane that can be more easily identifi ed by
forward traction of the rectum.
• Anterior dissection: Dissection takes place between the
anterior aspect of the rectum and the posterior aspect of
the anterior pelvic structures by opening the anterior peritoneal refl ection characterized by its horseshoe fold.
Dissection may be aided by careful retraction of the uterus
or bladder with the use of a laparoscopic fan blade retractor and countertraction on the rectum with the left laparoscopic blunt atraumatic grasper. The dissection is carried
Rectopexy
Rectopexy is performed in the same manner as a resection
and rectopexy procedure with the exception that suturing or
tacking is accomplished intracorporeally (Video 14.1 ).
• Mesh placement: If the use of mesh for a sling procedure
is planned, the mesh (size 5 cm × 2 cm) is rolled up and
introduced into the abdominal cavity via the right lower
quadrant port. The mesh is placed in a vertical fashion
along the sacrum from the sacral promontory caudal into
the pelvis and secured to the sacrum using endoscopic
tackers or laparoscopic staplers. Suturing the mesh to the
presacral fascia is possible but can be diffi cult due to the
smaller size of the needles that can pass through the laparoscopic ports [ 17 ]. The tackers or staples should be
placed below the promontory and close to the midline to
prevent injury to the hypogastric nerves.
• Securing the lateral edges of mesh: The lateral edges are
then secured to the rectal wall by nonabsorbable sutures
utilizing an intracorporeal suturing technique. Care
should be taken not to completely encircle the mesh
around the rectum to prevent kinking or postoperative stenosis (Figs.
14.20 and 14.21 and Video 14.2 ).
• Closure: The placement of pelvic drains is not routine.
When mesh is used, we prefer to close the peritoneum to
14 Laparoscopic Rectopexy
Fig. 14.21 Sagittal view with mesh placement to the sacrum and the mesorectum
avoid leaving the mesh exposed. Meticulous hemostasis
remains an important mainstay, and closure is achieved in
Complications
the same manner as described previously.
Complications may be divided into intraoperative and
postoperative (Table 14.2 ). Intraoperative complications typ-
Postoperative Care
ically occur in <5 % and include inadvertent enterotomy,
colotomy, ureteral injury, trocar placement injuries, and vas Standard postoperative management of these patients should
include early ambulation and initiation of enteral feeding.
Most patients may be started on a clear liquid diet on the day
of the surgery and advanced as tolerated to solid foods on
cular injury. Enterotomies and colotomies should be repaired
primarily if possible, and conversion to an open procedure
should be done if the injury cannot be safely repaired.
Ureteral injuries should be repaired intraoperatively if found
postoperative day 1, though some surgeons keep patients on
a pureed or liquid diet for the fi rst 7–10 days following
repair. Pain control should be balanced to avoid exacerbation
of ileus and can be achieved with the judicious use of narcotics and nonnarcotics such as ketorolac, acetaminophen, and
ibuprofen, which are all available in the parenteral form. The
bladder catheter is usually removed on postoperative day 1.
Antibiotics should be discontinued within 24 h postoperatively unless there are specifi c indications to continue them.
DVT prophylaxis should consist of early ambulation, sequential compressive devices while the patient is in bed, and
chemical prophylaxis (heparin or low molecular weight hep-
Table 14.2 Complications of laparoscopic rectal prolapse repair
Intraoperative
• Enterotomy
• Colotomy
• Ureteral injury
• Trocar placement injury
• Vascular injury
Postoperative
• Early
arin) until the patient is discharged from the hospital. We
prefer an aggressive bowel regimen with the use of stool
softeners (docusate) in combination with either an osmotic
laxative such as polyethylene glycol 3350 (Miralax™) or a
stimulant laxative (sennosides) to prevent postoperative constipation. Additionally patients should be counseled to avoid
straining when at the commode to prevent early recurrence.
• Late
Patients with rectopexy alone are typically discharged 1–4
days postoperatively, and those with resection and rectopexy
are discharged 2–5 days postoperatively with planned clinic
follow-up 7–10 days after the day of discharge.
165
− Urinary tract infection
− Respiratory tract infection
− Surgical site infection
− Fecal impaction
− Anastomotic leak
− Deep space infection
− Hemorrhage
− Bowel obstruction
− Rectovaginal fi stula
− Ureteral fi brosis
− Incontinence/constipation
166
and typically involve consultation of a urologic surgeon
when possible. Vascular injury is rare but can occur at several
locations: epigastrics during placement of trocars, gonadal,
and iliac vessels; during dissection and mobilization for
resection and mesenteric vessels; and during mobilization
and resection. Damage to the epigastrics is avoided by transilluminating the abdominal wall during trocar placement and
direct vision for all secondary trocar placements. If damage
does occur, direct pressure and electrocautery can be used
with good success. Refractory bleeding can temporarily be
stopped with a tamponade effect of a Foley catheter balloon
introduced via the offending port site. The gonadal and iliac
vessels are retroperitoneal structures and are avoided by
early identifi cation and careful dissection. If damage to these
vessels does occur, direct manual pressure should be used
and conversion to open should be considered depending on
the extent and location of the injury. Mesenteric vessel injury
occurs during mobilization and transection of the mesorectum and results from improper control prior to transection.
All vessels should be identifi ed and controlled prior to mesorectum transection.
Early postoperative complications include postoperative
hemorrhage, fecal impaction, deep space infections, anastomotic leak, urinary tract infections, surgical site infections,
and respiratory infections. Urinary tract infections can be
avoided by sterilized technique and timely removal of the
bladder catheter. Respiratory infections can be avoided by
early postoperative recruitment of alveoli and avoidance of
atelectasis with the use of incentive spirometry, deep breathing and coughing, and early ambulation. Surgical site infections are unfortunately not uncommon complications in all
colorectal procedures, but their incidence can be minimized
with the appropriate use of preoperative antibiotics, wound
protectors (if resection is performed), and sterile technique,
as appropriate. If a wound infection is encountered, it should
be treated in the standard fashion with wound culture
obtained to guide proper antibiotic treatment as necessary.
Anastomotic leakage, although a feared complication, has a
low incidence (<10 %). Leaks can be avoided by ensuring a
tension-free, non-rotated connection with an adequate blood
supply. If the anastomosis appears tenuous during the procedure, it should be taken down and re-created. If there is a
suspicion for a leak postoperatively and the patient is stable,
a CT scan with PO or rectal and IV contrast should be completed to determine the presence and location of the suspected leak. All patients with suspected leak that are
unstable should undergo fl uid resuscitation, the initiation of
broad- spectrum antibiotics, and return to the operating
room for exploration. Late postoperative complications
include bowel obstruction, ureteral fi brosis, rectovaginal
fi stula formation, and worsening or new fecal incontinence
or constipation.
M. DeBarros and S.R. Steele
Outcomes
Most of the outcomes following rectal prolapse repair are
reported in the open setting, though laparoscopic reports are
similar. The major problem for most patients with rectal prolapse is fecal incontinence, with most series demonstrating
up to 75 % of patients with some degree of incontinence. On
the other side of the spectrum, 15–65 % of patients have concomitant constipation or evacuation disorders [
Following successful repair of the prolapse, the literature
reports wide ranges of improvement in fecal incontinence
(11–100 %; mean 50 %) with resection and rectopexy. Some
patients may have improvement but not complete resolution
secondary to permanent damage to the sphincter mechanism
or pelvic nerves from the chronic prolapse.
Improvement in constipation similarly has somewhat variable results, with some patients improving and others developing new onset or worsening symptoms. There appears to be
better results when a resection is added to those patients with
prolapse and severe preoperative constipation (18–80 %) [ 8 ,
10 , 19 – 23 ]. Recurrence of prolapse following the open abdom-
inal approach are reported at 0–10 % in most series [ 1 , 10 , 24 ].
There have been two prospective trials comparing the laparoscopic technique to the open technique with equivalent outcomes with respect to recurrence [ 12 , 25 ]. Several other
observational retrospective studies have evaluated laparoscopic rectopexy with and without resection and found equivalent recurrence rates, mortality and functional outcomes when
compared to the open technique [ 26 – 29 ]. This was confi rmed
by meta-analysis in which laparoscopic rectopexy was associated with decreased length of stay and fewer postoperative
complications despite longer operative times when compared
to the open approach [ 13 ]. There are now reports that show a
decrease in operative times as more experience is gained using
laparoscopic techniques for colorectal procedures [ 12 ].
13 , 18 ].
Pearls and Pitfalls
• During the preoperative workup for prolapse, surgeons
should look for signifi cant pelvic fl oor abnormalities that
may need to be addressed at the time of surgery. Pelvic
fl oor disorders such as enterocele, cystocele, rectocele,
and uterine and vaginal vault prolapse are present in up to
50 % of patients with rectal prolapse. The repair of these
abnormalities in conjunction with prolapse repair is best
performed with a multidisciplinary team that may involve
a urologist, gynecologist, or urogynecologist, as well as a
colorectal surgeon.
• Unexpected conversion to an open procedure is not a
failure and should be considered if the procedure cannot
14 Laparoscopic Rectopexy
167
be performed safely secondary to dense adhesions or an
injury that cannot be managed laparoscopically has
occurred. Instruments for an open procedure should be
available if conversion is required.
• Determining the appropriate amount of tension can be diffi cult. Use the peritoneal refl ection as a guide, and don’t
hesitate to look endoscopically in the rectum to see if
redundancy is still present when you feel your rectum is
suffi ciently mobilized prior to performing your rectopexy.
• When adding the resection to the rectopexy, mobilize the
rectum fi rst and then perform the resection and anastomosis (and leak test). Once this is complete, perform the
rectopexy.
• Use sizers in the vaginal to help delineate the posterior
vaginal wall from the anterior rectum to ensure you are in
the correct plane of dissection.
Summary
In conclusion, laparoscopic rectopexy with or without resection is a safe, effective procedure with equivalent functional
outcomes, recurrence, and mortality rates when compared to
open techniques (resection and rectopexy, suture rectopexy,
and mesh rectopexy). The use of this approach also allows
for the inclusion of patients who previously would not have
tolerated the morbidity of an open abdominal approach and
results in decreased postoperative pain, early return of bowel
function, and decreased length of stay [ 29 ] .
Disclosures Dr. Steele works as a consultant for Ethicon Endosurgery.
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