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RECTAL PROLAPSE—RECTOPEXY (LAPAROSCOPIC VS OPEN)
Principle
Elective complete posterior mobilization of rectum down to pelvic floor with subsequent posterior resuspension to presacral
fascia, typically with implantation of mesh or collagen sheet (Figures 5–11A and 5–11B). Commonly amenable to
laparoscopic approach. This is the procedure of choice for recurrent rectal prolapse after previous perineal resection
(Altemeier, or unknown perineal technique), in which abdominal resection would carry a risk of creating an avascular
segment.
Figure 5–11A.
Rectopexy: posterior mobilization to rectal floor and mesh placement.
Figure 5-11B.
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Rectopexy: view into pelvis with suspended uterus and posterior mesh-fixation of mobilized rectum.
Setting
Inpatient, OR procedure.
Alternatives
Sigmoid resection, posterior rectal mobilization, with/without rectopexy (unless resection contraindicated).
Abdominal LAR with coloanal anastomosis.
Vascularity-sparing sigmoid resection.
Perineal rectal prolapse repair: Delorme, Altemeier, Thiersch procedure.
Indication
Full-thickness rectal prolapse,
Recurrent rectal prolapse postperineal resection ( risk of ischemic segment with abdominal resection).
Preparatory Considerations
Full colonic evaluation for all elective cases.
Bowel cleansing (traditional) vs no bowel cleansing (evolving concept).
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Prophylactic antibiotics.
Surgical Steps
1. Patient position: modified lithotomy position.
(A) Laparoscopic Approach
2. Creation of pneumoperitoneum (Veress or Hasson technique).
3. Placement of 3(–4) trocars: periumbilical 10–12 mm, bilateral 5 mm, possibly one RUQ 5 mm trocar for retraction.
(B) Open Approach
2. Laparotomy: lower midline, transverse suprapubic (transection of rectus muscle), Pfannenstiel incision (transverse
incision to skin and anterior rectus sheath with midline rectus-saving celiotomy).
3. Placement of abdominal wall retractor or wound protector to expose left portion of colon.
Both Techniques
4. Abdominal exploration: characteristic deep peritoneal reflection, secondary pathology (liver/gallbladder, colon,
female organs, small bowel), other abnormalities.
5. Female patients (in laparoscopic approach): fixation of uterus to anterior abdominal wall—percutaneous insertion of
long straight needle through avascular portion of lateral ligaments, guided around corpus uteri back through
contralateral lateral ligament to abdominal wall and tied outside over gauze.
6. Opening of right-sided peritoneal surface along base of mesosigmoid, extension to pelvis.
7. Incision of left-sided peritoneal surface along white line of Toldt toward pelvis, no mobilization toward splenic
flexure.
8. Identification of inferior mesenteric vessels. The space right behind vascular stalk is entered and a window created.
Developing plane below sigmoid mesentery vessels to bluntly reflect retroperitoneal tissues and expose left ureter.
9. Hypogastric nerves are identified and protected by pushing them toward the back. Blunt dissection behind vascular
stalk (avascular plane) to entry of pelvis and complete posterior mobilization along Waldeyer fascia to pelvic floor.
Avoidance of extensive bilateral mobilization to minimize risk of autonomic nerve dysfunction.
10. Positioning of implant: 6
x 10 cm implant (Marlex mesh, collagen sheet) inserted for laparoscopic procedure; mesh
is rolled up and pushed through camera port, unwrapped internally, and positioned posterior to mobilized rectum.
11. Fixation of implant to presacral fascia with interrupted nonabsorbable sutures (or hernia stapler) to promontory
and presacral fascia (caveat: presacral veins!).
12. Rectopexy wrap: sides of implant are bilaterally wrapped around rectum, leaving anterior one-third of rectum free
and fixed with bilateral series of 3–4 sutures.
13. Removal of temporary uteropexy.
14. Drains according to surgeon's preference. No need for NGT.
15. Closure of incision(s).
Anatomic Structures at Risk
Left ureter, presacral veins, gonadal vessels, hypogastric nerves.
Aftercare
Fast-track recovery: in absence of nausea or vomiting, oral liquids are started on POD1 and advanced as tolerated.
Maintenance of soft stools.
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Complications
Recurrent prolapse.
Bleeding (surgeon-dependent): presacral veins, gonadal vessels.
Ureteral injury (0.1–0.2%).
Mesh infection or mesh migration/erosion.
Cross-Reference
Prolapse (Ch. 1)
Defecating proctogram (defecography) (Ch. 2)
Magnetic Resonance Imaging (MRI) (Ch. 2)
Hemorrhoids (455.X) (Ch. 4)
Pelvic floor dysfunction (618.X) (Ch. 4)
Rectal prolapse (569.1) (Ch. 4)
Rectal prolapse—perineal Delorme repair (Ch. 5)
General perioperative management—abdominal (Ch. 7)
Fast-track recovery (Ch. 7)
RECTAL PROLAPSE—SIGMOID RESECTION AND RECTOPEXY
Principle
Elective resection of sigmoid redundancy, complete posterior mobilization of the rectum down to the pelvic floor with
subsequent resuspension to the presacral fascia. Considered the procedure with the lowest recurrence rate. Colon resection
is desirable in patients with underlying constipation, but should be avoided in case of underlying diarrhea.
Setting
Inpatient, OR procedure.
Alternatives
Laparoscopic approach.
Rectopexy only—laparoscopic or open.
Perineal rectal prolapse repair: Delorme, Altemeier, Thiersch procedure.
Indication
Full-thickness rectal prolapse.
Preparatory Considerations
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Full colonic evaluation for all elective cases.
Bowel cleansing (traditional) vs no bowel cleansing (evolving concept).
Prophylactic antibiotics.
Surgical Steps
1. Patient position: modified lithotomy position.
2. Laparotomy: lower midline, transverse suprapubic (transection of rectus muscle), Pfannenstiel incision (transverse
incision to skin and anterior rectus sheath with midline rectus-saving celiotomy).
3. Placement of abdominal wall retractor or wound protector to expose left portion of colon.
4. Abdominal exploration: characteristic deep peritoneal reflection, secondary pathology (liver/gallbladder, colon,
female organs, small bowel), other abnormalities.
5. Opening of right-sided peritoneal surface along base of mesosigmoid, extension to pelvis.
6. Incision of left-sided peritoneal surface along white line of Toldt toward pelvis, no mobilization toward splenic
flexure. Opening of retroperitoneum, identification of areolar tissue. Firm pressure against sigmoid mesentery to
bluntly reflect retroperitoneal tissues and expose left ureter.
7. Identification of inferior mesenteric vessels. The space right behind vascular stalk is entered and a window created.
Hypogastric nerves are identified and protected by pushing them toward the back. Blunt dissection behind vascular
stalk (avascular plane) to entry of pelvis and complete posterior mobilization along Waldeyer fascia to pelvic floor.
Avoidance of extensive bilateral mobilization to minimize risk of autonomic nerve dysfunction.
8. Defining resection margins:
a. Distal: upper rectum so that anastomosis is roughly at promontory.
b. Proximal: as much as is needed to eliminate sigmoid redundancy.
9. Stepwise division (between clamps and ligatures) of mesentery to proximal point of resection.
10. Devascularization:
a. Majority of patients: standard devascularization at vascular stalk (superior hemorrhoidal)—before tissue
division verification of ureter location. Creation of a window in mesorectum at distal point of resection (see
above). Division of mesorectum between clamps/ligatures.
b. Patient with history of perineal resection: risk of avascular segment with standard devascularization
correct
operations:
(1) Rectopexy only.
(2) Vascular arcade-sparing sigmoid resection, ie, devascularization close to bowel while preserving
vasculature to bowel distal to transection.
(3) Bowel transection at level of former anastomosis, elimination of redundancy and respective blood
supply.
11. Division of bowel by means of linear stapler.
12. Retrieval of specimen and gross examination by pathologist and/or surgeon.
13. Anastomosis:
a. Stapled: purse-string suture to proximal end, circular stapler anvil inserted, stapler body through anus, and
tension-free anastomosis.
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b. Hand-sewn: one-layer vs two-layer.
14. Testing of anastomosis: submerging under water, finger compression of bowel proximal to anastomosis, and
insufflation of air through proctoscope.
15. Rectopexy:
a. Suture rectopexy: series of three to four bilateral sutures to fix edge of rectum to presacral fascia.
b. Rectopexy with 6
x 10 cm implant (Marlex mesh, collagen sheet) after posterior mobilization of rectum—
fixation of implant with interrupted nonabsorbable sutures to promontory and presacral fascia (caveat: presacral
veins!) and bilateral wrapping around and series of three to four bilateral sutures to fix it to edge of rectum,
leaving anterior one- third of rectum free. Caveat: with resective procedure preferetial use of a biological
implant rather than a Marlex mesh to avoid mesh infection.
16. Drains according to surgeon's preference. No need for NGT.
17. Closure of incision.
Anatomic Structures at Risk
Left ureter, gonadal vessels, hypogastric nerves, presacral veins.
Aftercare
Fast-track recovery: in absence of nausea or vomiting, oral liquids are started on POD1 and advanced as tolerated.
Maintenance of soft stools.
Complications
Recurrent prolapse.
Bleeding (surgeon-dependent): presacral veins, inadequate ligature of vascular stalk, gonadal vessels.
Anastomotic leak (2%): most commonly due to technical error, tension, inadequate blood supply.
Ureteral injury (0.1–0.2%).
Mesh infection or mesh migration/erosion.
Cross-Reference
Prolapse (Ch. 1)
Defecating proctogram (defecography) (Ch. 2)
Magnetic Resonance Imaging (MRI) (Ch. 2)
Hemorrhoids (455.X) (Ch. 4)
Pelvic floor dysfunction (618.X) (Ch. 4)
Rectal prolapse (569.1) (Ch. 4)
Rectal prolapse—perineal Delmore repair (Ch. 5)
General perioperative management—abdominal (Ch. 7)
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Fast-track recovery (Ch. 7)
SIGMOID RESECTION (OPEN, ANASTOMOSIS VS HARTMANN)
Principle
Oncologic resection of the sigmoid colon with ligation of the vascular pedicle and corresponding lymphadenectomy. Primary
anastomosis is the reconstruction of choice but may not be suited to the individual patient. In that case, a discontinuous
Hartmann resection with blind distal stump and end-colostomy would be effectuated.
Setting
Inpatient, OR procedure.
Alternatives
Laparoscopic approach.
On-table lavage with primary anastomosis.
Colonoscopic stent placement as bridge to (semi-)elective surgery.
Indication
Sigmoid cancer, diverticulitis, volvulus, rectal prolapse.
LBO.
Preparatory Considerations
Full colonic evaluation for all elective cases, tattooing of small lesions is advisable.
Bowel cleansing (traditional) vs no bowel cleansing (evolving concept).
Ureteral stents for redo cases or extensive disruption of anatomy (eg, inflammation).
Marking of possible stoma sites.
Prophylactic antibiotics.
Surgical Steps
1. Patient position: modified lithotomy position.
2. Laparotomy: lower midline, transverse suprapubic (transection of rectus muscle), Pfannenstiel incision (transverse
incision to skin and anterior rectus sheath with midline rectus-saving celiotomy).
3. Placement of abdominal wall retractor or wound protector to expose left portion of colon.
4. Abdominal exploration: local resectability, secondary pathology (liver/gallbladder, colon, female organs, small
bowel), other abnormalities.
5. Defining resection margins:
a. Distal: at least upper rectum (confluens of teniae).
b. Proximal: oncologic margin, normal bowel wall texture (does not require absence of diverticula).
6. Retrograde dissection from sigmoid toward splenic flexure along white line of Toldt. Opening of retroperitoneum,
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identification of areolar tissue. Firm pressure against sigmoid mesentery to bluntly reflect retroperitoneal tissues and
expose left ureter. Incision of peritoneum is continued into pelvis.
7. Opening of right-sided peritoneal surface along base of mesosigmoid, extension to pelvis.
8. Identification of inferior mesenteric vessels. The space right behind vascular stalk is entered and a window created.
Hypogastric nerves are identified and protected by pushing them toward the back. Dissection of redundant adipose
tissue around vessels is carried out under direct vision.
9. Clamps are placed to vascular stalk (either inferior mesenteric or superior hemorrhoidal). Before tissue is divided,
ureter is again checked! Stalk is then divided and addressed with double ligatures and/or a suture ligature.
10. Stepwise division (between clamps and ligatures) of mesentery to proximal point of resection.
11. Blunt dissection behind vascular stalk (avascular plane) to entry of pelvis. In case of rectal prolapse: complete
posterior mobilization along Waldeyer fascia to pelvic floor.
12. Creation of window in mesorectum at distal point of resection (see above). Division of bowel by means of linear
stapler. Division of mesorectum between clamps/ligatures.
13. Retrieval of specimen and gross examination by pathologist and/or surgeon.
(A) Reconstruction with Primary Anastomosis
a. Anastomosis:
(i) Stapled: purse-string suture to proximal end, circular stapler anvil inserted, stapler body through anus and
tension-free anastomosis.
(ii) Hand-sewn: 1-layer vs 2-layer.
b. Testing of anastomosis: submerging under water, finger compression of bowel proximal to anastomosis, and
insufflation of air through proctoscope.
(B) Hartmann: No Reconstruction But End-Colostomy
c. Creation of end colostomy: site preferably marked preoperatively or by educated guess, maturing only after main
incision closed.
d. Closure of lateral aspect between ostomy-bearing segment and abdominal wall (to avoid internal wrapping of small
bowel around that segment).
Both Techniques
14. Drains according to surgeon's preference. No routine need for NGT (unless obstructed).
15. Closure of incision.
16. Maturation of ostomy (in case of Hartmann).
Anatomic Structures at Risk
Left ureter, gonadal vessels, hypogastric nerves.
Aftercare
Fast-track recovery: in absence of nausea or vomiting, oral liquids are started on POD1 and advanced as tolerated.
In case of Hartmann resection: planning of takedown after complete recovery.
Complications
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Bleeding (surgeon-dependent): presacral veins, inadequate ligature of vascular stalk, gonadal vessels.
Anastomotic leak (2%): most commonly due to technical error, tension, inadequate blood supply.
Ureteral injury (0.1–0.2%).
Cross-Reference
Large bowel obstruction (LBO, 560.9) (Ch.1), (Ch. 4)
Pain, abdominal (Ch. 1)
Colorectal cancer—colon cancer (153.X) (Ch. 4)
Colonic volvulus (560.2) (Ch. 4)
Diverticular disease (diverticulosis, diverticulitis, 562.1X) (Ch. 4)
Colonoscopic stent placement (Ch. 5)
On-table lavage for primary anastomosis in LBO (Ch. 5)
Creation of end-ileostomy or -colostomy (Ch. 5)
General perioperative management—abdominal (Ch. 7)
Fast-track recovery (Ch. 7)
LEFT HEMICOLECTOMY (OPEN)
Principle
Oncologic resection of left colon with ligation of vascular pedicle and corresponding lymphadenectomy.
Setting
Inpatient, OR procedure.
Alternatives
Laparoscopic approach.
Extended right hemicolectomy (inclusion of both flexures, part of descending colon).
Subtotal or total colectomy (inclusion of part of or whole sigmoid colon).
Long Hartmann stump and end ileostomy.
Indication
Left-sided colon cancer/polyps (splenic flexure, descending colon).
Preparatory Considerations
Full colonic evaluation for all elective cases, tattooing of small lesions advisable.
Bowel cleansing (traditional) vs no bowel cleansing (evolving concept).
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Ureteral stents for redo cases or extensive disruption of anatomy (eg, inflammation).
Marking of possible stoma sites.
Prophylactic antibiotics.
Surgical Steps
1. Patient position: modified lithotomy position (surgeon's preference).
2. Laparotomy: periumbilical midline incision.
3. Placement of abdominal wall retractor or wound protector vs dynamic abdominal wall retraction with hand-held
retractor to expose right side of colon.
4. Abdominal exploration: local resectability, secondary pathology (liver/gallbladder, colon, female organs, small
bowel), other abnormalities.
5. Defining resection margins: mid transverse colon (left branch of mid colic artery), splenic flexure, descending colon
with/without inclusion of sigmoid colon (left colic artery only vs IMA).
6. Mobilization of left colon from its retroperitoneal attachments, starting at sigmoid along white line of Toldt, moving
along colonic gutter to splenic flexure. Landmarks: ureter, gonadal vessels, omentum, spleen (avoid injury).
7. Development of lesser sac: oncologic resection requires at least half omentectomy—division of gastrocolic ligament
in several steps (alternative in proven benign disease: omental sparing with dissection of omentum off the transverse
colon).
8. Identification of left branch of mid colic artery.
9. Oncologic devascularization of left colon with clamping and transecting major vascular stalks (ligature, suture
ligatures): either taking IMA at aortic run-off + vein at inferior edge of pancreas or taking only left colic artery while
leaving superior hemorrhoidal artery. Caveat: before dividing tissue, remote location of ureters to be verified.
10. Transection of bowel colocolonic (sigmoid left) or colorectal (sigmoid taken) anastomosis: preferably end-to-end
anastomosis (stapled vs hand-sewn); functional end-to-end (side-to-side) anastomosis suboptimal for left-sided colon
because it results in "giant diverticulum," may cause constipation/stool trapping, and makes colonoscopy more
difficult.
11. Resection of specimen and macroscopic assessment of specimen: verification of pathology and resection margins.
12. Oversewing of staple lines with interrupted sutures.
13. Closure of mesenteric window.
14. Drains not indicated (unless specific indication). No need for NGT.
15. Closure of incision.
Anatomic Structures at Risk
Left ureter, gonadal vessels, spleen, pancreas tail, mid colic artery.
Aftercare
Fast-track recovery: in absence of nausea or vomiting, oral liquids are started on POD1 and advanced as tolerated.
Complications
Bleeding (surgeon-dependent): traction on spleen, inadequate ligature of vascular stalk, mid colic artery.
Anastomotic leak (2%): most commonly due to technical error, tension, inadequate blood supply.
Ureteral injury (0.1–0.2%).