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INDICATIONS

For full-thickness rectal prolapse, there are several commonly used laparoscopic operations. Laparoscopic sigmoid colectomy and suture rectopexy is ideal for patients with full-thickness prolapse and with moderate to severe constipation (<1 bowel movement every 3 days). For patients without constipation, resection is to be avoided. A simple sutured rectopexy or a posterior mesh repair (modified Wells repair) will suffice. The anterior mesh repair (Ripstein procedure) is not favored, as it tends to lead to postoperative constipation because the rectum is completely surrounded by nondistensible mesh (anteriorly) and sacrum (posteriorly).

PREOPERATIVE EVALUATION

When the patient sits on a commode and strains, the rectal prolapse can be confirmed by the surgeon. A rectal prolapse is seen as a series of concentric folds representing the full thickness of the rectum, protruding from the anus (Figures 1 and 2). The full-thickness prolapse should be distinguished from prolapsed hemorrhoids. Hemorrhoids do not have concentric folds and may be discernible as a series of three folds on the left lateral aspect of the anus, the right anterior anus, and the right posterior anus (Figures 3 and 4). Significant edema may obscure the anatomic definition of the three hemorrhoid columns.

A colonoscopy should be performed before any operative procedure. Should the patient have significant constipation, colonic inertia should be ruled out with a colonic transit study. The patient should undergo a mechanical bowel preparation the day before surgery. On the day of surgery, the patient should have pneumatic sequential compression devices (SCDs) placed on both legs prior to induction of anesthesia. Intravenous prophylactic antibiotic is given within 1 hour before incision.

POSITIONING

The patient should be placed on a beanbag to facilitate positioning. After induction of general anesthesia, an orogastric tube and Foley catheter are placed. The patient should be moved to a low lithotomy position with Allen stirrups (Figure 5). There must be free access to the anus. Each ankle, knee, and opposite shoulder should be aligned. No pressure should be placed on the peroneal nerves or calves. The angle between the knee and the plane of the bed should be between 0 and 10 degrees. Any more flexion will limit range of motion for the instruments. Any more extension may lead to an anterior dislocation of the hip.

Each elbow (ulnar nerve) is covered with a gel pad, and both arms are adducted and tucked at the sides of the operating table. Care must be taken to avoid compromising or kinking the intravenous lines. The beanbag is cradled above both shoulders and around the arms to prevent the patient from falling while in extreme positioning. The air is suctioned from the beanbag so it retains that shape. A gel ...

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