Chapter 14: Laparoscopic Rectopexy

INTRODUCTION

Laparoscopic rectopexy, with or without resection of the sigmoid colon, is one of the surgical options to treat rectal prolapse. In addition to the rectopexy, a sigmoid resection is recommended in patients who have constipation preoperatively, as the rectopexy alone may worsen the constipation symptoms.

PREOPERATIVE CONSIDERATIONS

Ureteral Stents

Usually, straightforward laparoscopic rectopexy does not need ureteral stent placement. However, in some cases with large, chronic rectal prolapse, the ureter might be more medial than expected due to traction and tissue laxity predisposing to ureteral injury.

PORT SITES

Four Port Diamond-Shaped Configuration (Figure 14-1)

• This configuration will allow you to do any colon or rectal operation.

• A periumbilical port (12 mm) is used for the camera.

• The right lower quadrant (RLQ) and the suprapubic ports will be used to mobilize the rectum. An energy source or laparoscopic scissors with monopolar cautery can be used to mobilize the rectum through the suprapubic port, while using an atraumatic grasper through the RLQ port to retract and provide better exposure.

• Left lower quadrant (LLQ) port: The initial dissection can be started with the above three ports. However, a second assistant who is standing in front of the surgeon, on the patient’s left side, can use this port. The second assistant can use an atraumatic grasper to help with retracting the rectum out of the pelvis or provide countertraction during the dissection.

STEPS OF THE OPERATION

• General steps.

• Exposure of the pelvis.

• Rectal dissection.

• Resection rectopexy.

• Fixation of the rectum.

Exposure of the Pelvis

Adhesiolysis may be needed in patients who have had prior surgery. The uterus may need to be suspended for proper exposure (Figures 14-2 and 14-3).

Rectal Dissection (Figures 14-4 to 14-15)

• Place the patient in the steep Trendelenburg position with the right side down.

• Reflect the omentum over the transverse colon.

• Start the rectal dissection by scoring the peritoneum in the left pararectal sulcus from the level of the sacral promontory downward. The dissection can ...