Laparoscopic Resection Rectopexy Periprocedural Care
- Author: Abhiman Cheeyandira, MD; Chief Editor: Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS more...
A thorough history and physical examination is essential, with special emphasis on cardiopulmonary status so as to optimize the patient's ability to tolerate surgical stress. Pelvic floor dysfunction should be studied with anal sphincter function testing and defecography. If colon dysmotility is suspected, a sitz marker or equivalent nuclear imaging study should be obtained.
The diagnosis of rectal prolapse is made through physical examination. Patients are usually able to force the prolapse out. The authors often have them push out the prolapse while on a commode and then confirm the diagnosis. Video defecography may be necessary to confirm diagnosis. All patients should then undergo colonoscopy to rule out any occult pathology.
For patients with constipation, colonic transit studies (sitz markers or nuclear scan) should be performed to check for colonic inertia. For patients with fecal incontinence and obstructed defecation, anal manometry and endoanal ultrasonorgaphy can provide documentation of the patient's preoperative physiologic status. Patient counseling about the risks and complications of the surgery should be performed.
Many surgeons perform mechanical bowel preparation, which is started on the day before the surgery to clear the bowel of fecal material. The authors have abandoned the traditional preparation and prefer that the patient undergo rectal irrigation in the operating room. All oral intake is stopped the night before the surgery, and only essential medications are allowed on the morning of the surgery with a sip of water.
Preoperative intravenous antibiotics, which cover for gram negative and anaerobic organisms, are given within 1 hour of incision time. The authors also use alvimopan to decrease postoperative ileus. Preoperative prophylaxis for deep vein thrombosis is imperative.
After the patient is induced under general anesthesia, a muscle relaxant is administered, and an endotracheal tube is placed.
A Foley catheter is inserted into the bladder for accurate measurement of urine output during the procedure and for decompression of the bladder. The authors remove the Foley catheter 24 hours after surgery. An orogastric tube is placed to decompress the stomach during the surgery.
The patient is placed in lithotomy Trendelenburg (modified Lloyd-Davis) position, with both arms tucked. The legs are placed on stirrups with adequate soft padding to prevent pressure sores on the skin and pressure-related nerve injury to the common peroneal nerves. Antiembolic stockings or compression devices are applied to the legs.
The entire abdomen is prepared with either povidone-iodine or chlorhexidine antiseptic solution. Sterile draping is applied, ensuring adequate exposure of the abdomen and perineum.
For laparoscopic procedures, the operating surgeon and assistant stand on the patient's right side after the ports are placed. The cords should be run off the left side to allow free range of motion. The scrub nurse or technician is at the foot of the bed.
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