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Laparoscopic Resection Rectopexy Periprocedural Care

  • Author: Abhiman Cheeyandira, MD; Chief Editor: Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS  more...
 
Updated: Feb 25, 2015
 

Preprocedural Planning

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.

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Patient Preparation

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.

Anesthesia

After the patient is induced under general anesthesia, a muscle relaxant is administered, and an endotracheal tube is placed.

Positioning

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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Contributor Information and Disclosures
Author

Abhiman Cheeyandira, MD Resident Physician, Department of General Surgery, Hahnemann University Hospital, Philadelphia

Abhiman Cheeyandira, MD is a member of the following medical societies: American College of Surgeons, Royal College of Surgeons of England

Disclosure: Nothing to disclose.

Coauthor(s)

David E Stein, MD Chief, Division of Colorectal Surgery, Associate Professor, Department of Surgery, Director, Mini-Medical School Program, Drexel University College of Medicine; Chief, Division of Colorectal Surgery, Department of Surgery, Hahneman University Hospital; Consultant, Merck; Consultant, Ethicon Endo-Surgery; Consultant, Health Partners; Consultant, Cook Surgical

David E Stein, MD is a member of the following medical societies: American College of Surgeons, American Society of Colon and Rectal Surgeons, Association for Surgical Education, Pennsylvania Medical Society, Society for Surgery of the Alimentary Tract, Crohn's and Colitis Foundation of America

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Merck<br/>Serve(d) as a speaker or a member of a speakers bureau for: Merck.

Leandro Feo, MD Resident Physician, Department of General Surgery, Hahnemann University Hospital, Drexel University College of Medicine

Leandro Feo, MD is a member of the following medical societies: American College of Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS Professor of Surgical Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, India

Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS is a member of the following medical societies: Association of Surgeons of India, Indian Association of Surgical Gastroenterology, Indian Society of Gastroenterology, Medical Council of India, National Academy of Medical Sciences (India), Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

References
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  2. Steele SR, Madoff RD. Nonresectional and resectional rectopexy. Wexner SD, Fleshman JW. Master Techniques in General Surgery: Colon and Rectal Surgery: Abdominal Operations. Philadelphia: Lippincott Williams & Wilkins; 2012.

  3. Luchtefeld M, Weimann D. Laparoscopic resection rectopexy. Wexner SD, Fleshman JW. Master Techniques in General Surgery: Colon and Rectal Abdominal Operations. Philadelphia: Lippincott Williams & Wilkins; 2012.

  4. Luukkonen P, Mikkonen U, Jarvinen H. Abdominal rectopexy with sigmoidectomy vs. rectopexy alone for rectal prolapse: a prospective, randomized study. Int J Colorectal Dis. 1992 Dec. 7(4):219-22. [Medline].

  5. Formijne Jonkers HA, Maya A, Draaisma WA, Bemelman WA, Broeders IA, Consten EC, et al. Laparoscopic resection rectopexy versus laparoscopic ventral rectopexy for complete rectal prolapse. Tech Coloproctol. 2014 Jul. 18(7):641-6. [Medline].

  6. Roblick UJ, Bader FG, Jungbluth T, Laubert T, Bruch HP. How to do it--laparoscopic resection rectopexy. Langenbecks Arch Surg. 2011 Aug. 396(6):851-5. [Medline].

  7. Demirbas S, Akin ML, Kalemoglu M, Ogün I, Celenk T. Comparison of laparoscopic and open surgery for total rectal prolapse. Surg Today. 2005. 35(6):446-52. [Medline].

  8. Laubert T, Kleemann M, Schorcht A, Czymek R, Jungbluth T, Bader FG. Laparoscopic resection rectopexy for rectal prolapse: a single-center study during 16 years. Surg Endosc. 2010 Oct. 24(10):2401-6. [Medline].

  9. Ayav A, Bresler L, Hubert J, Brunaud L, Boissel P. Robotic-assisted pelvic organ prolapse surgery. Surg Endosc. 2005 Sep. 19(9):1200-3. [Medline].

 
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