Approach Considerations
An ideal surgical procedure for rectal prolapse would have low recurrence rates and low morbidity and provide some improvement in fecal incontinence. The minimally invasive approach to rectopexy attempts to achieve these results. Laparoscopic rectopexy is an adaptation of the classic open posterior rectopexy. The three minimally invasive approaches discussed in this article are as follows:
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Laparoscopic rectopexy with posterior mesh fixation
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Robotic rectopexy - This technique is essentially the same as the laparoscopic approach, but the use of the robot facilitates suturing
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Laparoscopic "ventral" rectopexy - This approach, first described by D’Hoore et al in Belgium, focuses the dissection in the rectal-vaginal septum
Laparoscopic Rectopexy With Posterior Mesh Fixation
The patient is placed in the lithotomy position with arms tucked in order to facilitate inspection and rectal examination during the procedure. The abdominal cavity is entered by using the Hasson approach, which is the authors’ favored approach. Accordingly, Optiview entry or Veress needle entry is perfectly acceptable. Once the camera port is inserted and the abdomen is insufflated, a right-lower-quadrant (RLQ) port and a right-upper-quadrant (RUQ) port are placed. The authors prefer a 12-mm port in the RLQ to facilitate placement of the mesh.
A 30° scope is introduced into the umbilical port. To improve exposure, an additional port can be placed on the left flank. If the patient has a uterus that is affecting exposure, it can be retracted with a stitch to the anterior abdominal wall.
Dissection is started posteriorly. The plane between the mesorectum and retroperitoneum is identified; the retroperitoneum is usually whiter than the mesorectum. An energy device is used to enter the posterior pelvic plane under the superior rectal artery, and the left ureter and hypogastric nerve plexus are identified; dissection is extended downward through the presacral anatomic space, all the way to the pelvic floor. The dissection must be carried below the rectosacral (Waldeyer) fascia. Often, to facilitate exposure, the right lateral stalk of the rectum is also mobilized.
Once the right stalk and posterior areas are mobilized, dissection proceeds anteriorly into the rectovaginal plane. This location often contains a hernia sac; retracting the rectum cephalad and cervix anteriorly facilitates exposure. Subsequently, the rectum is mobilized anteriorly to the upper limit of the vagina. During this approach, the nervi erigentes and left lateral ligament are spared.
The rectum is then pulled out of the pelvis, and where the fixation will occur is assessed. A window is made on the left side of the rectum to facilitate the rectopexy. The authors prefer posterior placement of mesh. A small rectangular sheet of polypropylene mesh is inserted via the RLQ port and is placed all the way down to the pelvic floor, extending cephalad behind the mesorectum. (Polyvinylidene fluoride [PVDF] mesh has been described as an option in patients with obstructive defecation syndrome [ODS]. [27] )
The stalks are fixed to the sacrum, incorporating the mesh. Placement of a 5-mm suprapubic port is often necessary to facilitate fixation. The authors prefer using endoscopic tacks (Protack, US Surgical). The left-side tacks are placed first. An overly tight pexy must be avoided to prevent obstruction of the rectosigmoid junction. If suturing is chosen, the authors use a 0 Ethibond (Ethicon) suture.
The pexy should be 5 cm on each side, typically requiring three tacks spaced 1 cm apart or three sutures spaced similarly. It is important to identify the sacral venous plexus before tacking or suturing. The bony promontory is the ideal location for fixation.
If needed, a small incision can be made over the hypogastric area and fixation performed open.
Robotic Rectopexy
The technique is similar to the laparoscopic rectopexy technique described above. The authors dock the robot between the legs, and port placements are similar. The authors usually need only two arms, but, in the case of a redundant sigmoid or floppy uterus, the third arm is used in the left flank to retract.
The authors prefer to use a 30° scope, though the angle may have to be rotated by the assistant in some cases. The authors use a Grapter in the right cephalad port and a Hook diathermy on the right caudal robotic arm. The planes are identified as mentioned above, and dissection is similar.
Once the dissection is complete, mesh is inserted via an accessory port. It is positioned the same way, and sutures are inserted and sewn into position as described. Abdominal wall wounds are closed in the usual manner. [29]
Laparoscopic Ventral Rectopexy (D’Hoore and Penninckx)
The authors do not routinely perform this approach.
Although earlier reports described a significant learning curve for laparoscopic ventral rectopexy, subsequent reports suggested a learning curve of 25-30 cases in the context of proctored adoption. [30]
Ports are inserted as described above. The lateral ligaments and hypogastric plexus are preserved.
Dissection is carried down in the anterior space via Denonvilliers fascia to the rectovaginal space. In some cases, the hernia sac can be redundant, associated with an enterocele, or both. In these cases, the peritoneal sac is resected. Posterior and lateral dissection is avoided.
Once the anterior space is mobilized, polypropylene mesh is secured to the anterior aspect of the rectum and then secured to the sacral promontory with 0 Ethibond suture. This elevates the anterior wall without any traction on the rectum. The posterior vaginal fornix is then lifted up and sutured to the mesh (anteriorly), aiding in the repair of rectocele, as well as prolapse. [31, 32]
Tsunoda et al described a technique of introducing the mesh at the distal dissection while performing laparoscopic ventral rectopexy. [33] In this technique, a nylon thread with straight needle was passed through the posterior wall of the vagina at the distal extent of the dissection, and this was caught in the abdominal cavity and fixed at the end of the mesh extracorporeally. The mesh was then introduced, pulled toward the pelvic floor, and settled at the pierced site by the perineal operator. This technique enables the surgeon to confirm that the mesh is introduced and secured to the distal end.
This procedure has also been performed with robotic assistance. [34, 35]
