Open and Laparoscopic Resection Rectopexy Technique

A lower midline laparotomy incision is made from umbilicus to pubis. Abdominal wall retractors (eg, Balfour or Bookwalter) are placed. If the uterus is present, the authors place a stitch through it and anchor it to the bladder blade to facilitate exposure.

A thorough exploration of the abdominal cavity is performed. Moist laparotomy pads are used to tuck the transverse colon and the small bowel loops cephalad and to the right, away from the operative field, for adequate exposure of the sigmoid colon and the mesenteric vessels. A St Mark retractor should be available if access to the pelvis is required.

The assistant holds the sigmoid colon and retracts it medially and upward. The surgeon then starts dissecting along the white line of Toldt (the line of attachment to the parietal peritoneum on the lateral side). The ureter is seen crossing the gonadal vessels at the level of the pelvic brim; it has a characteristic peristaltic movement, resembling the movement of an earthworm.

The medial border of the mesentery is then lifted off the retroperitoneal attachments; this helps in identification of the inferior mesenteric artery (IMA) and other vascular branches. The sigmoid branches of the IMA and the inferior mesenteric vein (IMV) are then ligated beyond the left colic branch and divided. An effort should be made to spare the superior rectal vessels.

Once the colonic segment is mobilized, the descending sigmoid junction is divided with a stapling device. The mesentery is divided, and the superior rectal artery is lifted up. The authors mobilize the rectum posteriorly down to the pelvic floor and then open the anterior cul-de-sac. Peritoneal incisions on the right and left sides are joined in front (anteriorly) in the deep rectovesical/rectouterine pouch. The rectum is now divided just above the pelvic floor.

The descending colon-to-rectum anastomosis is usually performed with a circular stapling device, such as an end-to-end anastomosis (EEA) stapler. The anvil of the EEA stapler is sutured to the distal end of the proximal portion of the colon. The surgeon then stands between the patient’s legs and passes the stapler through the anal canal into the rectum until it reaches the proximal end of the rectal stump.

At this point, the EEA stapler is opened, exposing the spike, which is then attached to the anvil at the other end of the colon. The stapler is then closed and fired to complete the anastomosis. The donuts obtained after stapling are checked to confirm that complete rings have been obtained.

The anastomosis is tested for leaks by placing the patient in the reverse Trendelenburg position and filling the pelvis with saline. A rigid sigmoidoscope may be passed through the anal canal to enable direct visualization of the anastomosis. The colon is clamped proximal to the anastomosis, and air is then insufflated into the rectum via the sigmoidoscope.

The colon is checked for adequate distention with air and for any bubbling of air in the pool of saline in the pelvis. The presence of a stream of bubbles indicates a positive leak test result, in which case an attempt must be made to identify and oversew the leak. In rare cases, a complete revision of the anastomosis is required.

Once the sigmoid colon is resected and sent to pathology, the suture rectopexy is performed. An area 4-5 cm below the sacral promontory is chosen for the inferiormost aspect of fixation. The rectum is pulled superiorly and posteriorly, and several sutures are placed on either side of it to attach it to the presacral fascia. Simple or mattress or running sutures (No. 1 or 2 polypropylene or polydioxanone) are placed on either side; these provide temporary fixation until fibrosis develops between the rectum and the fascia. Fixation of mesh varies.

The abdominal wall is then closed in layers. The fascia is closed with No. 1 polypropylene or polydioxanone continuous suture. The subcutaneous tissue can be approximated with 3-0 polyglactin interrupted ties. The skin can be closed with staples or with 4-0 poliglecaprone subcuticular sutures.

Drainage must also be adequately addressed.

The placement of ports is crucial for dissection of the tissues and is similar to that used in laparoscopic sigmoid resection. The camera port (5 or 10 mm, depending on the camera being used) is inserted in the periumbilical area with either the Hassan (open) or Optiview technique (with or without the Veress needle). The additional 5-mm ports are inserted under direct vision in the right upper quadrant (RUQ) and the left lower quadrant (LLQ). A 1-mm port is placed in the right lower quadrant (RLQ), 2 cm below and medial to the anterior superior iliac spine (ASIS).

The patient is then placed in a deep Trendelenburg position with a tilt to the right so that the small bowel is retracted to the RUQ. Of the two possible approaches, the authors prefer the medial-to-lateral approach.

The redundant sigmoid is lifted up, placing the mesentery on traction. The sacral promontory is a useful guide. The mesorectum is opened just in front of the promontory on the right and extended both superiorly and inferiorly. Care is taken to spare the hypogastric nerves in front and below the sacral promontory. Further dissection of the mesentery is carried out laterally, and retroperitoneal structures (eg, the ureters, the gonadal vessels and the iliac vessels) are identified and preserved.

Once this is done, the sigmoid vascular pedicle (distal to the left colic artery) is isolated and divided with either a Harmonic or LigaSure dissector or an endoscopic gastrointestinal anastomosis (Endo-GIA) stapler. Care is taken to spare the superior rectal vessels. The rectum is then mobilized from its attachments (Waldeyer and lateral rectal fascia and anterior cul-de-sac) and divided with an endoscopic linear stapler.

Next, the proximal sigmoid colon is mobilized until reach from the descending colon to the rectum is possible. Gas is then exsufflated through the ports, and a 5-cm extraction incision is made. The sigmoid colon can be exteriorized by making a Pfannenstiel incision or by widening the 5-mm port incision in the LLQ or the umbilical port. The proximal sigmoid colon is then divided, and an anvil is placed either with a purse-string device or a running 2-0 polypropylene suture.

The descending colon-to-rectum anastomosis is usually performed with a circular stapling device. The colorectal anastomosis is performed in much the same fashion as in the open technique and is also checked for any leaks. This is done laparoscopically once the abdomen has been reinsufflated after closure of the extraction site. The resected specimen is sent to pathology for histologic analysis.

Once the integrity of the anastomosis is confirmed, the rectopexy is performed by placing at least one stitch between each of the lateral stalks of the rectum to the presacral fascia laparoscopically. Alternatively, laparoscopic tacks can be used (the authors’ preference).

Once this is done, the ports are removed. The extraction site incision is closed in layers, in much the same manner as a laparotomy wound. The fascia of the 12-mm port is also closed separately to prevent hernia formation. The skin is closed with either skin staples or 4-0 poliglecaprone subcuticular sutures.

An approach has been described in which laparoscopic resection rectopexy is performed with natural orifice speciment extraction (NOSE). ^[17]  Compared with conventional laparoscopic resection rectopexy, this approach appears to be safe, with a comparable operating time and a comparable rate of postoperative complications, and potentially to offer a shorter postoperative recovery time.

Robotic-assisted laparoscopic resection rectopexy is comparable with regard to complications and recurrence rates, at least in short-term follow-up, and has been associated with higher costs and longer operating times. ^[18] The cost and longer duration of the robotic procedure have yet to be rigorously weighed against the shorter length of stay and reduced morbidity.

Postoperatively, the patient is extubated and transferred to the recovery room for appropriate monitoring before transfer to the floor. The patient is started on clear liquids and avanced as tolerated. Intravenous (IV) fluids and IV nonnarcotic pain medication are continued for as long as 24 hours. Antiembolic stockings are continued, and agents for prophylaxis of deep vein thrombosis (DVT), such as low-molecular-weight heparin (LMWH), are started on postoperative day 0.

After 24 hours, the patient is weaned off the IV fluids. The Foley catheter is removed on postoperative day 1. The patient is encouraged to ambulate and perform incentive spirometry to prevent atelectasis.

Daily laboratory tests, including at least a complete blood count (CBC) with differential and a basic metabolic panel, are performed for the first 48 hours or as indicated. Discharge criteria include tolerating liquids, passing flatus, and adequate analgesia and ambulation. High-fiber diet and soft laxatives are used to avoid constipation.

Follow-up in the office 14 days after surgery is the ideal for standard postoperative care.

Early complications of resection rectopexy include the following:

• General complications (eg, hemorrhage, DVT, pulmonary embolism [PE], urinary tract infection [UTI], atelectasis/pneumonia, myocardial infarction [MI], and congestive heart failure [CHF])
• Wound infection (both superficial and deep), wound dehiscence and evisceration
• Intraoperative complications (eg, ureteral or vaginal injury)
• Deep pelvic infection
• Presacral hemorrhage
• Prolonged paralytic ileus
• Anastomotic leakage

Late complications include the following:

• Anastomotic stricture
• Recurrence of rectal prolapse (0-10% for both open and laparoscopic techniques; likelihood of recurrence may be greater with increasing length of prolapsed rectum ^[19] )
• Bowel obstruction secondary to adhesions
• Incisional hernia
• Sexual/urinary dysfunction (due to autonomic nerve injury)
• Loss of rectal reservoir function, which may result in urgency and diarrhea

Although the list of possible complications is long, complication rates in expert hands are low. Surgical-site infection (SSI) is the most common postoperative complication. Patients and referring physicians should look at hospital data (eg, Leapfrog safety ratings) to evaluate outcomes.