Resection rectopexy, laparoscopic

You have not purchased a license - paywall is active: to the product selection
  • MVZ St. Marien Köln - Ärztliche Leiterin

    Edith Leisten

Single Access

Access to this lecture
for 3 days

€4.99 inclusive VAT

payment

webop-Account Single

full access to all lectures
price per month

for the modul: vascular surgery

from 8,17 €

hospitals & libraries

for the modul: vascular surgery

from 390,00 euros

  • Rectum

    Paid content (image)

    Viewed functionally, by acting as a reservoir for feces the rectum prevents continuous fecal expulsion. The rectum is continuous with the sigmoid colon and its S-shaped a/p and lateral curvature (sacral, anorectal and lateral flexure respectively) resembles that of the sigmoid. Usually, the rectum is divided into three sections:

    1. Rectal ampulla (main reservoir, anterior to the sacrum)
    2. Anal canal (see below, closure region between the anorectal flexure and cutaneous anal verge)

    3. Between 1. and 2. an unnamed section emerging at right angles from 1. and transitioning into 2, also at right angles. Here, the mucous membrane displays characteristic folds (valves of Houston).

    The gross relations of the rectum are: Posteriorly sacrum and coccyx, laterally the internal iliac artery and vein and the regional lymph nodes, the sacral plexus, and parts of the autonomic nervous system as well as the ureters and uterine appendages. In women the rectum is related anteriorly to the uterus and vagina, and in men to the bladder and prostate gland/seminal vesicles. It is delimited inferiorly by the pelvic floor.

  • Anal canal

    Three muscles in the wall of the lower rectum acting together close off the rectum from the anal verge:

    1. The internal anal sphincter is the continuation of the circular smooth muscle fibers of the rectum, ending in a thickened edge and being innervated by the sympathetic nervous system.

    2. The levator ani is a striated muscle innervated by the sacral plexus; it also comprises the puborectalis attached to the pubis. Its fibers arising from the symphysis pubis form a large sling around the anal canal and its anteriorly directed pull creates the anorectal angle.

    3. The external anal sphincter is also a striated muscle and attaches to the perineal body (centrum perinei) and coccyx. Its voluntary innervation stems from the pudendal nerve. Its contraction completely closes off the distal end of the anal canal.

    The different innervation of the three closing muscles provides additional protection against failure with its subsequent incontinence.

    The mucosa of the anal canal contains numerous longitudinal folds (columnae anales) with dense arterial (!) plexus and venous drainage. During sphincteric contraction these plexuses fill up quickly with blood, thereby engorging and apposing the mucosa. Hemorrhoids and venous thrombosis are common vascular complications in this region.

    Defecation takes place by relaxation of the anal sphincters and puborectalis (initiated by the striated musculature, emptying of the cavernous bodies) and at the same time by rectal motility and actively increased intraabdominal pressure.

  • Blood supply

    Paid content (image)

    Three main arterial trunks provide blood supply to the rectum:

    • Superior rectal artery (from the inferior mesenteric artery) via the mesosigmoid (Caution: Dividing this artery at the level of the sigmoid will result in ischemia of the superior third of the rectum!)
    • Medial rectal artery (from the internal iliac artery), superior to the levator ani
    • Inferior rectal artery (from the internal pudendal artery), inferior to the levator ani

    The veins run as rectal venous plexus underneath the rectal mucosa. Through the superior rectal vein, they drain the blood of the superior rectum via the inferior mesenteric vein to the liver, while the blood from the middle and inferior rectum is returned to the inferior vena cava via the medial and inferior rectal veins and internal iliac vein (portocaval anastomosis).

    Lymphatic drainage of the rectum follows the vascular supply: At the superior rectum the large group of inferior mesenteric lymph nodes forms its own group (nodi lymphatici rectales superior), while the internal iliac lymph nodes receive lymph from the middle rectum (from the pararectal lymph nodes) and the superficial inguinal lymph nodes lymph from the inferior anal region, anus and perineal skin.

  • Perineum

    The perineum comprises the region caudad to the pelvic diaphragm (urogenital and anal region) and is delimited:

    • Superiorly by the inferior fascia of the pelvic diaphragm
    • Anteriorly by the pubic symphysis
    • Laterally by the ischium
    • Posteriorly by the lower margin of the gluteus maximus

    The posterior perineum corresponds to the anal region and in anatomical terminology is called ischioanal fossa ; the anterior perineum corresponds to the pubic region and in turn can be subdivided into three superimposed sections: the most superficial being a subcutaneous perineal space (between the stratum membranosum telae subcutaneae perinei and the perineal fascia = Colles fascia), a superficial perineal space between the perineal fascia and perineal membrane, and a profound perineal space (open to the pelvis) superior to the perineal membrane.

    The posteriorly located ischioanal fossa below the skin mainly comprises fatty tissue and numerous vessels/nerves (branches of the inferior rectal artery and internal pudendal artery as well as the pudendal nerve to the anal region). At the transition to the sacral region, an epithelium lined duct between the tip of the coccyx and the anal verge can develop in the gluteal cleft. This may be encapsulated like a cyst (pilonidal/dermoid cyst) or may have an external orifice (pilonidal sinus).

    The anterior superficial perineum (spatium superficiale perinei) comprises the superficial perineal musculature and the pathways to the genitalia (perineal and bulbi vestibuli artery as well as branches of the pudendal nerve to the labia/clitoris or scrotum).

    The anterior profound perineal space (spatium profundum perinei) is less clearly delimited: Posteriorly it continues into the ischioanal fossa and comprises the profound perineal musculature and other profound pathways.

Single Access

Access to this lecture
for 3 days

€4.99 inclusive VAT

payment

webop-Account Single

full access to all lectures
price per month

for the modul: vascular surgery

from 8,17 €

hospitals & libraries

for the modul: vascular surgery

from 390,00 euros

  • Indications

    Paid content (text)
  • Contraindications

    Paid content (text)
  • Preoperative diagnostic work-up

    Paid content (text)
  • Special preparation

    Paid content (text)
  • Informed consent

    Paid content (text)
  • Anesthesia

    Paid content (text)
  • Positioning

    Paid content (image)
    Paid content (text)
  • Operating room setup

    Paid content (image)
    Paid content (text)
  • Special instruments and fixation systems

    Paid content (image)
    Paid content (text)
  • Postoperative management

    Paid content (text)
date of publication: 24.12.2012

Single Access

Access to this lecture
for 3 days

€4.99 inclusive VAT

payment

webop-Account Single

full access to all lectures
price per month

for the modul: vascular surgery

from 8,17 €

hospitals & libraries

for the modul: vascular surgery

from 390,00 euros

  • Pneumoperitoneum and trocar positioning

    135-6

    The procedure starts with a minilaparotomy for the camera trocar (T1, 10mm) about 3cm cephalad of the navel. After inserting the trocar, establish pressure-controlled pneumoperitoneum up to 13mm Hg and inspect the abdominal cavity for possible adhesions (e.g., after abdominal hysterectomy via Pfannenstiel incision). Successively introduce the working trocars under laparoscopic view: T2 (5mm) right lower quadrant at the level of the anterior superior iliac spine, T3 (10mm) roughly centered on a slightly curved line connecting T1 and T2. Finally insert T4 (5mm) in the left lower quadrant suprasymphyseally in the course of the subsequent Pfannenstiel incision.

  • Opening the right pelvic peritoneum

    135-7

    Tilt the operating table to Trendelenburg, and with two atraumatic grasping forceps pull the greater omentum and small intestine into the upper quadrants or right middle abdomen. Pull the sigmoid colon (the video demonstrates a quite elongated sigmoid) to the left, thereby putting traction on the rectum and lifting it superiorly. With bipolar scissors (optionally: LigaSure® or BowaNightKnife®) open the right pararectal peritoneum at the promontory, identify the right ureter and iliac vessels, and carry the incision inferiorly along the peritoneal reflection. Open the posterior fascial space between the parietal pelvic fascia (Waldeyer fascia) and mesorectum as much as possible.

    Note

    • Identify the ureter before dissection is started, but it is not necessary to dissect it free or encircle it with a tape.
    • The lateral support of the descending colon should be left intact to prevent later descent into the lesser pelvis.
  • Mobilizing the posterior rectum

    Paid content (video)
    Paid content (image)

    Pull the rectum to the right and incise the lateral peritoneum on the left. Then mobilize the rectum posteriorly sparing the mesorectum and vascular axis. Connect with the opposite side so that the rectum can be lifted and continue the posterior dissection down to the pelvic floor.

  • Mobilizing the rectum laterally and anteriorly

    Paid content (video)
    Paid content (image)

    The incision of the anterior peritoneal reflection and subsequent dissection of the rectum in the anterior fascial space between the posterior vaginal wall and anterior rectal wall, while respecting the Denonvillier fascia, is facilitated by inserting a swab into the vaginal stump (previous hysterectomy). Mobilizing the rectum 360° (laterally and posteriorly down to the pelvic floor) allows it to be pulled far cephalad.

    Note

    • In the case shown, the prerectal peritoneum is incised and the rectum also dissected anteriorly down to the pelvic floor, thereby achieving the maximum rectal lengthening possible.
    • It is not mandatory to dissect the anterior fascial space between the posterior vaginal wall and anterior rectal wall, since dissection in the ballooned Douglas pouch may injure the vegetative nerve fibers. Sometimes only the anterior peritoneum needs to be incised to ensure enough lengthening of the rectum.
    • A number of studies demonstrate that sparing the preservation of the lateral stalks improves the postoperative functional outcome, but at the cost of increasing recurrence.
  • Dividing the superior rectum and dissecting the mesosigmoid

    Paid content (video)
    Paid content (image)

    It appears that the sigmoid and rectum has been mobilized enough. Since the hypermobile elongated sigmoid has almost no adhesions with the lateral abdominal wall, no further dissection is needed here. Now tunnel through the posterior mesorectum close to the rectal wall where the middle third meets the superior rectal third. After changing the camera location from T3 to T2 (solely a 5mm laparoscope is used) divide the rectum with an Endo GIA®. For this end, remove trocar T1 and introduce the cutter through the minilaparotomy. Then divide the mesosigmoid with the BOWA NightKNIFE® close to the intestinal wall, sparing the vessels (superior rectal artery), to the extent that the proximal sigmoid can be brought down to the rectal stump without tension.

    Note

    • The distal resection line should always be in the high-pressure zone of the rectosigmoid transition; usually, this is indicated by the lack of epiploic appendices and taeniae.
    • Select the proximal resection line such that afterward the course of the bowel to the rectal stump will follow a gentle S-shaped curve.
  • Delivering the rectosigmoid by extracorporeal resection

    Paid content (video)
    Paid content (image)

    Extend the trocar incision T4 in the left lower quadrant mediad by about 4cm. After inserting a circular wound edge protector, exteriorize the rectosigmoid outside the abdominal wall. Determine the resection line and check for adequate blood supply when dividing the marginal artery. After dividing the bowel with straight bowel scissors hand over the specimen to histopathology.

    Insert an over-and-over purse string suture, insert the anvil of the circular stapler (here 28mm) and tighten the suture.

    After returning the bowel into the abdominal cavity, close the Pfannenstiel incision in layers.

  • Laparoscopic end-to-end descendorectostomy

    Paid content (video)
    Paid content (image)

    Reestablish the pneumoperitoneum. After atraumatic dilatation of the sphincter muscles, introduce the circular stapler through the anus and perforate the rectal stump as best in the middle as possible directly adjacent to the staple line. When connecting anvil and spindle, check the position of the taenia libera to prevent accidental rotation of the bowel. Construct the anastomosis by closing the stapler and firing the gun and then remove the instrument through the anus. Check both punched out tissue rings for integrity.

  • Leakage testing the anastomosis

    Paid content (video)
    Paid content (image)

    Check the anastomosis with sigmoidoscopy confirming good blood supply and adequate lumen. At the same time, fill the lesser pelvis with irrigation fluid and occlude the bowel proximal to the anastomosis with a soft intestinal clamp. Insufflating air during sigmoidoscopy will test the anastomosis for any leakage. Any air bubbles during this maneuver indicates anastomotic failure.

  • Performing suture rectopexy

    Paid content (video)
    Paid content (image)

    After suctioning the irrigation fluid and checking for hemostasis, the rectopexy is performed as a reverse Y-shaped suture of the pelvic floor peritoneum. For this purpose, anchor the rectum anteriorly and bilaterally with V-Loc™ sutures at the margins of the incised peritoneum. After completion of the rectopexy, the "stretched" rectum is elastically fixated in its new position.

    After removing the trocars under view, close the abdominal wall with fascial and skin sutures.

Single Access

Access to this lecture
for 3 days

€4.99 inclusive VAT

payment

webop-Account Single

full access to all lectures
price per month

for the modul: vascular surgery

from 8,17 €

hospitals & libraries

for the modul: vascular surgery

from 390,00 euros

  • Prevention and management of intraoperative complications

    Paid content (text)
  • Prevention and management of intraoperative complications

    Paid content (text)
  • MVZ St. Marien Köln - Ärztliche Leiterin

    Edith Leisten

Single Access

Access to this lecture
for 3 days

€4.99 inclusive VAT

payment

webop-Account Single

full access to all lectures
price per month

for the modul: vascular surgery

from 8,17 €

hospitals & libraries

for the modul: vascular surgery

from 390,00 euros

  • Literature summary

    Paid content (text)
  • Intraabdominal procedures (laparotomy, laparoscopy)

    Paid content (text)
  • Local techniques (perineal, transanal)

    Paid content (text)
  • Ongoing trials on this topic

    Paid content (text)
  • References on this topic

    Paid content (text)
  • Reviews

    Paid content (text)
  • Guidelines

    Paid content (text)
  • literature search

    Literature search under: http://www.pubmed.com