Resection rectopexy, laparoscopic

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.

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.

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.

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.

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.

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.

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.

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.

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.