Ventral mesh rectopexy according to D'Hoore, laparoscopic

Supraumbilical mini-laparotomy, insertion of the optical trocar, and establishment of pneumoperitoneum. Under laparoscopic vision, the working trocars are placed:

5 mm left flank, 5 mm right mid-abdomen, 12 mm right lower abdomen.

The patient is placed in the Trendelenburg position so that the small intestine can be moved cranially out of the pelvis. Then, the adhesions of the sigmoid colon to the lateral pelvic wall are released.

Note: In women with an intact uterus, fixing the uterus ventrally to the abdominal wall can be advantageous.

This can be conveniently done with a straight needle. It is inserted percutaneously above the symphysis, then laparoscopically through the uterine corpus, and then back out through the abdominal wall. It is then tied extracorporeally so that the uterus is under tension.

Now the identification of the promontory takes place. At the level of the promontory, the peritoneum is opened to the right of the rectum. From here, a J-shaped incision of the peritoneum is performed. The incision is initially extended caudally pararectally to the right and then completed in an arc from right to left over the Douglas space.

Now begins the ventral mobilization of the rectum in the rectovaginal space down to the pelvic outlet.

The dissection in the rectovaginal septum ventral to the rectum is carried out down to the pelvic floor. The goal is for the pelvic floor (levator muscle) to be clearly visible anterolaterally on the left and right of the rectum. The dissection immediately ventral should also be carried out down to the pelvic floor.

Note 1: To facilitate the dissection in the rectovaginal septum caudally, if necessary, a swab introduced transvaginally can be used to elevate the vagina ventrally.

Note 2: The thin vaginal posterior wall, usually in postmenopausal women, and the ventral rectal wall must remain intact.

The adequate dissection caudally to the pelvic floor is finally checked digitally-rectally.