Perioperative management - Ventral mesh rectopexy according to D'Hoore, laparoscopic

Laparoscopic ventral mesh rectopexy was introduced by D’Hoore and Penninckx in 2004. However, similar open techniques were described as early as the 1980s. Initially intended for the correction of external full-thickness rectal prolapse, the indication was later expanded to include internal rectal prolapse (intussusception) and rectocele, provided these are combined with a complex pelvic floor dysfunction and show functional impairments in terms of obstructive defecation or fecal incontinence. However, the surgical outcomes for these latter indications are poorly documented, so the diagnostic and surgical indication setting is still considered very critical. The method is described for rectal ulcer syndrome and is also used, for example, in the prolapse of an ileoanal pouch and for prolapse after low anterior (especially intersphincteric) rectal resection. In these latter patients, the technique is even simpler because the dissection step is largely omitted.

In contrast to older pexy procedures, ventral rectopexy does not involve posterior mobilization of the rectum, thus preserving the autonomic nervous system located there. Resection of the sigmoid colon is also avoided.

Even though the rate of mesh complications is not comparable to those of transvaginally inserted meshes, strict indication criteria apply for the implantation of a foreign body in the context of a functional, benign disease, and especially in younger female patients, thorough counseling is required.

In the shown example, the indication is based on a third-degree full-thickness rectal prolapse.

• General inoperability
• Tumor diseases in the rectum

 Relative contraindication:

• Incomplete family planning
• Presence of endometriosis of the Douglas
• Multiple previous abdominal surgeries
• Previous surgeries in the pelvis, especially post rectal resection
• Foreign material from previous surgeries (e.g., implanted mesh after rectopexy or gynecological surgery)
• Post radiation of the pelvis
• Irritable bowel syndrome

 As alternative procedures, particularly transanal techniques should be mentioned:

• In the presence of an external full-thickness rectal prolapse, mucosal resection according to Rehn-Delorme and rectosigmoid resection according to Altemeier
• In the case of morphological obstructive defecation, transanal rectal resection with a stapling instrument (“stapled transanal rectal resection”, STARR, Contour®TranstarTM)
•  Dorsal mesh rectopexy according to Wells.
• Resection rectopexy without mesh
• Suture rectopexy without mesh

3.1 Standard Diagnostics

Medical History

• Prolapse only during defecation, with physical exertion, permanently?
• Mucous discharge
• Perianal bleeding
• Constipation/diarrhea, occasionally alternating
• Feeling of incomplete evacuation = repetitive toilet visits with intense, frustrating straining
• Tenesmus
• Incontinence, fecal smearing, pruritus ani
• Social impairments: e.g., toilet must always be nearby, fasting period before leaving the house.
• Vaginal prolapse?

Inspection/Straining Test

As impressive as an advanced rectal prolapse may be, it can easily be overlooked if it only occurs during defecation and the patient avoids strong straining during the examination out of embarrassment or – as often happens – confuses straining with squeezing.

• The prolapse often occurs only after several straining attempts
• If necessary, examination in a squatting position or on the toilet chair
• Patients can be asked to document the prolapse in a home setting after a bowel movement with a cell phone photo. This can be very helpful, especially if the prolapse occurs infrequently.
• Typical of complete rectal prolapse are circular mucosal folds

Digital Rectal Examination

• Usually does not contribute to the diagnosis. More for differential diagnosis, e.g., of a tumor disease.

Endoscopy

Proctoscopy

• may show a solitary rectal ulcer
• Possibly mucosal bleeding

Rectoscopy

• May show a solitary rectal ulcer (always located anteriorly).
• A distal proctitis beginning at the anorectal junction and abruptly ending at 10-12 cm from the anus is often caused by a rectal prolapse.

Colonoscopy

• Preoperative standard for examining colorectal topography and excluding endoluminal pathologies.

3.2 Additional Diagnostics

• No further diagnostics are required for a full-thickness prolapse. In case of suspected intussusception, defecography is mandatory. The significance of detecting rectoceles in imaging remains questionable because the overlap with normal findings is too large.

Scores

• Incontinence scores, e.g., Continence Score of the German Working Group for Coloproctology (CACP) or the Incontinence Score of the Cleveland Clinic.

• Antibiotic single-shot prophylaxis before skin incision with a second-generation cephalosporin and metronidazole i.v. or ampicillin/sulbactam i.v.
• Transurethral indwelling catheter

Particularly in the presence of a relative indication for surgery in the case of morphological OD (obstructive defecation), shared decision-making with the patient is of crucial importance. This requires a thorough informational discussion.

• Persistence or recurrence of symptoms, especially constipation or fecal incontinence
• Postoperative functional changes in other compartments with possible changes in bladder or sexual function
• Intraoperative complications with possible conversion
• Injury to the hypogastric plexus
• Injury to the common iliac vein
• Injury to the ureter
• Injury to the posterior vaginal wall or rectum, possibly resulting in a rectovaginal fistula
• Occurring mesh complications, such as mesh erosions and mesh infections with possible revision surgeries

Intubation anesthesia in case of capnoperitoneum

Intra- and postoperative analgesia with epidural catheter

Lithotomy position on vacuum cushion with right arm adducted.

• Surgeon and assistant to the right of the patient,
• the scrub nurse to the right of the surgeon next to the right leg.
• The laparoscopy tower with monitor is positioned next to the patient's left leg.

Basic Instruments for Laparoscopy

• 11 blade scalpel
• Dissecting scissors
• Langenbeck retractor
• Suction-irrigation system
• Needle holder
• Suture scissors
• Forceps
• Gas system for pneumoperitoneum
• Camera system (30-degree optics)
• Gauzes, abdominal towels
• Swabs
• Suture material for abdominal wall fascia and skin

Trocars (in the film example)

• Optical trocar (10 mm)
• 2 working trocars (5 mm)
• 1 working trocar (12 mm)

Additional Instruments

• Dissection instrument for vessel sealing with integrated cutting function
• Absorbable sutures (2-0 Polysorb)
• Non-absorbable suture material (e.g., Ethibond® size 2-0)
• Prolene mesh 4 x 15 cm

Postoperative Analgesia

• Current guideline Treatment of acute perioperative and post-traumatic pain.

Medical Aftercare

• Catheter removal the next morning
• Immediate oral intake
• No intravenous fluid administration

Thrombosis Prophylaxis

In the absence of contraindications, due to the moderate thromboembolic risk (surgical procedure > 30 minutes duration), low molecular weight heparin should be administered prophylactically, possibly in weight- or risk-adapted dosing, until full mobilization is achieved. Note: Renal function, HIT II (history, platelet monitoring).

Follow the link here for the current Guidelines on Thromboembolism Prophylaxis

Mobilization

• Immediate mobilization

Physical Therapy

• Possibly respiratory exercises for pneumonia prophylaxis

Dietary Progression

• On the day of surgery, the patient may drink freely (+yogurt+broth).
• From the 1st postoperative day, the patient can eat and drink normally.

Bowel Regulation

• In case of constipation tendency: early and consistent use of macrogol.

Discharge

• Possible from the 2nd-4th postoperative day.

Work Incapacity

• In most cases irrelevant, as it involves older patients. For younger patients, individually, depending on the occupation, between 2 and 4 weeks.