Perioperative management - Resection rectopexy, laparoscopic

In the film example, the indication for a resection rectopexy (rectopexy with simultaneous sigmoid resection) arose due to an obstructive defecation syndrome (ODS) with intussusception (internal rectal prolapse) in combination with a moderate rectocele, but primarily due to a pronounced sigmoid enterocele with concurrent diverticulosis.

Another indication for resection rectopexy is given in advanced rectal prolapse (grade 3) with a history of constipation. In the absence of a history of constipation and without sigmoid enterocele, the transanal and transabdominal approaches should be weighed against each other, particularly with regard to surgical fitness and comorbidities (e.g., Rehn-Delorme procedure in the elderly, multimorbid patient, see below evidences).

The goal of the treatment is the restoration of defecation and continence behavior and, if necessary, elimination of the rectal prolapse.

• General contraindications for a laparoscopic approach
• Functional outlet obstruction, e.g., paradoxical puborectalis syndrome, anismus

3.1 Standard Diagnostics

Medical History

• Prolapse: only during defecation, during physical exertion, permanent
• slimy discharge (due to mucositis: mechanical stress on the mucosa as a result of intussusception)
• perianal blood discharge, e.g. due to a solitary rectal ulcer (benign, common in rectal prolapse, always located anteriorly)
• Constipation/Diarrhea, occasionally alternating
• Feeling of incomplete emptying = repetitive toilet visits with vigorous, frustrating straining attempts
• Pencil-thin stools, scybala
• Tenesmus
• Incontinence: fecal smearing, pruritus ani
• in women often pelvic floor descent with urinary incontinence
• social impairments: e.g. toilet must always be nearby, fasting period before leaving the house

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 shame or – which is not uncommon – confuses straining with pinching.

• The prolapse often only occurs after several straining attempts
• If necessary, examination in squatting position or on the toilet seat
• Typical for complete rectal prolapse: circular mucosal folds

Rectal Digital Examination

• Active contraction or relaxation allows a rough assessment of the sphincter apparatus
• During straining, an intussusception or rectocele may be palpated if present
• Induration of mucosal areas: Could indicate a solitary rectal ulcer

Endoscopy

Proctoscopy

• Intussusception is often (not always) recognizable as a bulging of the ventral rectal wall through the anal canal when the proctoscope is withdrawn to the outer end of the anal canal and the patient is asked to strain.

Rectoscopy

• Can show a solitary rectal ulcer (always located anteriorly)
• A distal proctitis starting at the anorectal junction and abruptly ending at 10-12 cm from the anus is often associated with rectal prolapse

Colonoscopy

• Preoperative standard for examining colorectal topography and ruling out other pathologies

Functional Diagnostics

Functional tests such as anorectal manometry are recommended in patients with rectal prolapse, as in addition to evaluating continence, they can detect patients who will remain incontinent despite rectopexy.

In manometry, low resting and contraction pressures are typical for rectal prolapse with incontinence.

3.2 Additional Diagnostics

Additional functional tests such as electromyography and measurement of nerve conduction velocity are reserved for exceptional cases.

Defecography can confirm an internal prolapse; for an external prolapse, it can be dispensed with.

In case of suspected sphincter defect, endoanal ultrasound is helpful.

• Orthograde bowel lavage e.g. with polyethylene glycol
• Abdominal wall shave

in the operating room:

• perioperative antibiotic prophylaxis as single-shot with a first-generation cephalosporin (e.g., 2 g cefazolin) and 500 mg metronidazole i.v.
• Indwelling bladder catheter

General Risks

• Bleeding
• Rebleeding
• Necessity of transfusions with corresponding transfusion risks
• Thromboembolism
• Wound infection
• Abscess
• Injury to adjacent organs/structures (left ureter, iliac vessels, internal genitalia in women, urinary bladder, spleen, kidney, pancreas)

Specific Risks

• Anastomotic insufficiency with local or generalized peritonitis and consequences of sepsis, reoperation, discontinuity resection or creation of a protective ileostomy
• Impotence in men, fecal incontinence and bladder emptying disorders due to injury to the inferior hypogastric nerves
• Intra-abdominal abscess formation
• Primary creation of a protective ileostomy or primary discontinuity resection
• Conversion
• Change in bowel habits
• Trocar hernia
• Risk of injury to the sphincter apparatus by stapler
• Recurrent prolapse
• Postoperative constipation
• Persistent fecal incontinence or residual incontinence