When the pneumoperitoneum is established at 15 mm Hg and ports are placed, full evaluation of the abdominal cavity is performed, as the majority of these patients are elderly. The patient is placed in Trendelenburg position with the left side tilted up. The small bowel is gently retracted out of the operating field using atraumatic bowel graspers. The combination of sympathetic blockade afforded by the epidural administration of local anesthetics, gravity from the Trendelenburg position, and gentle manipulation of the small bowel allows visualization of the sigmoid mesentery and pelvis. The rectum, sigmoid, and descending colon are evaluated. Typically, there is a significant redundancy of the rectosigmoid with a very low peritoneal cul-de-sac.
Chapter 10.4 Rectopexy with and Without Sigmoid Resection 329 Rectopexy Without Sigmoid Resection
Using a bowel grasper, the rectum and colon are gently retracted up and out of the pelvis to allow for visualization of the sacral promontory and the vascular anatomy of the rectosigmoid area. Dissecting from the right side, the peritoneum over the sacral promontory is incised (Figure 10.4.3) and the superior hemorrhoidal pedicle is identified and retracted superiorly. The left ureter must be clearly visualized through the submesenteric window to avoid injuring it (Figure 10.4.4). When these two important structures are clearly visualized, the peritoneal incision is extended, first cephalad to the aortic bifurcation and the hypogastric nerves are swept dorsally away from the superior hemorrhoidal artery and vein, then caudally in the pelvis for several centimeters. The assistant at this time with the atraumatic bowel grasper is grasping the cut edge of the peritoneum and retracting the rectum anteriorly and to the left to allow safe mobilization of the rectum in the presacral space. This plane is avascular allowing for a bloodless dissection down to Waldeyer's fascia at the third sacral vertebra. This fascia is sharply incised and the dissection is continued distally down to the pelvic floor (Figure 10.4.5).
Next, the left lateral sigmoid attachments are incised and the rectum and sigmoid colon are retracted by the assistant to the patient's right side. The peritoneum to the left of the rectum is incised to allow complete mobilization of the rectosigmoid (Figure 10.4.6). The dissection is extended posteriorly to join the plane previously dissected on the right
Figure 10.4.4. The left ureter is clearly visualized through the submesenteric window.
side. The peritoneal reflexion is incised; however, the true lateral rectal stalks are exposed but left undisturbed.7 The completeness of dissection is determined visually or with the aid of a double-gloved finger in the rectum (Figure 10.4.7). Using a laparoscopic instrument, the surgeon's finger should be palpable just above the pelvic floor. Further mobilization of the peritoneal reflection is continued anteriorly at the level of the cul-de-sac if necessary. It is important again to preserve the lateral rectal stalks.7 At this point, if only a rectopexy is planned, the rectum is placed under moderate tension by the assistant through the left lower quadrant port sites.
A 0 nonabsorbable suture is passed through the right lower quadrant cannula into the peritoneal cavity. The needle is grasped by the needle holder in the right lower quadrant cannula and is driven through the presacral fascia, about 1 cm below the sacral promontory and about 1 cm to the right of the midline (Figure 10.4.8). The needle is then passed through the lateral rectal stalks in a location so that the rectum will be under mild tension (Figure 10.4.9). Intra- or extracorporeal knot-tying is performed. Often, we will use extracorporeal tying in which the suture is pulled out of the abdomen and a Roeder knot is performed and slit with a knot pusher to tighten the suture. At this point, a second rectopexy suture is placed in the same manner 1 cm cephalad from the previous one on the patient's right side.
The surgeon at this time places tension on the rectum toward the right presacrum. If this maneuver does not cause excessive angulation
or tension, rectopexy sutures can be placed on the patient's left side. This is indeed a controversial point and some authors would not place rectopexy sutures bilaterally in order to avoid possible rectosigmoid angulation especially when a resection is not planned. At the completion of the rectopexy, an intraoperative proctoscopy is performed past the rectopexy site to make sure that no angulation or constriction of the lumen has occurred.
After performing the complete mobilization, the sigmoid colon is then retracted toward the left side of the pelvis by the assistant. It is important to have a clear understanding at this point of the vascular anatomy of the rectosigmoid as well as the location of the left ureter, which was initially identified through the window underneath the superior hemorrhoidal vessels on the left side. This procedure preserves the left colic artery, dividing only the sigmoid branches of the inferior mesenteric artery.8 Viability of the distal bowel in this way presents no problem and is supplied by the middle and superior hemorrhoidal vessels. The proximal blood supply is usually adequate through the left colic artery, which is also preserved. The sigmoid branches are dissected at their takeoff from the superior hemorrhoidal artery and are sealed and divided with the LigaSure™ device. Mobilization of the mesentery leading to the proximal and distal transection points is also completed from the patient's right side. The assistant on the left side is retracting the sigmoid to the left side of the pelvis.
It is important to remember that when this operation is performed for prolapse, the rectum should be mobilized to the pelvic floor and laterally to the level of the lateral stalks, but the anastomosis should be performed at or just below the sacral promontory. At the distal resection point, the mesorectum is divided with the LigaSureTM device. The assistant retracts the rectum up and out of the pelvis and toward the left side with the surgeon completing the distal dissection from the right side.
Once this is accomplished, an endoscopic stapler is inserted through the right lower quadrant port site, placed across the upper rectum, and deployed. Because of the high level of transsection, the stapler may need to be fired twice to completely divide the rectum at this point. When this is accomplished, the left lower quadrant or umbilical cannula site is enlarged to 3-4 cm to allow exteriorization and proximal transec-tion of the specimen.
When the abdominal cavity is entered and the pneumoperitoneum is evacuated, a wound protector is inserted. The divided sigmoid colon is then delivered through the incision. Proximal division of the mesentery can be completed extracorporeally and the proximal limit of the resection is identified, circumferentially freed from the mesentery and divided between clamps. At this point, a pursestring is applied over the distal stump and the center rod and anvil of a circular stapler 31 mm is inserted and secured in place.
Tension over the mesentery of the sigmoid and descending colon is evaluated at this time and further mobilization is achieved if needed. The distal stump is inserted back into the abdominal cavity. Interrupted fascial stitches are placed to close the extraction site around a port and pneumoperitoneum is reestablished.
When that is achieved, the assistant holds the distal sigmoid colon to allow proper orientation of the mesentery and avoid torsion. The second assistant between the legs of the patient inserts the shaft of the circular 31-mm stapler. A suture is placed in the spike of the stapler to facilitate laparoscopic removal. The stapler is passed transanally and guided to the rectal staple line. The spike of the circular stapler is then advanced adjacent to the rectal staple line and removed by grasping the suture. The spike is removed through the right lower quadrant port site.
The surgeon then grasps the center rod of the circular stapler anvil and inserts it into the shaft of the stapler. Proper orientation of the mesentery is further checked. The assistant allows for retraction of the sigmoid colon for adequate visualization of the mesentery. The stapler is then closed and deployed. The stapler is released and extracted transanally. The two rings are checked. A leak test is performed by insufflating the rectum transanally while the pelvis is filled with fluid and the descending colon is occluded to detect air leaks from the anastomosis. The pelvis is then copiously irrigated with warm sterile saline solution using a laparoscopic suction irrigator.
The rectopexy is then performed distal to the anastomosis as previously described. Proctoscopy is performed to ensure that there is no angulation or constriction. The cannulae are removed in a routine manner and the cannula sites are closed.
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