Hand Assisted Laparoscopic Sigmoid Resection and Rectopexy

The patient is a 49-year-old female with full thickness rectal prolapse and constipation. Workup for neoplastic or metabolic ideologies, colonic inertia, and obstructive defecation was negative. Preparation for surgery included IV antibiotics and a mechanical bowel preparation. The patient is positioned in a lithotomy position with both arms tucked and secured to the table with a U-shaped beanbag and heavy tape. A foley catheter is inserted into the bladder, oral gastric tube in the stomach, and venodine boots are placed on the calves. The hip should be as horizontal as possible.

A 12-millimeter Hassan trocar is placed in the infirm bilical position, a 12-millimeter trocar in the right lower quadrant, and a 5-millimeter trocar in the left lower quadrant. An 8-centimeter phanen-stealing scission is placed two finger breaths above the pubic symphysis for the gel port or other hand assist device. The dissection is carried down to the anterior rectus sheath, which is open in a curvilinear fashion. The anterior rectus fascia is mobilized superiorly and inferiorly. The rectus muscles are split in the midline, entering the peritoneum. This picture demonstrates the placement of the ports.

A 30-degree 10-millimeter camera is used through the umbilical port. The mesentery of the sigmoid colon and rectum are mobilized in a medial to lateral fashion. The inferior mesenteric artery is grasped and raised between the first finger and thumb. An incision is made at the base of the mesentery, extending down into the pelvis. The retroperitoneal attachments are gently brushed away. The key is upward traction on the artery. The left ureter is identified before proceeding further with the operation. The incision at the base of the mesenter is extended down to the rectum, exposing the presacral space.

The hand provides upward traction on the sigmoid colon to aid in exposure. Using careful blunt dissection and electric artery, the rectum is mobilized posteriorly down to the tip of the coccyx. Upward traction of the hand posterior to the rectum facilitates the mobilization. The inferior mesenteric artery is isolated and the extra fat cleared using the electrocotery. The vessel is divided using an endo-GIA stapler with a vascular load. An endoloupe should be closed at hand in the case of failure of the staple line. The mesentery of the colon is elevated and the dissection is carried laterally.

The purple retroperitoneal attachments are swept away. The dissection is carried out to the left sidewall. Next, the lateral attachments are divided. A 5mm left-sided trocar has been placed. Once these attachments are open, the previous area of mobilization is seen. The descending colon does not need to be fully mobilized since the sigmoid colon is redundant. The lateral dissection is carried down toward the rectum. Some of the upper lateral rectal attachments are divided to ensure good mobility of the rectum. The lateral rectal attachments are not fully divided. This view demonstrates the fully mobilized rectum.

The cap of the gel port is removed to perform the resection and rectopaxi. The mesentery of the upper rectum is cleared. Using a right-angle bowel clamp, the rectum is divided sharply. A purse string of 2-0 proline is placed around the rectum. The mesentery of the sigmoid colon is divided. The extent of sigmoid resection depends on the redundancy of the colon. Using a purse string device, the proximal colon is divided. An anvil for a 29mm EEA stapler is secured in the proximal colon. The stapler is passed transannually and the rectal purse string tied around the stem of the stapler.

Before the anastomosis is performed, the rectopaxi stitches are placed. Zero ethobon sutures are placed through the lateral rectal attachments and into the pre-sacral fascia. The stitches are not tied until the anastomosis is completed. A total of four stitches are used, two on either side of the rectum. If there is any bleeding from the pre-sacral area, the sutures are tied immediately. If needed, other maneuvers to control pre-sacral bleeding should be considered at this point in the operation. Next, the EEA anastomosis is performed. This is a single staple, double purse string, end to end colorectal anastomosis.

Finally, the rectopaxi sutures are tied. This shows the excellent cosmetic result afforded by this operation three weeks after the procedure. In summary, this procedure utilizes the following steps. Medial to lateral mobilization of the sigmoid mesentery. Post-year mobilization of the rectum. Bascular division. Lateral mobilization of the sigmoid and upper rectum. Resection of the redundant sigmoid colon and suture rectopaxi.