|Year : 2018 | Volume
| Issue : 3 | Page : 89-93
Totally laparoscopic resection rectopexy with transanal extraction of the specimen
JS Rajkumar, R Prabhakaran, S Akbar, Anirudh J Rajkumar, G Venkatesan, Shreya Rajkumar
Department of Minimal Invasive Surgery, Lifeline Institute of Minimal Access Surgery, Chennai, Tamil Nadu, India
|Date of Web Publication||10-Sep-2018|
Dr. J S Rajkumar
47/3, New Avadi Road, Kilpauk, Chennai - 600 010, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Aim: The aim of this study is to show the functional and technical feasibility of hand-sewn verses stapler resection anastomosis, with transanal extraction of the resected colon in patients presenting with rectal prolapse and constipation.
Materials and Methods: From January 2011 to 2016, a number of 16 totally laparoscopic resection rectopexies with intracorporeal anastomosis and transanal removal of specimen was performed in our institution. All patients had complete rectal prolapse with constipation. Of the 16 patients, nine had stapled anastomosis and seven had totally sutured intracorporeal anastomosis.
Results: There were no leaks, no notable morbidity, and mortality in both groups. Time taken for hand-sewn anastomosis was longer (±47 min) and the cost was significantly less in this group.
Conclusion: Totally laparoscopic resection rectopexy with transanal removal of the resected dolichosigmoid with either hand-sewn or stapled intracorporeal anastomosis, is a technically feasible option with excellent results in patients with constipation, and full thickness rectal prolapse.
Keywords: Laparoscopy, rectal prolapse, resection rectopexy
|How to cite this article:|
Rajkumar J S, Prabhakaran R, Akbar S, Rajkumar AJ, Venkatesan G, Rajkumar S. Totally laparoscopic resection rectopexy with transanal extraction of the specimen. Saudi Surg J 2018;6:89-93
|How to cite this URL:|
Rajkumar J S, Prabhakaran R, Akbar S, Rajkumar AJ, Venkatesan G, Rajkumar S. Totally laparoscopic resection rectopexy with transanal extraction of the specimen. Saudi Surg J [serial online] 2018 [cited 2018 Nov 18];6:89-93. Available from: http://www.saudisurgj.org/text.asp?2018/6/3/89/240912
| Introduction|| |
Rectal prolapse is an uncommon but debilitating condition affecting, predominantly, women in the 5–7th decade of life.
A “Dolichosigmoid” or an extra-long sigmoid colon, has also been incriminated as a cause of the rectoanal intussusception, with the excessive peristalsis generated by the extra length, putatively contributing to the onset of the intussusception.
Conventionally, this surgery has either been done through an open approach (laparotomy and resection rectopexy) or a laparoscopic-assisted approach  (laparoscopic resection, Pfannenstiel incision, removal of specimen, insertion of anvil into the distal cut end of proximal colon, purse string to hold the angle in place, and transanal stapled anastomosis, which is either done open or laparoscopically assisted).
Based on our extensive intracorporeal suturing experience and on a wealth of data about transanal specimen extraction, we combined the two techniques of totally laparoscopic resection rectopexy.
We present in this article, our technical innovation to perform totally laparoscopic resection rectopexy with intracorporeal anastomosis by either the hand-sewn or the stapled techniques. The technical difficulties and the outcomes of these two techniques are compared. We found both to be technically feasible, with no mortality, morbidity, or recurrence, at a follow-up of 6 months to 5 years.
| Materials and Methods|| |
All patients who presented with constipation and rectal prolapse were taken up for resection rectopexy. Preoperative investigation included colonoscopy and magnetic resonance imaging (MRI) defecography. The only criterion being affordability, those who could afford the stapler guns were taken up for stapled intracorporeal anastomosis, and the others were offered intracorporeal sutured technique. Of 16 patients, 12 were female and four were male.
The age distribution showed a mean age of 49.3. Two patients were in the 20s and were both males. One of them had severe obsessive-compulsive disorder. The maximum period of follow-up was 5 years, and the shortest period of follow-up was 6 months. Patients were followed up at 3-month intervals, with queries on constipation, incontinence, incontinence to flatus, or recurrence to rectal prolapsed. Four of the patients were lost to follow-up, but all patients were seen at least twice at 3-month intervals in the postoperative period. There were no postoperative leaks or mortality in this series. The average time for the surgery was significantly more in the hand-sewn anastomosis group (±47 m) and the cost was significantly less in this group, and the postoperative pain and discomfort were the same in both groups.
A totally stapled intracorporeal anastomosis; we perform this in a series of following steps.
The patient is put in a semi-lithotomy position with steep head-down position to allow the small bowel to fall back in the pelvis. We use the combination of epidural anesthesia and general anesthesia to contract the small bowel and render it completely out of the way.
Diagnostic laparoscopy, visualization of the deep rectovesical, or rectouterine pouch, and checking the Dolichosigmoid.
The extra length of the sigmoid is measured by pulling the proximal sigmoid down toward the sacral promontory, giving an idea as to how much can be resected. We begin the resection at the level of the ampulla of the rectum, directly anterior to the sacral promontory. We resect the rectum only above the superior rectal vessels, and then enter the mesorectum. Keeping close to the wall of the rectum, we continue with either an ultrasonic shears or dissect the mesocolon close to the wall of the colon all the way proximally. This is done until a point, where one can easily bring the proximal colon to the cut edge of the rectum. At this point, the ultrasonic shears are used to transect the proximal colon.
With gentle anal dilatation, a crocodile laparoscopic forceps are introduced into the anus and is seen to emerge into the peritoneal cavity. The distal part of the colon is fed into the crocodile forceps and using gentle traction, the entire specimen is delivered out through the anus [Figure 1].
An adequately sized circular stapler (usually 31 or 33 circular end-to-end anastomosis stapler) is inserted into the anus and seen to emerge above the cut end of the rectum in the peritoneal cavity.
It is unlocked by rotating in the anticlockwise direction until the head of the anvil falls forward from the shaft.
Using a toothed grasper the head is detached from the stapler gun.
This is then inserted into the cut end of the proximal colon, and with the head in place 1–0 polypropylene purse string suture (a whip suture) is placed around the cut edge of the colon. This is tightened around the head of the anvil.
The circular stapler is now withdrawn into the anus, and a linear endo cutter (Edo GI) is applied across the ampulla.
The closed rectal stump can now be perforated by pushing the circular stapler up to the rectum and moving the spike forwards.
The proximal colon is brought in with the anvil, to engage with the spike. The stapler is closed and fired and the anastomosis is completed [Figure 2].
The posterior “Holy Plane” of Heald is opened up by the incision of the peritoneum only inferior to the superior rectal artery, and the sacral promontory and the first three pieces of the sacrum are exposed.
After the anastomosis, sutures are taken into the mesorectum and the wall of the rectum, the periosteum of the sacrum, and taking care not to injure the vessels and nerves. Thick bites are taken so that the distal rectum from the ampulla downwards is firmly anchored to the presacral fascia [Figure 3]. A leak test is performed, and with a drain in the pelvis, the ports are closed.
Totally sutured intracorporeal anastomosis
In this operation too, the initial steps are the same as explained previously.
After specimen extraction, the proximal colon and the distal rectum are first aligned with the mesocolon medially, to avoid rotation. As we usually suture from the right iliac fossa, we tend to take the left-sided corner Gambee bite first and hold it up with the cobbler's needle so that the posterior wall of the rectum and colon are co-opted under vision. Then, a series of vertical mattress sutures with 2–0 PDS are laid down starting from the left to right. The posterior layer of the anastomosis is completed.
The anterior wall is then closed with a series of interrupted modified Gambee sutures [Figure 4]. On an average, it takes us about 65 m to complete the intracorporeal anastomosis suture. A leak test is then performed, and then the ampulla of the rectum is sutured to the sacrum and presacral fascia as described already. With a drain in the pelvis, the ports are closed.
| Discussion|| |
The putative causes of rectal prolapse are myriad, such as Moschowitz (1912) theory of deep rectouterine or rectovesical pouch (which we found on laparoscopy in all the patients) and the rectoanal intussusceptions theory of Broden Smellmann (1968), which has subsequently been proved by cineradiography. Apart from these two main theories of disease from above, weakness of the pelvic floor  and internal/external sphincter dyssynergia, have also been blamed for rectal prolapse. Pudendal neuropathy, due to pressure on the pudendal nerve against the ischial spines such as the fetal head in a prolonged second stage of labor or neuropathy induced by pelvic surgery, has also been implicated in the genesis of prolapse.
Several studies have documented the rectoanal intussusceptions on MRI defecography or cineradiography, and the association of the dolichosigmoid to constipation and rectal prolapse is a confirmed entity.,
Thus, resection of the excess dolichosigmoid, coupled with fixation of the rectal ampulla to the sacrum, either with sutures or with a mesh, has been advocated for the time of Frykman and Goldberg. Resection rectopexy, over the past four decades, has now become accepted with sutured rectopexy of the ampulla of the rectum along with resection of the excess sigmoid colon.,
Search of transanal specimen removal showed that NOSE (Natural Orifice Specimen Extraction) has been sparingly reported and favored in diverticular disease, and some patients with rectal malignancies in whom the specimen were extracted through a pack.
Kessler and Hohenberger in Disease of Colon and Rectum in 2005, and Ashari et al. in Disease of Colon and Rectum in 2005 showed that laparoscopic resection rectopexy for rectal prolapse was safe and feasible, with improvement in symptoms. However, in both these groups, there were no hand-sewn anastomoses. A study by Laubert et al. in the International Journal of Colorectal diseases, did an outcome analysis of aged patients undergoing laparoscopic resection rectopexy, and although not statistically significant, there was a slightly higher incidence of complications. Again, they had used the purely stapled technique in their series. A 19-year experience study of patients with obstructive defecation, reported in Techniques of Coloproctology by Laubert et al. also used resection rectopexy for patients with obstructive defecation syndrome (ODS), and it showed very acceptable results concluding that laparoscopic resection rectopexy was safe and a feasible alternative for ODS. One study by Formijne Jonkers et al. comparing laparoscopic resection rectopexy with ventral rectopexy concluded that the continence and constipation scores were a little better with resection and complications were slightly more, compared to the ventral mesh rectopexy group. Mostly, the analysis of the resection rectopexy groups has been confined to continence data (slightly better than mesh rectopexy), functional outcomes (equal to or little better than mesh rectopexy), and complication rates (a little more, but statistically significant only in one study). In our group, we have found that the technical feasibility is excellent, and the complication rate is very low. We have not addressed long-term functional outcome as our patients were not available to do a detailed functional anorectal study in the long term.
The additional cost burden of one linear endo cutter and circular stapler comes to nearly 40% cost of the surgery and in a country like India, where economics are as important as ergonomics and this is a significant step. Both the stapled group and the hand-sewn group had no leak and this over a 5-year period. We believe that this clearly defines technical feasibility of this option. Performing a single-layer hand-sewn colorectal anastomosis is a daunting surgical task, but with the viability of this option, we hope many others will also take this up.
For the hand-sewn technique, we use the technique first described by Krukowski and Matheson, and known as the Aberdeen technique. Vertical mattress sutures for the posterior layer and Gambee sutures for the anterior layer, are the recommended combination in this technique, and we used this in all our patients. The leak test was performed in every one of the patients and finding a negative test correlated with an uncomplicated postoperative period.
The treatment of full-thickness rectal prolapse is still quite controversial, with no single accepted procedure. Among the abdominal approaches, rectopexy is done either with suture or with the mesh. We have no experience with laparoscopic ventral mesh rectopexy, as our results with sutured rectopexy, with or without resection have been extremely good. With the worry of pelvic sepsis, the surgical community too has moved away from mesh implantation (except in some pockets).
Resection becomes required when there is a history of constipation with or without an obvious dolichosigmoid. All of our patients are subject to MRI defecography, colonoscopy, and wherever there is a suspicion of pelvic floor disorder and anorectal manometry. Of these three procedures, we found that the MRI defecography, especially when it showed a significant descent of >3 cm, correlated with success when resection was done.
We had to utilize colonic lengthening procedures only in two patients, in the stapled anastomosis group. The reason was probably that when the free end of the rectum was stapled across, the requirement of the colon to reach the site of the anastomosis became a little augmented, necessitating the release of the splenic flexure, and the distal transverse colon to decrease the tension.
Thus, in the evaluation of patients with full thickness rectal prolapse, those with constipation underwent colonoscopy, and MRI defecography. The MRI defecogram showed in 92% of patients, a significant descent of the anorectum during real-time screening. The colonoscopy had not contributed. We found that in this group of patients, performing resection rectopexy by measuring the length of the colon to reach the sacral promontory without tension, and proceeding with the anastomosis either hand sewn or stapled, gave excellent results regarding postoperative complications and recurrence of rectal prolapse.
| Conclusion|| |
We believe that this technical innovation, of totally laparoscopic resection rectopexy, will in the future, be adopted by the most surgical workers across the country and hopefully across the world, in the treatment of this still mysterious problem, namely rectal prolapse with constipation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]