Task Analysis of Laparoscopic and Robotic Procedures

Task Analysis of Laparoscopic Rectopexy
General Surgery / Oct 1st, 2021 2:06 pm     A+ | a-
Laparoscopic Management of Rectal Prolapse

DR. MOHAMMAD FAROOQUE
DEPARTMENT OF GENERAL SURGERY
SUMANDEEP VIDYAPEETH
GUJARAT
 
Rectal prolapse is a debilitating condition that affects 1% of people older than 60 years. Surgical approaches to its treatment include a perineal approach and an abdominal approach. Laparoscopic rectopexy was initially described in the early 1990s and has since become the abdominal procedure of choice for rectal prolapse.
 
Indications:
 
Once rectal prolapse is diagnosed, surgical repair is indicated to prevent worsening fecal incontinence and discomfort.
 
BEAHRS ET AL CLASSIFICATION: 
 
1. Incomplete (Mucosal Prolapse)
2. Complete (Full thickness wall prolapsed) 
 
First degree: High or Early, “Concealed”, “Invisible”
 
Second degree: Externally visible on straining, sulcus evident between rectal wall and anal canal
 
Third degree: Externally visible
 
Patient Preparation:
 
- Proper history taking and clinical examination of the patient
- Routine investigations and additional investigations based on comorbidities
- Anesthetic fitness 
- Informed Consent
 
In preparation for the procedure, the patient is kept on NPO (nil per os) status, beginning the night before surgery. Prophylactic antibiotics are given per Surgical Care Improvement Project (SCIP) criteria.
 
Periprocedure:
 
A Foleys catheter is inserted for the duration of the case but is removed before extubation. Clippers are used to remove abdominal wall hair.
 
Patient Position:
 
The patient is placed in modified Lloyd Davis position(head down lithotomy) to make bowel fall away from the operative site. Special attention is given to the legs, avoiding excessive posterior or lateral compression, sparing any injuries to the calf muscle and lateral superficial peroneal nerve.
 
STEPS:
 
1. After successful pneumoperitoneum with veress, an 11mm smiling incision is made in the inferior crease of the umbilicus using no.11scalpel.
 
2. Use mosquito forceps to dilate the obliterated Vitello intestinal duct (Scandinavian technique).
 
3. Insert the 10 mm cannula with trocar  with guarded screwing movement, perpendicular to the abdominal wall till give away sensation is perceived.
 
4. Remove the trocar and push the cannula in.
 
5. Introduce the 30-degree telescope in after white balancing and focussing at 10 cm distance and visualise the area directly under the port for presence of any bleeding or injury.
 
6. Transilluminate the abdominal wall and insert one 10 mm port on the left and one 5mm port on the right under vision by the Baseball Diamond concept. You can also use the ipsilateral port with a 7.5 cm distance in between.
 
7. Do a complete examination of the abdomen and pelvis and push the bowel above the sacral promontory.

8. If the patient has a uterus that is affecting exposure, it can be retracted with a stitch to the anterior abdominal wall.

9. Dissection is started posteriorly(Holy plane of Heald). The plane between the mesorectum and retroperitoneum is identified; the retroperitoneum is usually whiter than the mesorectum. 

10. A harmonic scalpel is used to enter the posterior pelvic plane under the superior rectal artery, and the left ureter and hypogastric nerve plexus are identified.

11. Dissection is extended downward through the presacral anatomic space, all the way to the pelvic floor.

12.  The dissection must be carried below the rectosacral (Waldeyer) fascia. Often, to facilitate exposure, the right lateral stalk of the rectum is also mobilized.

13. Once the right stalk and posterior areas are mobilized, dissection proceeds anteriorly into the rectovaginal plane. 

14. Subsequently, the rectum is mobilized anteriorly to the upper limit of the vagina. During this approach, the nervi erigentes and left lateral ligament are spared.

15. The rectum is then pulled out of the pelvis, and where the fixation will occur is assessed. 

16. A window is made on the left side of the rectum to facilitate the rectopexy and dissection on sacral promontory is done to expose it.

17. Posterior placement of mesh approximately of size 12*8 cm is done inserted via the right-lower-quadrant port and is placed all the way down to the pelvic floor, extending cephalad behind the mesorectum.

18. The mesh should cover the posterior part of rectum and some of the lateral stalks of rectum.

19. An overly tight pexy must be avoided to prevent obstruction of the rectosigmoid junction. If suturing is chosen, then use Ethibond suture.

20. It is important to identify the sacral venous plexus before tacking or suturing. The bony promontory and presacral fascia is the ideal location for fixation.

21. Then the mesh is fixed on right and left lateral stalks of rectum with the sutures.

22. Close the fold of peritoneum by continuous intracorporeal suturing so that the mesh is extraperitonealised. You can also use Dundee jamming knot with Aberdeen termination. Care should be taken not to include the mesh while suturing the peritoneum.

23. Desufflation of abdomen done
 
24. Ports are withdrawn under direct visualisation and optical cannula is withdrawn by sliding over the telescope.
 
25. Skin incisions are either sutured or stapled.
 
26. Abdomen is cleaned.
 
27. Antiseptic dressing done
 
28. Post-op vitals are noted and the patient is shifted to the recovery room.
1 COMMENTS
Dr. Reena Khandwal
#1
Oct 1st, 2021 2:20 pm
Nicely written task analysis of laparoscopic rectal prolapse. It is very useful for surgeons who want to perform laparoscopic rectal prolapse surgery.
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