with Dr. Raul Almenara, Dr. Ana María Otero
A 59-year-old female patient with a previous history of diabetes mellitus, chronic bronchopathy, fibromyalgia, uterine fibroids, two vaginal deliveries and a surgical history of ovarian cyst resection.
The patient had a complete rectal prolapse associated with moderate fecal incontinence. A normal colonoscopy, endoanal ultrasound, and defecography were recorded. A manometry was performed in which a moderate insufficiency of the internal and external anal sphincters was found.
It was decided to perform a laparoscopic rectopexy.
The patient was placed in the supine position
with open legs. The surgeon stood at the right side of the patient with one assistant on each side.
A total of 4 trocars were used. A 12mm trocar was placed in a supra umbilical position for a 30° scope. A 12 mm trocar was placed at the right iliac fossa and a 5 mm trocar was placed at the right flank, serving as working channels for the leading surgeon. One 5mm trocar was placed at the left flank as a helping channel for the assistant.
First of all, the surgical field is prepared, leaving the pelvis free. To do this we separate the bowel and fix the uterus to the abdominal wall with a stitch. The patient is in the Trendelenburg position.
Then we proceed to carefully open the peritoneum with the hook to dissect the mesocolon and release the promontory where the mesh will then be fixed. We continue with the release of the rectum at the level of the posterior side and towards the lateral sides, using the hook and ligasure.
We progress distally by opening the peritoneal reflex at the level of the anterior side of the rectum. We dissect the anterior side of the rectum very carefully so as not to injure it, performing plenty of blunt dissection to avoid possible burns. At this level care must be taken not to injure the vagina. It is even helpful to perform a digital vaginal exam to make sure that we are not injuring it.
Once we have completed the dissection we continue with the placement of the mesh. In this case we use a titanized mesh. It is important that the assistant maintain the traction of the colon to fix the mesh correctly.
We make a total of four stitches at the level of the anterior side that we had released, two on each side, thus fixing the mesh to the rectal wall. Now we pull the mesh and fix it to the promontory that we released with tackers and one stitch of non-absorbable suture.
Finally we close the peritoneum with a continuous bearded suture (V Lock) to cover the mesh and place the structures in their natural position.
The surgery took 90 minutes. The postoperative course was correct. The patient started oral intake 24 hours after the surgery and left hospital on the 2nd postoperative day.
Share it with your network and help spread clinical knowledge.
