Robotic Rectopexy

This course provides you the practical knowledge for an individual surgical procedure.

After this course, you have :
  • a clear understanding of the steps to be taken to execute the procedure;
  • seen an example of how the procedure is executed;
  • a clear understanding of all anatomical structures encountered during the procedure;
  • seen an example of how the anatomical structures look within the setting of the procedure.
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Step by step

Abdominal cavity approach

Trocars

Introduce

Introduce five trocars to gain access to the abdominal cavity (in da Vinci Si type; In Xi type the trocar placement may differ slightly). First the camera port is inserted just below the umbilicus. Trocar 1 and 3 are located just medial to the anterior superior iliac spine. Assistant and trocar 2 are placed between the camera and the other two ports.

Abdominal cavity

Insufflate

Insufflate gas into the abdominal cavity to produce a pneumoperitoneum.

Rectosigmoid exposure

Uterus

Fixate

Fixate the uterus to the anterior abdominal wall to give more exposure and ease the dissection of the rectovaginal septum later on.

Uterine fixation

Place a straight needle proximal to the pubis into the abdominal cavity. The straight needle is placed from dorsal to ventral through the uterus and is then stuck back through the abdominal wall again. The thread is knotted extracorporeal over a gauze, suspending the uterus to the abdominal wall.

Sigmoid

Retract

Retract the sigmoid to the left lateral side to gain exposure of the peritoneum.

Peritoneum

Identify

Identify the peritoneum and the underlying promontory, iliac vessels and ureter.

Rectal mobilization

Peritoneum

Incise

Incise the peritoneum over the promontory until the bone is visible without overlying structures.

Peritoneal incision

The incision should not be medially as the hypogastric nerve lays there. The peritoneum should be opened slightly on the right lateral side and the nerves should be carefully moved away from the promontory bone where the mesh will be fixated.

Extend

Extend the incision in the peritoneum starting from the promontory downwards to the rectouterine (or rectovesical) pouch. Here a J-shaped incision of the peritoneum is made.

Rectovaginal/ rectoprostatic septum

Dissect

Dissect the avascular rectovaginal or rectoprostatic septum between the dorsal side of respectively the vagina or prostate and the ventral side of the rectum to approximately 1.5 cm proximal of the anal verge.

Correct plane identification

If adhesions between the dorsal side of the vagina and the ventral side of the rectum are present (eg. after previous hysterectomy), the dissection plane can be unclear. An obturator might be helpful to identify the vaginal contours and guide the dissection.

Rectum

Check

Perform rectal examination to confirm whether the dissection of the rectovaginal or rectoprostatic septum is conducted to approximately 1.5 cm of the anal verge.

Mesh placement

Mesh

Position

Position the mesh from the deepest point of the rectovaginal/rectoprostatic space (1.5 cm from the anal verge) towards the exposed promontory.

Fixate

Fixate the mesh on the rectum at least 7 times with non-absorbable woven sutures. Then fixate to the promontory (eg. with 4-5 tacks or 3-5 non-absorbable woven sutures).

Mesh fixation

After placement of the sutures the traction force on the rectum should be divided equally over the tissue.

Peritoneal closure

Peritoneum

Close

Close the incised peritoneum over the mesh with a running suture.

Incomplete peritoneal closure

If the peritoneum is closed incompletely and the mesh is not completely covered, the small intestine may attach itself to the mesh. This could complicate the postoperative course (postoperative ileus due to adhesions or rotation).

Peritoneal suturing

A self-anchoring barbed suture can be used, but alternatively an absorbable braided suture may be used, ensuring the whole mesh is covered with peritoneum.

Wound closure

Uterus

Reposition

Reposition the suspended uterus under laparoscopic vision (risk of bleeding).

Trocars

Remove

Remove the trocars under laparoscopic vision.

Fascia

Close

Close only the fascia of the 12 mm camera port with absorbable braided sutures (see procedure “Trocar placement”).

Skin

Close

Close the skin with absorbable monofilament sutures intracutaneously.