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Leroy J, Marescaux J. Rectal prolapse repair using laparoscopic Douglasectomy and indirect ventral rectopexy and posterior colpopexy with polyester meshes. Epublication: WeBSurg.com, Feb 2013;13(2). URL: http://www.websurg.com/ref/doi-vd01en3922.htm

J Leroy (France), J Marescaux (France)

English - 09'37''
February 2013

For the authors of this film, the objective is to present the tips and tricks of their laparoscopic repair for rectal prolapse with elytrocele and rectocele. The procedure is outlined in a stepwise fashion and explained meticulously.

Keywords: Rectal prolapse repair, laparoscopic Douglasectomy, indirect ventral rectopexy, posterior colpopexy, polyester meshes

00'20'' Objective
The objective of this film is to demonstrate the treatment we used for prolapse repair associated with rectocele, elytrocele and perineal descent in a woman in her sixties who experiences increasing pain, and all the more so as she suffers from dyschezia.
00'38'' Exposure of operative field
As soon as the patient has been placed in a Trendelenburg position with arms alongside the body and legs spread apart, the pelvis is exposed by retracting the small bowel loops above the promontory. The pelvis is exposed as much as possible by suspending the uterus, by means of the T’Lift™ tissue retraction system introduced percutaneously in the suprapubic region. This device is passed underneath the round ligaments to the right and to the left as can be seen on these images. A zero-degree scope has been placed in the supra-umbilical region. In addition, two working instruments are positioned on the right flank and in the right iliac fossa respectively. A suprapubic port is used to introduce an instrument which grasps the right lateral aspect of the sigmoid mesocolon’s root to expose the root of the sigmoid mesocolon.
02'02'' Dissection of perirectal area
The peritoneum is opened anterior to the sacral promontory, and using traction by means of the surgeon’s left hand as can be seen here, the right lateral rectal peritoneum is grasped and the peritoneum is progressively opened from the anterior aspect of the promontory until Douglas’s pouch. Here, one can see that the deep portion of Douglas’s pouch is accountable for the elytrocele. One can also identify the presence of a thickened and edematous peritoneum suggestive of potential episodes of compression with local impairment forcing the patient to use digital maneuvers in order to defecate.

The opening is completed on the anterior aspect of the rectum, and the dissection is carried on posteriorly to the vagina, which is lifted as one can see here. Dissection is performed in a stepwise fashion until the pelvic floor. The use of curved Roticulator™ Mini-Shears™ scissors helps to open the dissection plane on a visual scale, hence improving visualization of anatomical structures. Here, one can see the progressive freeing of the anterior aspect of the rectum, which is pulled upwards above the promontory so that it is maintained in a position that resembles the final position after fixation.

One can see the interest of using a high-definition camera during the dissection. This camera makes it possible to visualize the anatomical planes in ideal conditions. Digital exploration through the anus shows the inferior limit of the dissection, which is just above the sphincter.
04'39'' Ventral rectopexy of rectum
Now suspension of the rectum still needs to be performed by fixation of a double polyester strip on its anterior aspect. This strip has two legs, one that is fixed to the anterior aspect of the rectum and the other one to the posterior aspect of the vagina.
This polyester strip is about 15cm long and 2cm wide. It is fixed on the anterior aspect of the rectum by means of Ethibond® stitches using an extracorporeal knotting technique, which makes it easier to tie knots.
The mesh is fixed by maintaining the rectum above the promontory and several stitches are placed on this anterior aspect staying superficially to the rectal wall, which should not be transfixed by the needle. Stitches are anchored on the left edge of the strip, then on the right edge of the strip, hence providing sufficient anchoring of the strip on the terminal and anterior portion of the rectum.
Tension on the strip should now be adjusted. The adjustment should be completed once the strip has been fixed in order to prevent any excessive anchoring.
06'34'' Posterior colpopexy
Now the second strip remains to be placed. It will be fixed on the posterior aspect or posterior pouch of the vagina where polyester stitches are placed. The vaginal wall is quite resistant. The strip is securely fixed by these sutures. The vaginal wall has been positioned perfectly.
The strip is 15cm long and 2cm wide. It is fairly long but the extremity of the strip will be kept in the rectovaginal space in order to induce fibrosis and to facilitate suspension by means of the fibrosis alongside the strip.
07'49'' Douglasectomy and peritonization
Sometimes, after excision of the excess peritoneum by performing a Douglasectomy, the peritoneum is then re-approximated meticulously. Closure is achieved by means of an absorbable V-Loc™ self-blocking suture, which helps prevent kinking at the beginning and at the end of peritoneal closure.
Closure is performed meticulously. It should preserve anatomical structures. Sometimes, the peritoneum is fixed to the strip in order to maintain Douglas’s pouch anchored cranially. The end of the closure is performed by means of horn stitches to allow for self-blocking.
The intervention is completed with the removal of suspension systems.
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Joël Leroy 

Jacques Marescaux