Robot Assisted Rectopexy

Transcription

1 1. Abdominal cavity approach 1A 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. 1B Abdominal cavity Insufflate Insufflate gas into the abdominal cavity to produce a pneumoperitoneum. 1 / 6

2 2. Rectosigmoid exposure 2A Uterus Fixate Fixate the uterus to the anterior abdominal wall to give more exposure and ease the dissection of the rectovaginal septum later on. TIP: 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. 2B Sigmoid Retract Retract the sigmoid to the left lateral side to gain exposure of the peritoneum. 2C Peritoneum Identify Identify the peritoneum and the underlying promontory, iliac vessels and ureter. 2 / 6

3 3. Rectal mobilization 3A Peritoneum Incise Incise the peritoneum over the promontory until the bone is visible without overlying structures. HAZARD: 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. 3B 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. TIP: 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. 3C 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. 3 / 6

4 4. Mesh placement 4A 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). TIP: Mesh fixation After placement of the sutures the traction force on the rectum should be divided equally over the tissue. 4 / 6

5 5. Peritoneal closure 5A Peritoneum Close Close the incised peritoneum over the mesh with a running suture. HAZARD: 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). TIP: 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. 5 / 6

6 A. Wound closure AA Uterus Reposition Reposition the suspended uterus under laparoscopic vision (risk of bleeding). AB Trocars Remove Remove the trocars under laparoscopic vision. AC Fascia Close Close only the fascia of the 12 mm camera port with absorbable braided sutures (see procedure Trocar placement ). AD Skin Close Close the skin with absorbable monofilament sutures intracutaneously. 6 / 6