Laparoscopic treatment of a rectal prolapse: modified Orr-Loygue technique

The purpose of the movie is to show our technique of laparoscopic repair of a rectal prolapse using indirect pexy with a mesh.

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Laparoscopic treatment of a rectal prolapse: modified Orr-Loygue technique

Authors

J Leroy, J Marescaux

Abstract

The purpose of the movie is to show our technique of laparoscopic repair of a rectal prolapse using indirect pexy with a mesh.

Classification

tips and tricks

Keywords

Laparoscopic treatment, rectal prolapse, modified Orr-Loygue technique

Media type

Surgical video

Duration

08'49''

Publication

2008-12

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E-publication

WeBSurg.com, Dec 2008;8(12).
URL: http://www.websurg.com/doi-vd01en2456.htm

Laparoscopic treatment of a rectal prolapse: modified Orr-Loygue technique

1. Clinical case presentation 00'11''

The purpose of the movie is to show our technique of laparoscopic repair of a rectal prolapse using indirect pexy with a mesh.

2. Exposure 00'36''

The 1st step of the procedure is the opening of the presacral space. After exposure of the pelvis, we open the peritoneum anteriorly to the promontory and using traction and counter-traction, we do the dissection of the presacral space. The suspension of the uterus will expose better the Douglas’ pouch. Afterwards, we continue the dissection anteriorly to the rectum. The opening is done dividing the peritoneum back to the cervix or the vagina, and using traction and counter-traction, pushing the anterior rectum posteriorly, we open the pre-rectal space. Once we have divided the posterior and anterior space of the rectum, we remove the Douglas’ pouch doing a Douglasectomy. The pouch is very deep in this type of disease. Removing the pouch is better to reduce the risk of elytrocele.

3. Colpopexy 02'39''

Then we will do the indirect pexy with polyester mesh, 2 legs, 10cm in length, fixed first on the promontory using tacker, and fixed also with sutures. The danger is to injure the iliac vessels laterally and medially the sacral vessels. It is why we have to be cautious when we put the different stitches and staples or tacker. When fixed, one of the legs is pushed down to be fixed anteriorly to the rectal wall using non-absorbable sutures, Ethibond in this case, with extracorporeal knots, with the Endosuture system that facilitates knot-tying. We fix with 2, 3 or 4 stitches depending on the length of the anterior rectum. The fixation is done with care avoiding any perforation of the rectal wall. Then we continue the fixation higher on the polyester mesh and the distal excess is removed. Maintaining the rectum in this position, we fix afterwards a second mesh. It is 10cm in length and 2cm in width, fixed also on the promontory (as for the 1st mesh). We do a posterior colpopexy with non-absorbable sutures, in polyester too (Ethibond sutures) fixed to the mesh. This is facilitated by the use of an extracorporeal knot suture with this pushing knot device. Two or 3 stitches are used to ensure a good fixation. Afterwards, the distal part of the mesh is pushed down in order to create more fixations lower. During this operative step, exposure is maintained by anterior retraction of the cervix and the rectum is maintained up above the pelvic rim.

4. Closure of the peritoneal gap 06'24''

We then have to close the gap, doing a perfect closure to avoid bowel obstruction using monofilament absorbable sutures, PDS in this case, with intracorporeal knots and a running suture to complete the closure on the right first, and then on the left. In some cases, in the event of constipation, we have a sigmoid resection to the pexy. This sigmoid resection is performed after the closure of the Douglas’ pouch. The advantage of the monofilament is to pass different stitches and to pull on the sutures afterwards. The sutures can slide easily due to the monofilament. The closure is achieved on the right. We do exactly the same on the left, and we see that the douglasectomy is a good operative step to reduce the risk of elytrocele. We can sometimes add a fixation to the mesh. No drainage is necessary in this type of procedure, and particularly in this case there when there was no bleeding.