Tech Coloproctol (2015) 19:475–476 DOI 10.1007/s10151-015-1330-5
VIDEO FORUM
Wrap technique for rectal prolapse: video step by step J.-F. Gravie´1
Received: 27 March 2015 / Accepted: 24 June 2015 / Published online: 8 July 2015 Springer-Verlag Italia Srl 2015
Introduction
Operative technique step by step
The aim of the present video is to show a new method of fixation using a self-adhesive prosthesis (AdhesixTM) in laparoscopic ventral rectopexy for the treatment of rectal prolapse. The use of a non-absorbable prosthesis combined with an anterior limited dissection is now well accepted since D’Hoore and Pennickx publication in 2004, with good anatomical and functional results. The recurrence rate is low, but the risk of mesh detachment still exists. However, the main reason why surgeons choose a non-prosthetic technique has to do with complications associated with the prosthetic material. One must admit that the complications associated with prosthesis material (sepsis and erosion), although rare, are potentially serious, especially considering that the surgery is done for functional purposes. These complications are likely to be related either to the type of mesh used or to the technique of fixation (sutures, stitches, staples) on the rectum and the posterior side of the vagina. The goal of our wrap technique with AdhesixTM is to avoid these problems by carrying out a very low dissection and by using a synthetic self-adhesive prosthesis which coats widely the lower part of the rectum without requiring sutures between the rectum, mesh and vagina.
The video starts with two examples of re-operation for recurrence after initial rectopexy. In these two cases we see the shrinkage of the prosthesis, due to the ingrowth of fibrous tissue, and the limited surface of rectal wall covered by the mesh can explain the recurrence. This was also due to an incomplete dissection in the anterior plane not reaching the pelvic floor, which results in a level of fixation too high on the rectum. Laparoscopic ventral rectopexy is performed with 3–4 ports. Only one 10-mm port is used at the lowest level of the umbilicus for the camera. The dissection follows the following principles:
Electronic supplementary material The online version of this article (doi:10.1007/s10151-015-1330-5) contains supplementary material, which is available to authorized users. & J.-F. Gravie´ [email protected] 1
Department of General and Visceral Surgery, Clinique St Jean Languedoc, 20 Route de Revel, 31400 Toulouse, France
• • • • •
incision of the peritoneum at the level of the promontory, avoiding the hypogastric nerve, peritoneal incision to the right, up to the end of the Douglas pouch, no lateral and no posterior dissection of the rectum, ventral mobilization distally as far as possible in the plane between the anterior wall of the rectum and the vagina.
At the end there is a limited rectal mobilization, and only the right lateral ligament is exposed and will serve as a bed for the path of the prosthesis. In order to ensure the lowest possible anterior dissection of the rectum we think it is important to dissect both sides of the anterior rectal wall. This deep dissection starts just in front of the lateral ligaments in an avascular plane, creating two lateral pockets down to the pelvic floor. By bluntly retracting back the lateral ligaments the prosthesis can be wrapped around the widest segment of anterior rectal circumference. This manoeuvre, which is specific to dissection
123
476
in women, secures the widest contact with the rectovaginal area and allows for a better rectocele correction. This should not be performed in men, where the dissection has to remain more medial in order to avoid damaging the nerve plexus on the apices of the seminal vesicles. Finally, the anterior wall of the rectum is coated by a large adhesive prosthesis. As prosthesis we use a lightweight (40 g/m2) polypropylene mesh coated with a hydrogel synthetic film: polyvinylpyrrolidone polyethylene glycol (AdhesixTM, Cousin Biotech, Wervicq-Sud, France). The prosthesis is introduced in a bag via a 10-mm umbilical port. It is cut to the dimension of the rectum with a wide part (8/7 cm) which allows it to overlap the anterior side of the rectum and a narrower upper part (10/3 cm) which is fixed on the promontory. Its adhesive properties are activated in a wet environment. The prosthesis is repositionable, («post-it» effect), and perfectly coats the dissected organ, («wrap» effect). Its plastic properties in a wet environment make it possible to coat the various surfaces: the pelvic floor on both sides, the anterior side of the extra-peritoneal rectum and the lateral rectal ligaments. Adherence to the rectum is without tension and no other fixation is necessary, thereby avoiding the risk although of perforation. However, in order to optimize the wrapping of the rectum at times we have used absorbable sutures or tacks to fix the mesh to the levator ani and/or to the lateral ligaments. Finally, the mesh can be either sutured or stapled on the promontory. At the end the rectum should lie in a tension-free, proper anatomical position. The incised peritoneum is then sutured closed. Vaginal packing facilitates the joining of the vagina and the rectum.
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Tech Coloproctol (2015) 19:475–476
The packing is left in place for 24 h. Laxatives are prescribed for 10 days in order to prevent any effort during defecation.
Conclusions With our wrap technique and thanks to the absence of sutures to the rectum and vagina we have limited the risk of incomplete pexy and of some fixation-related mesh complications. The risk of mesh detachment is present, but limited [1]. Moreover, the procedure is made easier and faster by the lower number of sutures needed. Conflict of interest of interest.
The authors declare that they have no conflict
Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent Informed consent was obtained from all individual participants included in the study.
Reference 1. Gravie´ JF, Maigne´ C (2015) Wrap technique: a new operative procedure using a self-adhesive prosthesis for laparoscopic ventral rectopexy. Tech Coloproctol 19:361–363
VIDEO FORUM
Wrap technique for rectal prolapse: video step by step J.-F. Gravie´1
Received: 27 March 2015 / Accepted: 24 June 2015 / Published online: 8 July 2015 Springer-Verlag Italia Srl 2015
Introduction
Operative technique step by step
The aim of the present video is to show a new method of fixation using a self-adhesive prosthesis (AdhesixTM) in laparoscopic ventral rectopexy for the treatment of rectal prolapse. The use of a non-absorbable prosthesis combined with an anterior limited dissection is now well accepted since D’Hoore and Pennickx publication in 2004, with good anatomical and functional results. The recurrence rate is low, but the risk of mesh detachment still exists. However, the main reason why surgeons choose a non-prosthetic technique has to do with complications associated with the prosthetic material. One must admit that the complications associated with prosthesis material (sepsis and erosion), although rare, are potentially serious, especially considering that the surgery is done for functional purposes. These complications are likely to be related either to the type of mesh used or to the technique of fixation (sutures, stitches, staples) on the rectum and the posterior side of the vagina. The goal of our wrap technique with AdhesixTM is to avoid these problems by carrying out a very low dissection and by using a synthetic self-adhesive prosthesis which coats widely the lower part of the rectum without requiring sutures between the rectum, mesh and vagina.
The video starts with two examples of re-operation for recurrence after initial rectopexy. In these two cases we see the shrinkage of the prosthesis, due to the ingrowth of fibrous tissue, and the limited surface of rectal wall covered by the mesh can explain the recurrence. This was also due to an incomplete dissection in the anterior plane not reaching the pelvic floor, which results in a level of fixation too high on the rectum. Laparoscopic ventral rectopexy is performed with 3–4 ports. Only one 10-mm port is used at the lowest level of the umbilicus for the camera. The dissection follows the following principles:
Electronic supplementary material The online version of this article (doi:10.1007/s10151-015-1330-5) contains supplementary material, which is available to authorized users. & J.-F. Gravie´ [email protected] 1
Department of General and Visceral Surgery, Clinique St Jean Languedoc, 20 Route de Revel, 31400 Toulouse, France
• • • • •
incision of the peritoneum at the level of the promontory, avoiding the hypogastric nerve, peritoneal incision to the right, up to the end of the Douglas pouch, no lateral and no posterior dissection of the rectum, ventral mobilization distally as far as possible in the plane between the anterior wall of the rectum and the vagina.
At the end there is a limited rectal mobilization, and only the right lateral ligament is exposed and will serve as a bed for the path of the prosthesis. In order to ensure the lowest possible anterior dissection of the rectum we think it is important to dissect both sides of the anterior rectal wall. This deep dissection starts just in front of the lateral ligaments in an avascular plane, creating two lateral pockets down to the pelvic floor. By bluntly retracting back the lateral ligaments the prosthesis can be wrapped around the widest segment of anterior rectal circumference. This manoeuvre, which is specific to dissection
123
476
in women, secures the widest contact with the rectovaginal area and allows for a better rectocele correction. This should not be performed in men, where the dissection has to remain more medial in order to avoid damaging the nerve plexus on the apices of the seminal vesicles. Finally, the anterior wall of the rectum is coated by a large adhesive prosthesis. As prosthesis we use a lightweight (40 g/m2) polypropylene mesh coated with a hydrogel synthetic film: polyvinylpyrrolidone polyethylene glycol (AdhesixTM, Cousin Biotech, Wervicq-Sud, France). The prosthesis is introduced in a bag via a 10-mm umbilical port. It is cut to the dimension of the rectum with a wide part (8/7 cm) which allows it to overlap the anterior side of the rectum and a narrower upper part (10/3 cm) which is fixed on the promontory. Its adhesive properties are activated in a wet environment. The prosthesis is repositionable, («post-it» effect), and perfectly coats the dissected organ, («wrap» effect). Its plastic properties in a wet environment make it possible to coat the various surfaces: the pelvic floor on both sides, the anterior side of the extra-peritoneal rectum and the lateral rectal ligaments. Adherence to the rectum is without tension and no other fixation is necessary, thereby avoiding the risk although of perforation. However, in order to optimize the wrapping of the rectum at times we have used absorbable sutures or tacks to fix the mesh to the levator ani and/or to the lateral ligaments. Finally, the mesh can be either sutured or stapled on the promontory. At the end the rectum should lie in a tension-free, proper anatomical position. The incised peritoneum is then sutured closed. Vaginal packing facilitates the joining of the vagina and the rectum.
123
Tech Coloproctol (2015) 19:475–476
The packing is left in place for 24 h. Laxatives are prescribed for 10 days in order to prevent any effort during defecation.
Conclusions With our wrap technique and thanks to the absence of sutures to the rectum and vagina we have limited the risk of incomplete pexy and of some fixation-related mesh complications. The risk of mesh detachment is present, but limited [1]. Moreover, the procedure is made easier and faster by the lower number of sutures needed. Conflict of interest of interest.
The authors declare that they have no conflict
Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent Informed consent was obtained from all individual participants included in the study.
Reference 1. Gravie´ JF, Maigne´ C (2015) Wrap technique: a new operative procedure using a self-adhesive prosthesis for laparoscopic ventral rectopexy. Tech Coloproctol 19:361–363
