Laparoscopic Suture Rectopexy with Culdoplasty, Vaginal Wall Repair, and Perineorrhaphy for Rectal Prolapse

CHAPTER 1

Our operation today will be a laparoscopic suture rectopexy with culdoplasty- and vaginal repairs, possible anterior repair, posterior repair, and extended perineorrhaphy, as well as a cystoscopy. So there's a lot of words to describe what we'll be doing, and I think it will make sense to understand the anatomy and - the pathophysiology of rectal prolapse and why we chose this particular surgical approach. Of course, everybody knows, who's watching, that rectal prolapse, while common, is not always the same from patient to patient. The clinical picture always starts with full-thickness intussusception of the rectum and I have a little picture for you to remind you. Where the intussusception of the rectum is includes all layers of the rectal wall and the peritoneum on the other side. And with that comes important details. First of all, patients are extremely uncomfortable because of the mucus drainage, because of the pain. And with time they can develop rectal prolapse, and they also have obstructed defecation symptoms, where they simply can't defecate because the stool is getting blocked by the intusseptum. So it's a very bothersome condition, and it can happen in women and men, but it's more common in women, and it can happen anywhere across the age spectrum, from 15, 16, 17 years old, up to 100.

So this particular patient is 87 years old and that obviously had to be taken into account when we were choosing an operation for her. How do we choose an operation in general? Well, obviously we look at the age, but we also take into account the symptoms that the patient is complaining about and the physiology that the symptoms are generating. So this particular patient had minimal constipation and minimal incontinence, but on intrarectal physiology testing, and by that I mean anorectal manometry, she had very low rectal pressures. And that's important because that told us that we could not perform an operation where we remove a portion of the bowel. So that took off the table the opportunity of doing a suture rectopexy with a sigmoid resection, and it took off the table the possibility of doing a perineal repair with a rectal sigmoidectomy. So we're looking at either doing a perineal repair with the intussuscepting of the rectum, that's called a Delorme procedure, or doing a transabdominal repair with a suture rectopexy.

The next thing we'll look at is what does the gyn exam look like because at least a third of patients with rectal prolapse have concomitant vaginal prolapse. So what did her exam look like? So when we saw her in the office, we do what's called a POP-Q examination, in which we're measuring what compartment is prolapsing. She didn't have a lot of symptoms of vaginal prolapse, most of her symptoms were of rectal prolapse, but on exam she did have, mostly posterior prolapse, but she also did have some apical prolapse. So we just examined her, we did a very thorough pelvic exam. Women also can have stress urinary incontinence, which is loss of urine with coughing, laughing, sneezing. And that goes with it because of this loss of support. So it's a loss of support of the pelvic floor.

So she also underwent what's called urodynamic testing, and that was actually negative, so she did not need any concomitant surgery for urinary incontinence. So that is all done with physical exam alone, but there is also a part of this pathology that's invisible to the eye and it is something that can only be seen on defecography, which is a test where the patient has contrast inserted into the vagina and into the rectum, and they're actually asked to defecate. And we look at the images of what does the small bowel, the sigmoid colon, and the peritoneal - the omentum, do while the patient is expelling. And what we're looking for is essentially whether or not anything falls into the space between the vagina and the rectum. And if it's the small bowel, we call it an enterocele. If it's the sigmoid, then it's a sigmoidocele. If it's the omentum, it's an omentocele, etc., etc. And here's what her defecography looked like. And I think it's quite dramatic and it's an example of how, if you don't look, you don't know. But essentially, when this patient empties, and that's her rectum emptying, you can see that the small bowel is coming behind into the space between the rectum and the vagina and it keeps coming and coming and it's actually - she's pushing her small bowel out through the intercepting rectum. So the small bowel is coming out of her body, in addition to her rectum, when she's defecating. So it's quite dramatic. And what that told us is we can't fix this prolapse by simply resuspending the rectum. We have to do something more.

So - There are options. One is what we did, and it's the simplest of the options, which is after we're resuspending the rectum, is to close the space between the rectum and the vagina and recreate the pouch of Douglas at a higher level so that the small bowel can't fall between the 2 structures. And we chose this option because of her age and because we wanted to choose the simplest operation possible, especially since it's her first operation. But, we could've also used mesh, and there's a million configurations and different procedures that we could have used. But not for this patient. So that's, pretty much in a nutshell, the decision-making process for why we ended up offering this patient this procedure.

And now we can tell you about the steps. So, as in any laparoscopic procedure, you start by placing your ports and insufflating, and if the patient tolerates the insufflation procedure, then - in this case, we needed 3 ports: a 12 mm port in the right lower quadrant, a 5 mm port in the right upper quadrant, and another retractor port in the left lower quadrant. With these ports, one would then eviscerate the small bowel, the sigmoid colon, out of the pelvis, and inspect the pelvis. Usually with these patients, we expect a very wide cul-de-sac, so that the small bowel can fall into that cul-de-sac, and a very redundant rectum, because the rectum was falling out of the patient's body, so the ligaments are all very lax. We then dissect the sacral promontory and continue our dissection posteriorly all the way down to the levator ani muscle to the top of the anal sphincter complex, but we don't stop there. We take the lateral attachments of the rectum on the left and right, and - and this is critical - we also dissect the rectum completely off the vagina. Anterior dissection is essential because all prolapse starts anteriorly and the septum begins in the front, so if you don't address that, the prolapse is more likely to recur. Once we do all of these steps, the next is simple suturing. It's really just pulling the rectum on tension and placing 2 or 3 sutures on the sacral promontory and then to the side of the rectum and securing the rectum in this new orientation. So, what starts as a rectum following the sacral bone is now a straightened-out rectum that's floating. And that looks a little disconcerting because now you have a lot of space posterior to the rectum where a small bowel can fall in, and also it doesn't address the deep pouch of Douglas that we mentioned, and this is where Dr. Von Bargen comes in on the white horse and does her part of surgery. So we use the same ports that Dr. Bordeianou uses, and we use a barbed suture to close off that deep space, that pouch of Douglas, the posterior cul-de-sac, with that running suture. If this was a younger patient, someone who wanted a reconstructive surgery, then we would also usually incorporate the uterosacral ligaments, or we'd do something call the sacrocolpopexy, in which we're supporting the entire vagina. But really, for this patient, we just closed off that dead space and preventing that small bowel from dropping back in there and causing a recurrence of her rectal prolapse. And then afterwards, after we finished the laparoscopic portion, we went below, and like you saw in that picture, that this woman had very - really had no perineal body. The perineal body is vital for support of the pelvic floor. So we did what's called a posterior repair and a perineorrhaphy, which is basically just building back up that support of the perineal body. And again, because this patient wasn't sexually active, we made her genital hiatus, which is the opening of the vagina, quite small, and that, again, prevents any prolapse from coming back. And then we did a cystoscopy, because that's part of - when we're doing that laparoscopic procedure, the ureters, as you can see, are on the lateral side. While we're bringing that peritoneum together, we want to make sure that there is no kinking or injury to the ureter. That's pretty much in a nutshell.

CHAPTER 2

Superior iliac spine. That means that the sacral promontory is right here. So if you put your camera here, you're going to be looking right on top of it, and that's a little bit inconvenient because you want to have a panoramic view. And so that's why I kind of try and go just a little bit above the belly button and because I like the Hasson, we'll use the Hasson. Okay, so Adsons times 2 and a knife, please. We'll do a straight up and down because you see, she's got this paramedian incision from her appendectomy scar in childhood 70 years ago. And so, if we need to, we might somehow incorporate that. Okay, so pick up here. I'll pick up there, make a small incision. Okay, we'll take S retractors times 2. Okay, so pick up the fascia right on your side. I'll pick it up on my side. We'll go through some of this fat with a Bovie. And then when we get a little bit deeper, I'm going to switch to - Can I have a Metz, please? So even though her incision is here, we don't know whether or not the actual abdominal part was paramedian as well, or whether or not then they cheated and slid, right? And so it's possible that there will be some scarring underneath there, which is another reason to go slow. I'll switch to the knife for a sec. Okay. Let's see if we're in or whether we're - I think we’re in. I will use my little... Before we do anything, we're going to look. So I'll take the Hasson port. So that's my little trick. I use it instead of the finger. It's just a little smaller than the finger, and this way the opening is not so big that you're leaking air throughout. Okay. So I do it on the skin. This is not my final fascial closure. This is just so that this port doesn't slide in and out when we're operating. And that's why it's a loose suture that we can easily cut afterwards. Okay? So - you can do one on your side. All right, so - why don't we take a little look - I actually like the wide view as opposed to the circle view, it's just personal preference. It looks like not too bad as far as adhesions. So that's good. This is her transverse colon, by the way. You know, flopped all the way towards her pelvis. But that's the cecum. Okay. I'm going to be putting my 12s here, and this will be my right hand and the needle driver hand. And then I'll be putting my 5 in far away, so that I'm not criss-crossing, and a little bit more medial - again, because my target is here, and so I want to look that way. And then, we won't give you your ports for now, because I don't know what you'll need, but we'll definitely need a 5 on this side for retraction. So, just in case you're then using it, is this a good spot for you? - Yeah. - Yeah. Right there? Yeah. All right. So we'll do a 5 here. Looks like I am not spearing any major vessels. Always a good move. All right. The next one is going to go here. Can you see me? Yep. And it's so funny, because sometimes, you have this - you know, she's obviously loose, right, that's why her prolapse, but don't assume that the tissues are going to be loose. In fact, they're pretty sturdy. And prolapse - it's one of those diseases where nobody understands the pathology, but it's not necessarily connective tissue abnormality. Even though it can coexist with connective tissue, I think it's just much more complex than that.

CHAPTER 3

The first thing we'll do is simply reduce the bowel out of the pelvis. Okay. She had a bowel prep. I do it because then it's easier to manipulate the tissue and also it decreases the risk of infections - if you have a small tear in the rectum, for example, small enough for it to heal, but - that's the small bowel. Look how thin her mesentery is. Yeah. She is - um - and I want to point out to you how deep the small bowel is in the pelvis. And, you know, I showed you on the defecography that she has an enormous enterocele that's protruding through her anus. And so this is, you know, what we're seeing internally. Now, typical features of rectal prolapse are going to become apparent right now as soon as I finish reducing this bowel and making it stay in the upper abdomen. Hopefully it will stay without annoying us for the rest of the case. Is it possible to Trendelenburg just a little bit more? - Okay, so, now - this is sigmoid, right? - Yeah. Now, watch. This is the most dramatic step right here. I'm going to pull on the sigmoid and I'm going to keep reducing. And it keeps going - and going - and going - okay, still sigmoid - going - ha. You see this? This is an incredibly redundant rectosigmoid. One of the features of rectal prolapse. I've now reduced the prolapse. Now look in the pelvis. This is her small uterus, she's never had children, she's nulliparous, okay. Which is another interesting feature of this disease you don't have to have children, it's not associated with childbirth. So, you can see this enormously deep cul-de-sac. And - that's why you need a 30 camera, because - if you hold here, I'm going to turn it this way - you can now see that it goes anteriorly and up. You see that? All the way down there. wWhich is why some surgeons like the robot because it gives them the ability to see in that area, okay? But you should also be able to do it laparoscopically. So - Enough pontification. Now let's get going on the case.

CHAPTER 4

So, what I'm going to do is I'm going to find the sacral promontory, so the sacral promontory is way here, so you're going to pull out so we can see it, and I'm just going to pull the small bowel out of my face again, and here it is, right? Now, look on the- as you're looking at the sacral promontory, you can see the iliac on the right, you can see the ureter crossing it. Let's see if we can see it. Yeah, here it goes, right? And then we're going to clear the promontory, so that we can put our sutures on it, and so you want to pull out as much as possible for this step, and then maybe get your hand in the left, and just keep the small bowel out of my face.

You see this thing here? That's the left iliac vein. So, that's the right iliac artery, right iliac vein. The biggest mistake you can do right now... Is incorporate it. Is incorporate it into your coagulation - not a good move. Also not a good move if you're using tackers to suspend your rectum as opposed to sutures and you'll, you know, firing the tacker without realizing where the vein is. That's one of the common cause of sacral bleeding when you're doing a rectopexy. And that's why we'd like to, if we can, clear the sacral promontory well enough to know our anatomy and know where we're putting out sutures. I have a question, does this bed go down at all? Now you're going incise the perineum down to the levators, or? So... Does it depend on each case? No, it's always all the way down to the levators. It does not depend - back up just a little bit, I want to clear this just a little bit more, and the small bowel keeps irritating me, but I'm going to take this peritoneum, and then kick it out. I don't want to manipulate the small bowel without the harmonic, that's why I keep switching back to the- to the grasper, and again part of this pathology is redundancy, and so counter-traction and traction is one of the parts of the case that are hard - you see the vein? It's becoming a little bit more apparent. And this is the sacral promontory, and I want to see it better, so I'm going to put you there, and I'm going to clear it just a little bit more because I want to see the periosteum, so that when we are actually ultimately suturing to it, the sutures go into that periosteum and not into that little fatty flim-flam on top of it because that's how they will hold when we put the tissue on tension. Okay. Careful, careful. All right, come in a bit. Bring the camera in just a tiny bit. Okay, you're starting to see a little bit of whiteness there, that's going to be our target. And again, I don't have to take every cell layer of tissue, but I want to see this white clearly enough, so that when I'm suturing, I know that my sutures go where I intend them to go. Exactly, yeah… So that should be a reasonable target eventually.

CHAPTER 5

So now I'm going to get the panoramic view you've just given me, and I'm going to start taking the peritoneum on the right side, and that's the same move you'll do for rectal cancer dissection or any kind of low anterior resection, and it's not different in any way, and it's just taking the lateral attachments of the rectum except that these are very long. They just keep going, and going, and going, and going, and they keep sort of- folding on themselves, and going some more. And so before we go deeper, I am going to put a little bit of air underneath the rectum here, so I just lift up. Yeah, and I'm lifting both the rectum, but also its blood supply because I don't want to devascularize it, right? And I'm putting a little bit of air posterior to the rectum, you see this? So the mesorectum in these women is usually very thin. Again, think about it, the rectum is intussuscepting on itself and coming out of her body, right? If it was bulky, it probably can't do it, you know? So most women with rectal prolapse are thin. Not all of them - there's always an exception to the rule, but the majority of these patients are thin. and, yes, you see? So this is the posterior plane. Yes, wow, so the mesorectum is there. Right, and you see how the rectum used to be sort of C-shaped and hugging the sacral promontory, and now it's kind of starting to straighten out, so back up the camera just a little bit, and we're going to get oriented here and figure out how much more we need to go, and it's a lot more, yeah? So I'm going to start taking a bit more of these lateral attachments, and just keep going. And so, I'm going to do a little bit here, and then we'll decide what way we need to push the uterus, or stitch the uterus up, or just hold it up, or whatever, but for now, I can see what I'm doing, so I'll just stay with my view, and then when we start losing view, this is where your 3D camera helps you because now you're going to go posterior and lift your hand up a little bit, and that will get you the view underneath the rectum, so lift your hand up more so that you can see that space, whoops - all right, so come out and wash. This is a good view, stay put. I'll try and get myself in, and I'll just start taking these first because I see them, so why not. And- you can see, you know some people think that this case is a good practice for robotic surgery and getting comfortable with colic dissection, and it's a big mistake because obviously there's no real mesorectum here. The anatomy is very different in terms of wideness of their pelvis, and the cul-de-sac, so it does not prepare you for rectal cancer surgery in any way, so it's - but I guess it teaches you how to set up your robot and things like that, but I would not recommend this case as a case that makes you an expert in treating that other pathology. Completely different sort of challenges here. And the biggest challenge here is not the dissection of the mesorectum, but this redundancy and stretchiness that keeps going and going and going, so I'm going to have you let go of the rectosigmoid for now, and actually instead, kick the uterus up for me a little bit. Just so that I can see. Oh yes, great, and I want to point out another feature of prolapse, and that is this.

This here is the pouch of Douglas. It's incredibly redundant. It's essentially her hernia sac, right? And it keeps going, going, and going. And it's only here that you can start seeing the vagina, you see that? And it's super redundant, so back up, and we're going to score anteriorly, along this pouch of Douglas, so even though we're doing a traditional suture rectopexy, the proper mobilization of the rectum still requires complete anterior dissection, okay? This is not- it's not sufficient to only mobilize the rectum posteriorly because actually, the majority of the pathology start anterior. I also want to point out that even though she's a small woman, and she's not morbidly obese, because we're going so deep in the pelvis, I am using the long laparoscopic instruments and the long harmonic as opposed to the short ones because you can see how redundant this is, and how it's in there. So all of this is a redundant pouch of Douglas, you see? This is not the rectum. The rectum is underneath. And obviously, I don't want to march into it by mistake, but all of this is pouch of Douglas, and I just have to separate it. And sometimes we excise it. Sometimes we don't. Hold this side. But this is part of the pathology of this disease. These incredibly redundant tissues right in front of the rectum, and this is where the prolapse goes through. And so I have to free all of that. And then we will, at the end, create a new pouch of Douglas with the help of our gyn team that will be elevated and hopefully keep the bowel from falling in into this dark hole all the way on the levators and keep banging on the rectum, the resuspended rectum, every time she tries to push and defecate. And that will decrease her risk of recurrence, we think. A lot of this is hypothetical because there is no randomized control trials on this disorder, so there's a little bit of "I do it this way," and- I'll take another grasper, and "you do it that way," but there is definitely consensus that rectal prolapse starts anteriorly, and that if you don't address that anterior portion, and you only focus on stitching the rectum up, the recurrence is higher. Okay, so go back, and let's see, what did we do here? So I separated the pouch of Douglas a little bit, right? And you can see that by just doing that, right? Now this layer, look at the sacral promontory for me, reaches almost to the sacral promontory, and I haven't even gotten to the levators yet. I haven't even freed the left side, right? And look here now, come in closer with the camera, and let's point out this incredibly deep space here, so where is the uterus again? It's all the way there, right? This is the cervix here, this is the vagina, and you can see that there is an empty space that goes all the way down to the pelvic floor. See this? All the way here, down. So, you could actually push on the perineal body, and see that- don't back up because I want to take this just a little bit more here. I'm going to take these attachments here, and then we'll go posterior and work some more. All right, show me here, try not to get smudged. I'm going to take this a little bit more. Try not to be too lateral to the rectum because I don't need to. And then we'll pull the rectum up again and see how much more freeing we can do. See? All of that can go. Can I ask for a favor? Can you put a finger in the vagina for a second, I just want to point out the anatomy here. Yes, and pull up on it. So that shows you the space between the two structures, and you see how little connection there is between the rectum and the vagina other than the cul-de-sac. It's very loose, you see? All right, thank you. I think I'm pretty happy with my anterior dissection, but I still have to work on the posterior dissection, so back up with the camera a little bit.

Look down and turn the view so that we are looking normally, and now as I straighten this out, you can see that my lateral attachments of the rectum are still intact here, so I have to take all of those. Those are the so-called "lateral stalks." You're going to see a lot written about them in the rectal prolapse literature, and the reason they are so much talked about is because there is this suspicion that by taking them you increase the risk of postoperative constipation because of the parasympathetic nerves that travel in the lateral stalks. Now this particular patient has diminished anal pressures on anorectal manometry, and a little bit of urgency to start with. And so, causing a little bit of constipation postoperatively is actually potentially to her benefit because it decreases her chance of having fecal incontinence, which is another disease the coexists in these patients. And so I don't mind lysing the lateral stocks. The advantage of taking the lateral stalks is that it decreases recurrence rates, so when you can, it's better to take the lateral stalks than leave them. And the only times I don't take them is when there is a significant concern for postoperative constipation because somebody already has severe constipation, and she doesn't. So I'm just going to take that little puddle that I created and evacuate it because I had a little oozing there, and then we'll keep on focusing on those stalks. And again, you can see that by now the rectum is sort of free-hanging, right? It's pulling up, it's pulling up, it's pulling up, and so I just need to make sure I don't march into the rectum, but I'll take these attachments a little bit more, and then probably free a little bit on the left side. All right, so show me here. Hi Mr. lateral stalk. You can see that by taking it, I get a lot more stretch. There is no blood supply to the rectum in the lateral stalks, so you are not devascularizing the rectum. That's not the concern. The blood supply to the rectum is not lateral, it's superior rectal artery and the hemorrhoidals. So I'm not doing anything to her blood supply, but to see how by taking them, I have gotten a lot more mobility, so now let's look on the left.

So we're going to find the lateral attachments. And we'll get a little bit of mobilization on this side, and you can see the challenge is the redundancy of everything, so I'm going to reduce the small bowel again. I'm going to put you on a sidewall with your grasper for a second, just to get a little counter-tension, and maybe the fallopian tubes and ovary too while we're at it, and I'm going to look here, John. And again, I don't have to actually clear the sacral promontory on the left, there's going to be no sutures on the left, but I want to free the rectum on the left. And so, since I am on the left, I have to be careful for various left-sided structures, and the most important one is going to be the ureter. And so we're going to keep an eye out, and stay very shallow. At some point we'll see it, I don't see it quite yet, but I also know that I'm nowhere close to it quite yet, so I'm safe right there. I'll take a grasper again, I'm just going- I use the grasper to allow me to sort of pull tissues back and forth a little bit, and to get a little bit of air dissection going, and that makes it safer. Okay, so anyone spotted the ureter yet, guys? Because I haven't. Let's see, she's thin, so we might see it. So that's the left iliac artery. That's the left iliac vein, see it? Vein. Artery. And so the ureter needs to be right there, now I see it. Yep. Okay, so I'll stay away from that. And I'll keep on taking the peritoneal attachments of the rectum on the left. Rectosigmoid on the left. And you can see how redundant things are, so that you keep thinking well how much longer do I have to do this, you know? And it just keeps going, and going, and going. Okay, come in closer. And then I'll grab again and pull. and do you mind picking up here, and now I've got my direction sort of shown to me, I just need to connect those dots. So come in closer, so we can make sure that we don't do anything bad, and then keep scoring the peritoneum. Come even closer with the camera. And you see this blackness? It means that I've dissected on the other side already, and so I can connect the dots, and that will get me to the other side in a second. You see? Now, the left and the right are talking to each other, which means that I can take this a little bit more. Come in a little bit, yeah, thank you. All right, obviously I need to be careful not to march into the rectum- that's not stylish. Bowel grasper? Let's kick the vagina back up. You see? And that gives me the remainder of the target, and do you see that bowel behind? So she is so redundant that the bowel is just going to start sliding behind the rectum, and that's something that we need to remember when we are finishing up this case because- and the advantage of doing the culdoplasty that we'll be doing at the end is not only the resuspension of the anterior cul-de-sac, which is an important reason to do it. But it also decreases the risk of postoperative small bowel obstruction, and so even if we don't do a formal culdoplasty, I would close the peritoneum in these cases, and that's something that people debate back and forth, but that's the reason I do it. It's not a step that's essential for suspension of prolapse, but I think it just decreases the risk of long-term complications like small bowel obstruction, and there is nothing more difficult than dealing with a small bowel obstruction deep in the pelvis, you see how deep we are here, you know? When the- When the content is posterior to the rectum after you've resuspended the rectum, so that's why I think that that has the extra benefit. Back up again, let's get an idea panoramically what we've done already, so now the rectum is straight, out of the pelvis, and we are probably almost ready, I just want to just a) I have to decide if I want to take the left stalk or not- if I take both stalks, the rate of post-op complication and pushing is higher than if I only take one, and I'm pretty happy with the dissection here, so I'm not sure that I'll take it, but I want to look here and see if I've actually gotten all the way to the coccyx or not.

Yeah, and so I'm going to have you go upside down with the view, and then you're going to wiggle in here and look around here like this, see? And then I can take these little posterior attachments of the rectum just an itsy bitsy bit more. Carefully, obviously, but I think that by doing that, see? I can mobilize the rectum posteriorly just a tiny bit more, and encourage a little bit of additional straightening. All right, I have a little oozing there, that should stop. I'm not going to perseverate over it, I'm keeping an eye on it, but I'm not perseverating over it. And you can see, now I am right next to the rectal wall, but this is not rectum so I can take that, and I'll look at this here and finish this bleeding because it's irritating me. Okay, so back up panoramically, let me grab the rectum and pick it up, straightening it out again, taking a look. I really like what I see, and when we're done, this pouch of Douglas is going to be way higher than where it was before because it was all the way on the perineal body, right? And so, why don't we get ready to suture?

CHAPTER 6

Pull the rectum for me, and then I also need to decide where on the rectum I want my sutures, and I usually like to use the pouch of Douglas for my benefits, so there's all this redundant tissue here, see? And show me the sacral promontory again? It's there. Because what I need is this tissue, this tissue on the sacrum. So, can I get there? Not quite, and so if that's not going to come, then I'm going to use this tissue, but I have to decide ahead of time what is it that I'm resuspending, so show me sacral promontory again. We're going to be coming here, right? And show me the rectum again, there. So, obviously, it has to reach. And so- because there's no benefit in putting the stitches so low- that's going to be it, right? A lot of tension. Okay, I will start with the needle driver on the sacral first, so we're going to be coming here, last time to decide on whether or not I see I'm going to take a look again at that vein, make sure I know where it is. I think I can clear out that space just a tiny bit more. See how I can take that strand here and that might get the vein down- up a little bit, so show me right here. It just will give me a little bit more exposure. Oh yes, oh yes, because now I can push the artery and vein up a little bit if I need to, to get the stitch here. I like this view.

So if you load your needle driver needle right on, next to, like she did for me, you see even though I'm not holding the needle, the needle stays pretty sturdy, and so I can now grab it, but you need to come in just a little bit closer with the camera when I'm manipulating the needle, so I have a little bit more of the 3D feel, even though it's not 3D. And now we'll look here, and here's that sacral promontory, and here's the vein, right? So this is my target, I push in, I have a good feel. That's pretty sturdy. I could even make it a little bit deeper, yes? Generally, you don't want to move the needle in-and-out too much because you can stir up bleeding, but at the same time you want to be happy with your bite, and so I'm pretty happy with this bite, I'm going to reload the needle. I'm going to bring it down- by the way, is the next stitch a zebra or is it a regular stitch? A zebra, awesome. No, is it a zebra, can you make it a zebra for me? Okay. So, what I'm going to do is remember how I said that I like the pouch of Douglas? I'm going to load some of this redundant tissue from the pouch of Douglas. This is going to be what I use for my suspension. Yep? And I'm going to push it through. I think I want just a little bit more. Because remember how we're not sure about the tension, so I'm just going to get a little bit higher, more of the stuff- oops, don't spear the rectum. All right, pick this up again, push it through. See, close to rectum, but not in the rectum. I'm going to pull this out. Okay, let me pull this out. I'll take a SNaP, please, and a scissors, and then I'll take the second stitch. I'm not tying these until I put all the stitches down. All right, so show me promontory, and I see the vein, and I'm going to try not to spear the vein, I'm going to go here, so back up the camera just a little bit, yep, thank you. And push, turn my wrist. Am I happy? Not a lot. I think it's a flimsy bite, so I'm going to not pull it out this time just because I don't know if it will ooze or what, but I'm going to take one more bite on the promontory just so that I'm happy that it's not going to pull out. Please note that my stitch is black and white, that's called a "zebra" stitch. It's just- a marker that the nurse puts on the white stitch beforehand to make it striped, so that I can tell which stitch is which when I'm working with it later in tying my knots. Okay, so this is going to be a little bit higher than the first one, I'll put it there. I'll take a little bit of fat, but mostly the things that are going to hold this in space are going to be this perirectal peritoneum, okay? And- one of the big debates is do you grab rectum itself or do you not grab rectum itself. I am on the don't grab the rectum wagon because I don't know that that adds any sturdiness, and I worry about all the expected complications. Okay, you can let go of the rectum now.

And gently I'm going to pull this out, and now we're going to do extracorporeal tying, so let's cut this, and I like to throw all of my knots ahead of time so I do a surgeon's knot first, so that's one. I leave a little space, and then I do two, three, four, five, okay? Then I take the snap and I put it on, it's my little handle. It gives me a little stretch, and now I'll take the knot pusher, that's my finger extender, and I gently start pushing these knots down, and I push the zebra first because it's a higher tie. All right, so it's sliding, and I'm pushing, and I'm pushing, and I'm pushing. And can you please keep that small bowel out of my way, and then straighten the rectum a little bit. I will do this, here. Just hold it there, John, with this hand, and that will give us, yes, exactly. So the first knot is down And now we'll just keep going. So, the second knot is here. The zebra's are funny because they confuse you a little bit, but here's my second knot. And then here's my third knot coming down, and I just go over the small bowel and- okay, so the reason this bowel gets in the way a little bit is because we lose a little bit of pneumoperitoneum every time I have my instrument in, and so I wait a little bit between each- oops, caught, uncaught, down. Okay, and then the last one is going to be number five, and then we'll take suture scissors, laparoscopic. Okay, so those are my knots, you can see them there. We're going to cut this so we're not tripping over it, and I know what to cut because it's a zebra, so that's the benefit of the zebra. Yep. And now I can do the second one. And I'll leave it long because then if I have a failure later on I can figure out why it failed. So that will be the second one. So again, one, two surgeon's knots, three, four, five, six, whatever you want. SNaP. And let's tell Emily that we're ready for her. I'll take the knot pusher, please? So I'm going to push this knot down 1, 2, 3, 4, 5, 6, 7, 8, 9, here it goes. The rectum is on stretch. It's quite resuspended. Because this is a surgeon's knot, it slid a little bit, but that's okay because I'll push it down with the next one, you know? Here it goes. Okay? And then I'll do one more. Again. Three, four, five. That's it, I think. Scissors? Okay, so that's it, that's the operation.

CHAPTER 7

And while we're waiting for Emily, we're going to just take a look and make sure we're happy, that we haven't done anything bad, and also I want to point out all the dangers of stopping here and closing, right? So I don't need to resuspend the left because the left is going to be resuspended during the culdoplasty. Okay? And it will then end up looking like this as opposed to turned. This turn, people think, can cause, you see how the bowel can go there? It can cause an obstruction right at this location, so there's solutions for this, and one of the suggested solutions is to do a sigmoid resection, so you don't have the sigmoid colon posteriorly and you have a straight line, but then you're adding a lot of morbidity, okay? And if you just take another stitch, and you put it here, it's going to look pretty, but it doesn't prevent the small bowel from going in there, and especially in her where we started with a significant enterocele, something else needs to be done, and this is where resuspending the posterior vaginal wall just a little bit, which is what Emily's going to do, here, and closing this entire space, all of it, by bringing the peritoneum across like this, and like that, see? Suddenly the bowel won't have anywhere to go, and as long as we don't capture the ureters in those sutures, which we won’t, you see? Then the new pouch of Douglas is going to be all the way here, sigmoid can go across, yeah? And it's just going to restore it to the more normal anatomy that she wasn't born with or that she developed, it's unclear. And then the rectum will be straight like this, resuspended and straight because right now it's resuspended, but it wants to fall in, into that cavity. Okay?

CHAPTER 8

Yeah these together- this… Yes, she's so stretchy, huh? Yeah, we will, we'll close that all. Perfect, yeah. And we'll incorporate the uterosacrals. Yes. Yeah. You're saying close up higher? To resuspend, so that… Oh yeah, yeah, yeah. Oh yeah. If you can resuspend the top of the vagina… Yeah, I'm going to grab her uterosacrals. We're going to- we're going to do a more of an obliterative procedure because she's so, we won't totally- I mean, she would be a perfect colpopexy, but she's not sexually active, so yeah. But yeah, that's what we'll do, we'll grab this, we'll put all this together. We'll just purse-string it. Oh yeah, that's nice. Could've been a nice colpopexy, all right, okay, perfect. So I was thinking about just like reefing around the uterosacrals around as like a purse-string and closing it that way because we're not suspending it just…

CHAPTER 9

Like this? Yeah, right here. So, it's deep. It's really deep. Yeah, that's good. I'll grab that for you, yeah. Mm hmm. Good. I'll grab that, you got it? I'll grab it for you. Mm hmm. Don't go- don't lock it. Okay. So Dr. Bordeianou did a lovely job suspending her rectal prolapse, so suspending the rectum, so what we are doing now is we are going to be closing off this very deep cul-de-sac as you can see here, so this is the suspension procedure, which you saw prior attached to the sacrum. So now what we're going to be- Can I have a Marilyn? Is closing off this deep space. This patient is not sexually active, so we are not going to do really a suspension of her vagina for her, we're going to go below after we close this off and actually do an obliterative procedure. In someone who is sexually active, we would be doing something like a colpopexy, a sacral colpopexy or a uterosacral ligament suspension in which we are suspending the vagina. So right now, what we're really doing is we're closing off this dead space to prevent the small bowel and the large bowel from coming down and causing a recurrence. Yep. A little bit bigger. Mm hmm. Good. Good. It's rolled here, let's get that roll out. Just the edge. Mm hmm. The edge is down here, so you're going to roll that out. So we're going side-to-side, grabbing peritoneum, we don't want to go too lateral. The ureters are lateral. If you go too lateral, you can pull the ureters, and then you can cause some ureteral kinking So we're really just grabbing the peritoneum. Good. Travel a little more. So let's run it now, we'll do a purse-string around, and then we'll go below, we'll go and we'll finish that. Mm hmm. I should have used a 6-inch, you're going to lock yourself. Let me grab it for you. Mm hmm. Yeah, there we go, good. Okay. And then if you want to just grab actually right, yeah. Grab that out. Yeah, perfect. Yeah, and then I'm going to go, yeah, exactly. I'm going to try to- yep, let go for a sec- yeah. Get that to come out. I'm not going to be able to get that. Yeah. Yeah, I'm about to backhand that baby. Now up with that probe, in and up. In and up. Yep, good. That's fine. All right, so now let's try to- she does, so let's pull. Let's pull this suture. Liliana, will you help me pull some of this suture out? We'll try to start- Yeah, there we go. Good. Taking this slack out, so we'll start seeing a closure here. Yeah, nice, beautiful. Awesome. Yeah, thanks. So see now how we're closing that. So no we're going to have to go back and kind of close so the bowel doesn't sneak in there, but, all right. Okay, so let's go back now, down, let's grab that, yeah thanks, that's perfect. Get in there. I think we can grab, I think there's an edge here. A little bit. Oh, no. Yeah, that's good, that's it, yeah. I'll grab- yeah, perfect, yeah. Got a big… Okay. Okay, do the same thing. I'm going to go kind of right behind you, yeah. So let's pull this- V-loc a little more. Yep, good. Nice, okay. Yeah, I'll pull that up more. Good. Now I'm going to go side-to-side there, close that little. Yeah, nice, love it. Love it. I'm going to- yep. Yeah, grab that out for me. Yeah. Okay, now we'll pull that up. Good, so now you can see how this is really coming together nicely, that big huge open space is now becoming closed, so… You want to grab that other side again? Thanks. Thanks. All right, that should do it. Impressive. So we're going to cut this. It's going to go out in this part. Okay. Mm hmm. Yep.

CHAPTER 10

So what you're doing is you're now connecting this to this to this. That will complete your pouch of Douglas. Mm hmm. Do you want me to go a purse-string again or side-to-side? Side-to-side because now… Right, it doesn't look like it's constricting, right? Here to there, there to there. Yep. So at this point, side-to-side, but the side is the rectum, not the other side. Oh, got it, okay, oh, yeah, yeah, yeah. See what I mean? Yeah. Not worrying about that left side at all. Cool. Okay, yeah. Right on peritoneum here to rectum to... To the, yep. And that finishes the pouch. Right, that we've disrupted, yeah, so... Come in closer with the camera. Set me up for success. Thanks. All right, let's pull that so it doesn't get in our way. Yeah. ...so you want to grab this is in huge bites, obviously without… Big, okay. Do you sometimes excise the pouch? I sometimes excise it, but… Come in closer with the camera. You got it, yeah. I can come in, it's all right. Let me just... Oh yeah, thanks. Good? Yep. Awesome. Yeah, if you grab that little- see that tag a little higher? Yeah. That, yeah, that's fine. Yeah, if you just pull that out more lateral- make me in the center of the screen. Good. So nice, we're grabbing- so you can see we're grabbing just peritoneum here, we are going a little bit deeper on this- a little deeper on the rectal side, closing off again that dead space. So the nice thing about a V-loc suture, this is a barbed suture so it kind of grabs the tissue around it, and you don't have to tie knots after using it. It locks itself. Yeah, it looks nice. That's really nice. So now it shows you… Where we are, yeah it shows… You go across left and right here, and then close the left side. You see what I did? Come back up. Yeah, so across the entire peritoneum. I'm stuck here. If you want to grab it again for me, that spot that… Yeah, towards you. Thanks, and I can sneak in behind it. That, there. Yep, that's good. Come in closer with the camera. And then pouch of Douglas and then left peritoneal wall, so back up again so we can see. Show me what I'm looking for… I think if you tighten that, yep, and then we just- nice, perfect. As you can see, now we have to take the left side of the rectum here. Can you move that cord for me? So the next one can still be a generous one, but then after that we'll start taking smaller bites because… So you want to go to the left side of the patient, right? Yep. Let's pull - yeah. This is now peritoneum, not pouch anymore, so we can take smaller bites. You want me to grab still on the side though, yeah? Yeah, oh yeah. Yep. Yeah, the cinching, yeah. I think we're good- get that little part and then go back and grab that peritoneum. All right. It's all feel. Yeah, I just want to get, I'm going to go… Let's get this little… I think we'll be okay here, we'll need the scissors up. Yeah, we'll probably need another one. You happy? You want to go… I am debating whether or not… We want to… One right through here because there's this pocket, so maybe put one through here because it's supposed to be on this side, and that will make the pouch even less… Grab that- wow, she does have a really deep pouch. With this suture? Reef it back around and just.... Yeah, just come around with this one. Okay, yeah. But you see what I mean about the cul-de-sac needing to disappear. Yeah. So let me see if I can- maybe I'll come back here first, just so you don't have too much of a… So, you might want to pick this up. So we'll make a- I'll grab this side. I would pick it up now, it's going to be really hard to pick it up later. Okay, but that's going to be the last one, I think. That really does elevate it, yeah. Mm hmm. Just straighten that... Yeah. See where the small bowel needs to go. Come in a little closer, Marcus. So now, it's just the peritoneum on the left side. That, yep. And then that's right on the sutures. And then we go above the sutures and close what's left. Okay, let's just pull this because they did a little… Ohh, yes. Helps, helps. Now it just sits, yeah.

CHAPTER 11

Nice, so the pouch of Douglas is closed, now we're just continuing to close the peritoneum here. So one just there, and then one with all this above the stitch. Got it. So now I'm not worried about the rectum falling in there anymore, and- the only thing left to do is… Okay, can you show me that side? Somehow. Let's see- yeah, if you can retract that bowel away. I'll just grab that, yeah, Yeah, yeah, yeah, yeah. I'll just grab that. There it is. You're going to- no, don't, it's all right. I'm just going to grab this because I don't want to lose it. All right, here you go. See, so now? I will reduce everything out, tighten it, and that's all we need. Yeah, nice. And it's not tight to the point where the bowel can't move, it's still moving, so I'm not worried about obstructing, but I'm also happy because now no small bowel is going to go through. Right. Still going to go in here. Right. So you still have a pouch of Douglas, and it's not a small one, right? That's right. But it's significantly smaller than it was before. Good. So the peritoneum is closed, the rectum is suspended, the pouch of Douglas… March down and just get across that little hole there. Yeah, yeah. I can do that. I'm just going to march up. Yep, now we have it totally closed. And we've gone back on the V-Loc enough times so that it locks in, so we can cut it.

CHAPTER 12

As you can see here, so she- her front wall, she doesn't actually have any anterior or apical prolapse. Her back wall is also very straight, but she does have this, when I do a rectal exam, she has this pocket here, and this very, very, very weak perineal body, so what we're going to do is we're going to build this back up, and she is not sexually active, so we're actually going to make her opening quite small, we're going to do what is called a levator plication, meaning that we're going to bring the levator ani muscles together, and that actually does help prevent prolapse from coming back. But it precludes sexual intercourse, so you only can do this in women who are not sexually active like this patient.

So we've kind of set us up for a triangular incision, which we're going to make, we're injecting now with a dilute, we're injecting with dilute Marcaine. This allows for both hydro-dissection as well as analgesia. Can we get a suction for the bottom, please? Oh, thanks, perfect. So she also has this- this is a urethral caruncle, which is actually- looks like it's starting maybe even to have a urethral prolapse. So she definitely has some collagen/vascular disease that's causing her prolapse for someone who's not had children.

We're actually just going to do a perineorrhaphy. She doesn't need any anterior support, so we're just going to do a really big perineorrhaphy with a levator plication and build up that perineal body. So she is good. Mm hmm. And go up more of like a butterfly, up to the Allises. So now we're undermining underneath the vaginal epithelium. So we're going to do a little posterior repair or posterior colporrhaphy. Epithelium, you can just cut that off. I'll take a little bit less T-berg. Less T-berg? Yep. So the ports have been closed by Dr. Bordeianou and team. So we're dissecting the muscularis tissue off of the epithelial tissue to plicate in the midline. So below us is the rectum, so we're making sure we're superficial along the epithelium. We do not want to get into the rectum. Vaginal surgery is all about traction, counter-traction, so I'm providing counter-traction to the traction, which is allowing us to find our plane, where to dissect. Okay, that's good. So there really is no perineal body here, it's like nothing, so we're going to build that back up. All right. Let's tag the apex. Can we get a 2-0? 2-0 Vicryl? Yeah, and a CT-2?

Just get the epithelium, yep. Mm hmm. Yeah. We just have to cysto after this. All right, let's do one more, and then we'll do our U-stitches. She does not need muscle relaxant anymore. I'll take that 0 Vicryl.

So we just tagged the vaginal apex because when we do this extended perineorrhaphy with levator plication, it's difficult to see the vaginal epithelium, so if you don't tag it, you struggle closing the excision, so that's what we just did, we just tagged it, and now we're going to bring together the levator muscles, and thereby making the genital hiatus smaller, and building back up the perineal body. Let's take these off. It's deep in that. That is deep, grab that epithelium. Same thing, deep underneath the… Do you have more of these? One more?

So what this does is it kind of creates what I call a shelf, so if you put your finger in the vagina, you can actually feel that you're building up a shelf, which is not something you again want in someone who is sexually active, but in someone who is not, then that's what you kind of want to feel, you're just building back up that body of muscle, the perineal body. All right, cut that. Right, exactly, under. Dive kind of deep and then up. Mm hmm. Same thing on the other side. Mm hmm. Deep to deep, yep. Mm hmm. Yes, good, that's going to get a good one. It's coming nice. Okay, tie that, and then we'll feel if we want to do anymore. And our cysto is set up? Awesome.

So I can put- it's really, you know, one finger in. So her genital hiatus is quite narrow. Now we're going to close- we can give her the… This is a 70 degree, right? It's the 50 that comes in the... Okay. Good, nice. So now we're just closing the epithelium. I'll take a wet Raytek. Try to go- can you try to dive underneath that skin, sub-q. I like to tie the knot behind the hymen so that they're not sitting on the knot. Good.

So, you can get one finger in so you can do an exam. We've built back up the perineal body. When I do a rectal exam, the perineal body is now built up. And we also make sure that there's no sutures in the rectum at the end of the procedure. I need another right glove, please.

CHAPTER 13

So, we're doing a cystoscopy now. We want to make sure that we see the ureteral jets. Again, when we were doing that laparoscopic procedure, you can have ureteral kinking when you close that peritoneum, so I want to make sure we see nice ureteral jets, we want to make sure we see no stitches in the bladder. The patient got Fluorescein, so that will allow us to see the ureteral orifice and the stream of urine coming from the kidneys. So let's look at the ureteral orifices first, if we can find them. There it is. Right there, so focus, and you can fill her a little more. Here we go, so there is nice, neon green, that's Fluorescein, that was given IV. So that was her right ureteral orifice, so her right ureter is working, so now we're going to look at her left. There you go. It's going.

CHAPTER 14

So you just saw a standard suture rectopexy, and the key points there is full dissection of the rectum down to the pelvic floor, both posteriorly and anteriorly. I can't over-stress the importance of anterior dissection. After the suture is placed and the rectum is resuspended, it's always a good idea to close the peritoneum, and if the patient has an enterocele, to also close down the pouch of Douglas like we did in this operation. You have to think about closing the pouch of Douglas, to plan for it, and I advise involving your urogynecology colleagues in this step of the procedure because sometimes they might also want to resuspend the posterior vagina with or without mesh. I think it's really critical to have a conversation with the urogynecology team every time when one addresses any kind of pelvic organ prolapse, including rectal prolapse, because so many of patients with this condition have coexisting pathology, and if you don't think about it, then you only fix half of the problem, and then that patient may need another operation at a later time. We've gotten quite systematic in our approach about addressing these patients, and discuss each of these patients before they go to the operating room in a multicenter multidisciplinary team meeting. It's essentially the same thing you would expect for a cancer patient except in this case it's for a pelvic organ prolapse patient where we sit in the room with the urogynecology team, with the gastroenterology team, with the urology team, with the physical therapy team, with our radiologists, and we review the pathology and come up with a plan that make sense and addresses each of the compartments, and I think that that's critical in ensuring the success of an operation.

Postoperatively, the course of recovery in these patients is actually straight-forward, and in young patients we routinely send them home the same day. She's a little bit older, and she might stay overnight- we'll see. What we usually do is in the recovery room we do what we call a gyn voiding trial where we fill the bladder with fluid and then we see whether or not the patient can empty their bladder. Sometimes there is a little bit of a delay of emptying, and if that's the case, we keep the patients overnight, and we try again in the morning. Sometimes even in the morning the patients can't empty their bladder, in which case we end up having to send them home with a catheter for about a week. Presumably because we're disrupting the parasympathetic innervation to the bladder when we're doing the dissection, but fortunately, that's very rare, and that's probably the most common complication. Other than that it's the usual - infections, abscess, which are thankfully incredibly rare. Yes, in theory you could perforate the rectum during the dissection, which would be a disaster, and that would require a laparotomy and even a temporary diversion. And finally, if you don't- especially if you don't close the peritoneum, you could get an early small bowel obstruction from the small bowel falling into the space between the rectum and sacrum, posteriorly, and getting trapped in there.