Altemeier Perineal Proctosigmoidectomy for Rectal Prolapse

CHAPTER 1

Rectal prolapse occurs when the rectum extends beyond the anal muscles. We are demonstrating a perineal proctectomy, or Altemeier procedure, for rectal prolapse, with the patient in lithotomy position. The rectum is prolapsed out of the anus. The anal canal is exposed with a retractor, and the dentate line is identified along the anal canal. The prolapsed rectum is scored about 2–4 cm above the dentate line. Epinephrine is injected for hemostasis. Dissection is taken through all layers of the rectal wall. The anterior rectal wall is visualized with the mesenteric blood supply on either side. The rectal edge is everted, and the lateral mesenteric attachments are divided close to the bowel wall in order to deliver more of the rectum out of the anus. The filmy pouch of Douglas is opened in order to enter the abdominal cavity and palpate the sigmoid colon. When there are no more redundant loops of sigmoid colon, we can identify a location for transection. Before transecting the rectum, a levatorplasty is performed to narrow the pelvic floor muscles. This is thought to help with postoperative bowel control and procedure durability. The pouch of Douglas is closed and the prolapsed rectum is divided. Sutures are placed from the proximal to the distal rectum in the 12, 3, 6, and 9 o'clock positions. Intervening sutures are placed circumferentially until there are no gaps within the anastomosis. Marcaine is injected at the end of the procedure as a pudendal block for postoperative anesthesia.

Hi, I'm Dr. Brooke Gurland, and I'm a specialist in colorectal and pelvic floor, and I see a lot of patients with rectal prolapse. This case is a patient who had a large rectal prolapse, and she will be undergoing a perineal repair for rectal prolapse. So essentially there's two main approaches when dealing with rectal prolapse, either an abdominal approach or perineal approach. And the approach that we choose is based on patient features, prolapse features, as well as some other characteristics. In this specific patient, she's frail, is limited to a wheelchair, has some other limitations. I can't remember her age offhand, but is over 70, although age in itself is really not a criteria for choosing a perineal approach. In my opinion, a criteria is based more on frailty. In the perineal approach, that means I will be removing the rectum from the perineum or from the rectal area, and I have two main ways of doing that. One is to remove the full thickness of the rectum. The other is to remove the inner lining, or the mucosa. One is called an Altemeier, the other is called a Delorme. Based on the size of the prolapse, I'm going to choose one versus the other. In this specific case, the prolapse is quite large, and she will get an Altemeier, which means I will cut across the prolapsed segment, remove the prolapse, and then suture one end of the rectum, or sometimes it's even sigmoid colon, to the distal end of the rectum. And that is essentially a coloanal anastomosis, so it's a very distal anastomosis. Seems strange to do a very low connection, especially in a frail patient, but overall, the complication rates are quite low and well-tolerated by patients. This is a case of an 80-year-old woman who complains of fecal incontinence and a feeling of pressure or bulging from the rectum. She reports a lot of pain in the area. She's actually wheelchair bound, and she's constantly sitting on what she feels is a bulge, which is actually the rectum that is prolapsing out. This is really what's motivating her, is the pain associated with it. It's been present for about 2–3 years. She has multiple medical conditions, which put her at a high risk, more of like a ASA III, a high risk category for surgery. And after an evaluation and finding on physical exam findings consistent with rectal prolapse, she's undergoing repair. So preoperative workup for individuals with rectal prolapse is a little bit controversial, in the sense that if we see the prolapse, which either the patient can demonstrate on exam in the office, sometimes they have a cell phone picture, some sort of selfie, once I know they have the prolapse, do I need to do further evaluation? So, recommendations say it's dealer's choice, or surgeon's choice, for that matter. And the testing that could be considered would be something called anorectal manometry, where we check pressure testing, also rectal sensation and function. And another test would be a specific type of either MRI or fluoroscopic defecography. Those are imaging tests. The tests can help give us some information about the anal sphincter function. And so, in someone with fecal incontinence, they might have a weakened sphincter and that would give us some baseline information on both sensation and function. And then the imaging studies can help show if there's either additional vaginal prolapse, or a cul-de-sac hernia, or some other findings, pelvic floor findings. I specifically, in very frail patients, do not get additional imaging. This is very difficult for the patient. It's hard for them to get around. Sometimes they have caregiver issues. So, if there is a frail patient, such as in this specific case, I do not require additional testing. However, when I do the bigger abdominal cases, and there's multi-compartment prolapse, that might be a different story, and I could potentially change my mind.

CHAPTER 2

All right, so just from a consideration about why we chose this positioning: I can actually do this operation in the prone or in the lithotomy position, but in this specific case, she had some neck issues and there were some other things that made her frail that made us want to opt to do it in the lithotomy position opposed to a prone position. You know, we really go case by case, patient by patient, as far as what's going to be best for them. It will be in lithotomy position, and then we'll sit between the legs to do the operation.

So this is her exam before the procedure, and now I'm going to deliver the prolapse. And this is her full-thickness rectal prolapse, and that's what we'll be removing.

I like to give myself exposure first, and so I am going to use this Lone Star retractor. And the Lone Star retractor will expose the dentate line. Let me see if I can do it this way. Can I have the table up a little bit, please? That's fantastic, thank you. All right, and can I get a tray for this case? Can I get a tray for my lap? All right, and then I would get ready for me the Marcaine with epi or just a little epi, phenylephrine. I use that to help with hemostasis because the rectum is highly vascular, and so, we inject to help with hemostasis. All right, and then can I have a Debakey, please? Or anything. Yeah, Allis is fine. I want this.

Okay, so just to see, look at the anatomy, this is the dentate line, this differential right here. Again, that's exposed, the dentate line. And now I'm going to deliver out the prolapse, which you guys have already seen. And now I'm just going to kind of use this - I prefer a Babcock, if I can have it. It's a little gentler, if you have one. Just take a Babcock to hold that. And my first incision, what do you have the Bovie on? 30/30. 30/30. Okay, so you could put it at 45/60. So, I'm probably going to go somewhere around here. This is about 2 cm. I like to leave myself a little ledge. I'm going to go all the way around, I'm going to mark that out, and then I'm going to put local in there. So, I'm just going to score this, so I just can see, and then we'll put the local. So you can take the local in your hand, go grab the local. Great. And then, table up just a little bit, please. You want the table up? Yes, please. Okay. That's great. And I'll take another Babcock, please.

All right, so you're going to give that local into that line. So, you're going to kind of follow my line around, and this is for hemostasis. So, you're going to kind of direct it this way. Sorry if I - okay. Yeah, go ahead. And inject all the way around and just use the length of your needle. You know what I mean by that? Yes, okay, great. Then come out and now go to your next spot. So, it helps with hemostasis. Go ahead, I'm going to get - yep. You can change your - angle your body. There you go, nice. Uh-huh. Good, advance your needle, advance your needle. Advance your needle to follow that line. Keep going, keep going. Okay, fantastic. Now come over here. Actually, let's come down this way. So you follow… See that line there? So, I'm about anywhere between 2.5–5 cm. That's going to be my other - And then I'll meet over here, this last bit. I think we're okay. I think you got it. I'm going to hold like this.

CHAPTER 3

Okay, and you can see where this is prolapsed out and it's chronically irritated. Can you take the suction so we don't get… So, this can be pretty bloody, just to let everyone know. No, no, no, I'm just saying it for them. It's not for you, you're fine. Yes, you're fine. You're fine, she's fine, everything's fine. So, I'm going to go across until I see the fat - along this… I'm trying to make this kind of a clear cut - can you move this part of the Bovie? Yeah, this cord? So, I'm going through the layers. It's pretty thickened here. Go straight until I see the rectum on the other side. Okay, and I'm about to get to that. See this fat here? That's going to be - so these are all rectal wall layers, and I don't know if you could tell, I went like as a straight shot all the way through. Okay? Because what I'm going to do is I'm going to evert the rectum. Okay, and I don't want to get to the mesentery or the other - this is going to be mesentery over here. Okay. Okay. Okay. Let's clean this. This is the mesentery of the rectum on the other - when I say the other side, I mean the inside. I find it actually helps to go faster versus slower because it's just - yeah, that's exactly right. Like, I just have to wait until I can evert the whole rectum. Let's see, I just saw something kind of bleeding. Yeah. Maybe you can grab a DeBakey and see if you can grab that. That looks pretty good. We got it, I think. You want to grab it? You go ahead. You can grab it, and then I'll grab you. We're going to, yep. You got it. I got it? Okay. Okay, great. Okay. Can you adjust our light so we can see? And then suction here? Okay. I'd rather get through the rectal. Yeah, I'm going to come through here. Okay. I'm going to ultimately evert this whole part of the rectum, but I need to - can you hold this a little bit like this? Let me take a… This is always the tough - I just have to connect the dots right here. I don't know if you can kind of see that. That's where I have this left. Once I do this part… I really have no light in here, but I… Okay. I'll take this.

CHAPTER 4

Okay, all right, you can take the LigaSure now. Okay, so now, this is - I'm going to evert, so I see the whole rectal edge and I'm going to take this mesentery that's up against the bowel wall with the LigaSure. So something like that, I usually double. Yep. Uh-huh, okay. And then I got a little bit of bleeding here. Yeah, all right. I'm going to have you take this. Can I have a dry lap pad please? Thanks. Great.

Okay, and then we'll clean up. Okay, so you're going to take the lap - you're going to take the LigaSure. Okay, and I'm going to make you small windows. Okay, you can take the LigaSure here. Yep. You got it. There you go, nice. Go ahead, double buzz that, and then we'll drop it down. Okay, go ahead, cut. Very nice job. Okay, good. All right, so let's see. All right, can I have a little Trendelenburg, please? Great. Okay. Okay, that's good for now. Can you take the LigaSure and put it right here? Where my finger is? Uh-huh. Okay, I'm going to position you. Great, now buzz that. Okay, cut it, very nice. All right, so let's see. I still have a little band right here. And a little bit more Trendelenburg, please. I have a band right here. Okay, that's good, thank you. My light is really not great here. Just, I'm tethered here. Okay. Okay, I'm going to have you take the LigaSure here. Mm-hmm. Right here? Mm-hmm. Great, all right. And now, so the rectum is - so this is the fat that's going to get us into the pouch of Douglas. So we're going to open up here. And this will get us into the peritoneum and the pouch of Douglas. You're going to open up this band right here, uh-huh. Yep. Mm-hmm. Very nice. Okay, so let's see. So we want to get into, so let's see what I can show you here. Here's the rectum. I'm going to drop this down even a little bit more. So take your LigaSure here. I want to give you a kind of a good view, because the rectum was everted, and now we've come across, this is our distal - where our - just, go ahead, you buzz here. Go ahead, let's see, all right. So for us to get into - we're going to get into the abdominal cavity. We're not quite there yet. What I'm going to redo, do now is I'm going to reposition these hooks. All right, and I'm going to do that because this is going to be our distal anastomosis, so I like to reposition those. And, yep. Let's see. Sometimes I leave myself a little bit more length on the distal end, because they retract. I've got one here. We don't want to stick ourselves with these hooks. They're sharp. Okay, let's dry things off a little. Looks pretty dry, you okay with that? Dry it off. See what I meant about going fast? Like I'd like to go fast up front because it can be bloody? I think we're pretty good now.

CHAPTER 5

All right, so anterior, posterior, this will get us into the cavity. Can we get rid of the little - the Trendelenberg? So see, I want everybody to be able to see right here. This here - the - sorry, reverse-T, yeah. This here will get us into the abdominal cavity. So look, I'm going to show you, Can you get rid of this? I have like too much of them right here. Just move that a little bit away, thank you. Okay, so this is anterior rectum. This here is going to be pouch of Douglas. So let's just get into that. Let's just open it up. Can I have a Kelly or something like that? Yep. That's fine. Can you hold that like that? Okay, I'll take another one. Okay, I'll just do this. Okay, so this you're going to see, this gets us into… Okay, this is the anterior peritoneum, and now we're inside of the abdominal cavity. And this is really going to show us like if any sigmoid or if anything is looped. So this is a really good example of that, of the getting into the abdominal cavity. Okay, you can relax that now, you can just drop that down. Okay, and we're going to clear - you're going to take the LigaSure. And I'm going to just slowly work around the rectum and I hug the rectum because this is all coming out. So you're going to slowly kind of work your way here. Let me make you a better window. And then you'll… Okay, go ahead. Uh-huh, go ahead, a double buzz. Okay, good job. Let's see, all right.

CHAPTER 6

So what we're going to want to - you know, some of the considerations are going to be, how much do we take? You know? And that really depends on the individual, so this is the part that was prolapsed out. But how much of this - how high do we have to go? And one of the techniques - we say we want to get into the peritoneum and we want to see if there's a floppy loop of sigmoid. It seems like a pretty straight shot. I'm not feeling - oh, maybe, maybe a little bit here. I do not want - so I can kind of feel that there's some diverticula. I do not want to be on, I do not want to do a connection to diverticula. So I'm thinking if I could get somewhere up to here? So I'm going to kind of - I'm going to keep working, taking small bits of mesentery. And we're going to do that with this here. Okay, go ahead. Let me, yep. Go ahead, double burn that. Great. For me, the technique is to hug the bowel wall. You can come the other direction. Sometimes that will help. And then I just keep slowly working my way around and making you little windows and hugging right at the bowel wall. That's okay. So I'm going to come somewhere over here. This is taking a little of the pouch. Go ahead, you can take over here. Okay, good, all right. I need to be above here because you could see, I tore a little of the rectum there, but that's okay. I'm going to say that, based on this, I'm going to be somewhere right here is going to be where my optimal anastomosis is going to be. Okay, so, let's see. Okay, I'm going to have you divide here. Uh-huh. All right. Okay, this bowel wall looks okay over here. This looks good here. And again, I'm not feeling anything… Can I get anymore out on her? So in surgery, for a connection to be healthy, you don't want any tension. Right? You want a good blood supply, and technique. Those are the things that we talk about. So I do not want this under any tension. On the other hand, I would like to, I don't want her to recur either. Okay, so this looks good to me. I'm trying to decide if I can get any more, like it feels like there might be something here, but I do not want to anastomose to a tic. Yeah, so how about if we say that our spot is there, that we're going to do something there, and I've cleared the back wall here. That looks pretty good to me. This all looks okay, and I think this might be the best I'm going to do. Can you hold this up for me? Let's just take a - let's take this like this. I'm going to take this off the bowel wall a little bit. We're going to end up closing a little bit of this. Okay. So - something like this, maybe. I'll take this from you for one second. Just take a little bit of that. Okay, all right. I think, and then what I'll do is I'll close the pouch of Douglas, should push that back in. Okay, and let's look and see what we have here. Okay. So what I'm doing is I'm looking all the way around. This is going to be our distal. You can drop this down. All right, this is our proximal end here, I'm just trying to decide if I want to see if I can get a little bit more. You know, there's always - I don't think so. I think that it has to kind of be, I think it has - oh, maybe a little bit without being that tic, right? Maybe we can get a little bit when we come out this way. Okay.

CHAPTER 7

So, all right. This is - so I'm pretty happy with my extent of dissection. What we're going to do now is something called a posterior levatorplasty, where we're going to tighten up - find the muscles, and tighten up a little bit posteriorly. So can I have a - let me see what sort of retractor I need. It's either a malleable, or a - angle, do you know what I'm saying? Like, or a deeper, not that, not a right angle. I need something a little bit deeper. Yes. That, that, that, I'll take that. That'll work. All right, and we're going to use PDS for it, So I'm going to use 2-0 PDS for the levatorplasty. Yeah. I'm just going to free up a little bit in here. So, the rectum is underneath my fingers, I'm just going to free up a little bit of this. Okay. All right, and I got to take a little bit of this in this direction. Yeah, because I'm working in the dark a little bit. Take a little bit of that. Lucky for me, I'm going to take that from you a little bit. And can I have another one of these retractors? Okay, great. All right, so I'm going to put - so the levators are going to be over here, posterior levators, and I'm going to put a PDS to tighten those up a little bit. All right, good. All right. I'll take the PDS, please. Great. Okay, and I'm going to come above. How's that light in there? Not perfect, but okay. This is the prolapsed segment, and again - oh, let's readjust our needle. Yeah, my light is awful, now I'm completely in the dark. Yeah, all right. I'll take a snap, and then I'm going to do another one of these. You can cut, snap this and, okay, put another snap on the end here, snap there so I don't pull through. Uh-huh, thank you. Again, I'm going to come across. Yeah. Thank you so much. I should really drop yours down. Because I went behind it instead of in front of, which I normally - could you drop this? This? Okay, great. Okay, cut off this. So that's my levatorplasty. So I went upper levators. I don't go wide, but I - all right. This gets pushed in. I'm going to tie this into place. Okay, go ahead. You can cut that. Okay, nice. Great, and then you can kind of take your scissors and just push this little bit of fat in so we could - yeah. That way we can see - Yes, nice. Okay. Okay, cut that. Okay, great. Okay, we'll take a little bit of irrigation.

CHAPTER 8

Just going to clean up, so it's not quite as messy. All right, so so far, we've done the posterior levatorplasty. Next, we're going to close the - we're going to close that anterior peritoneum. And then we'll be ready to dissect the specimen. All right, okay. So, I'm going to, okay. I will take, let's get rid of this here. Drop this down a little bit, how about that? So I like to set myself up so that - can I have an Allis, please? I like to set myself up so I can see the full thickness. So you see primarily mucosa there, but I really want the full thickness of the rectum. Can I have another Allis, please? Okay. So I'm going to hold the - this is going to be my distal end. All right, and what I'm going to do here is I'm going to drop some of this down, so it doesn't annoy me and get into my… I don't have to do a lot of this, but just so that it's not in my way when I go to - okay. All right, and theoretically, we could do also another levatorplasty, but I don't need too much levatorplasty. Okay. That's this end here. This is going to be our proximal. And then this is this pouch of Douglas. I'm going to free this up just a little bit more, so… Okay, so I'm going to close this and push this back in. And then this is where I'm going to transect here, and this is going to be the distal end, and this is the proximal end. Can I have a 3-0 Vicryl or a 2-0 Vicryl, something to close the… Doesn't matter. Just kind of… Thanks. I'm going to be operating as a lefty today. All right, so something like this, I'm just kind of closing this up. This is what got you into the abdominal cavity. All right, and I just do it more like an over-and-over type of deal, kind of like you would close… It's not super… I just kind of - hold that like that for a second. Yeah, if you could hold that up, that would be great. I'll tell you what we'll do. Yeah. I'm just going to kind of close it almost like a - oh, something like that. I push that out. So you're kind of going circumferentially? Yeah, I'm kind of closing this space off and I'm going to push this back in. Okay. You can cut that. Okay, and that, we're going to kind of push back in there. All right, and we're going to say that this is where we're transecting to, giving that back to you.

CHAPTER 9

Okay, so next - all right, so here's - we've done - we've chosen how much prolapse we want to resect. We've done our posterior levatorplasty. We've closed the pouch of Douglas, and now I'm ready to choose my spot, like where exactly I want to do my - the part that I'm going to transect on the rectum, and what I'm going to do is I'm going to transect, and then I'm going to put the sutures to hold them in place at the 12, 3, 6, and 9 o'clock. And I have this, you know, just a preference. That's what I would call this is my preference, that I do those in one color. And I do the intervening ones in another color. And so here you can see the whole rectal wall, right? Like, so again, this is mucosa. And then this is through, this is kind of a submucosal layer, and you can see the muscular layer, and when we transect, we're going to want - or when we sew it together, we want a full-thickness bite of this. Okay, so...everybody following? You got a good view, you're okay? Okay, great. Okay, so I'm going to get this loop out of here and I'm going to come across kind of half of that. Thank you. So I see a little bit of bleeding, which makes me happy, right? Because bleeding is good blood supply. All right. Okay, so we're going to open… So this looks nice and pink on the inside here. And this is going to be our 12 o'clock bite. So are we doing dyed or undyed for these four? We're going to have four - these are going to be 2-0's, what? I have both. So are they swages or are they pops? It doesn't matter, just let me know. Okay, let me do the undyed for the corners. Yep. Mm-hmm, and lefty. And you'll need three more of these? Yes, please. I think I can get two out of each one, not sure. Okay, you can let go of what you're holding. You can take it off. I'm just kind of showing everybody. Okay, and I don't need - so I'm going to go in this 12 o'clock position. I don't really need a ton of mucosa. I just want to make sure that I get it. And you can see sometimes I take a little bit more length on that distal end because it can retract. All right, and you can see it's a little bit friable because of the prolapse, and now I want a nice bite on the anterior rectum. And again, I don't need a ton of mucosa, but I do want to - I do want some. All right, I'm going to snap these. I'm not going to tie. I get everything all set up, and then I tie later. So we'll get two out of each one. So you put a snap on both ends and then cut, okay? And that's going to go up here. All right. So I pretty much want the halved distance here, and you can see, we're going to need to take a little bit more of this mesentery, possibly. All right, I'll take that stitch back. Please put a snap on the end of it. Okay, and so I'm going to come in this direction. Again, I don't need a lot of mucosa, but I want a nice bite of the rectal wall. So it's full thickness to full thickness. Okay, and now I am going to - yes. So here you can also see the rectal wall layers here from the outside, right? To the inside and get some of the mucosa. And again, I don't need a huge bite of the mucosa. Okay, am I locked here at all? We don't want to - yeah, no, I'm good. Okay. Okay, so snap this. Okay. Okay, that's here. Okay, all right. I will take another stitch, please. Same kind of stitch, loaded as a lefty. And we're going to need to take a little bit of this. Okay, so let's say… I made sure I got the full thickness, and… I want to make sure we get the full thickness of the wall. Okay, all right. Snap that. Okay, and that's going to go this direction, right? That's where that's lined up. All right, so now we're going to take off the rest. Okay. So now… So we still have mesentery on here that we're going to need to take, but I'm going to take that off with the LigaSure. Okay, so let's do something that's like this. Okay, let's take the LigaSure. I'm going to take that from you if I can, thank you. Yep, mm-hmm. Okay, and I'm going to hug the distal end because the distal end is the specimen side. Maybe a little bit more here just because it's a… Okay. All right. And this is, I have to take this off here. Yeah, so you see how you're just left on the mesentery here? Okay, and which is fine, like I wanted that. That was great because then I could have cleared more before, but now I know I've got plenty from my distal segment, or my proximal segment. It's going to get a little bit - I think we have a little bit more of the bowel wall we can take here. Mm-hmm. Okay. All right, here's the specimen. I'm going to give that to you. I know that actually also Maddie needs it. Maybe, Katie, you'll let her know that it's out. Okay. This is this end, all right. This looks good. Okay, and it fits in great. Okay, I'll take that, another stitch, another one of those white stitches. Actually, before you give me that, let me just irrigate. Okay, that all looks good. I don't see any bleeding. I'm happy with that. I always check. DeBakeys to me.

CHAPTER 10

Fantastic. Okay, and now I want the full thickness of the rect- here. All right. All right. Okay. And then this - is a little bit messy here, and here's a little bit of mucosa. Okay, it's going to come up there to meet that. Okay. So you can do, we're going to do half. You can take a little bit more than a half, so it's easy. Okay, cut. Okay, so then what I do next - so now, I'm set in all quadrants. Like, and again, I wasn't worried that it would retract because that would just sort of imply to me that I had too much tension, but I do like to set it up and see exactly where that is. And then, what I do next, then I'll do half, half everywhere else around because there's going to be a luminal discrepancy. Let's make sure nothing's bleeding in here. Do you see anything? I don't think so. No. I think it's okay. I think it's just from the edges. Okay, then I go half, I do half around. Like I then bisect everything. Okay, I'll take now the pops and the other color. So I'm going to go half in each one of those quadrants and then I'll start sewing. So, you're going to snap the next set also. So you're just going to have them rapid fire set up for me. All right. Okay, and then maybe you can adjust our light. So I'm going to say halfway between these two. All right. And I want to make sure that I've got the full thickness. That's what matters to me, that looks pretty good. See that, maybe I'll even take it a little bit. Yeah, so because you see the muscle layer there? That gives me the full thickness. So again, I'm bisecting again. All right, okay. And then you're going to end up - then I'm going to take this end. Okay, and I want a little bit wider on the - on the bowel wall side. I need a little less mucosa because I want a nice bite of the submucosa for a lovely anastomosis. Okay, and then you're going to snap them. I'll take the next stitch, please. Okay, and then you're going to put it in the direction, see how it goes between these two? Great, yeah. And then, and I know I'm totally lined up my bowel wall. Okay. All right, and I think what I will do is I'll angle this a little ratty, how I did this here. So this is halfway in between here. I want to make sure I have a nice bite. I don't know why that happened. I can't explain that to everyone, but it happens. Okay. And now let's do this up. We can kind of hold that this way, and I want to be able to see. Yeah, so see, I've got a nice bite of the bowel wall. See that's the bowel wall, but I want also a little bit of mucosa. All right, good. Okay, snap. Put it in between the two. I'll take the next stitch. Yep, perfect. Okay. All right, I see we're going to have some luminal, but it should be pretty good. Okay, kind of hold that this way a little bit. Let's go half, again. Oh, where's half? Like maybe right here? Okay, make sure I get a nice bite. I don't like going in and out of the bowel to be honest, but I think I'm okay here. Okay, good. All right. Snap, next stitch. Put it in that angle. Okay. Yep. Okay, and let's come this direction. All right, So half should be somewhere maybe around here, but I want to make sure I get really get a nice bite. Yep, there we go. I'm pleased with that. I want to see… Now that goes - belongs over here. So the bowel wall… Yeah. It'll be over here, okay. Let's snap this. Okay. Okay, so now what I'm going to do is I'm going to tie my 12, 3, 6 and 9 o'clock. I'm going to tie… So I'm going to tie - okay, so this will go in this direction, let's say. I'm going to tie these. Right, and you're going to cut one and then leave one long. So that's how I know that's my little message to myself that I have… Okay, so snap one, cut one. So, maybe snap this one, cut this one. I know that when I have a one - yeah, snap that one. Yep. Great, good. And now cut this one? Okay, fantastic. We'll do that. I'm just going to do all those, and then I'm going to work my way around. All right, and we're going to want to push that in. Okay, so see how we're going to have to kind of make up some of that? Okay, snap. Okay, and cut. All right. Okay, we can… Okay, good job. Okay, and then I'll do this one. So now it's about lining everything up. Snap. Okay, and cut. So maybe what I'll do is I'll start working this - I'm going to start on this one because this one to me is the biggest luminal discrepancy. I'm going to take stitches, please, and I'm just going to snap, I'm not going to tie right now. Okay, so you're going to snap them because I want to be able to see - you see how I've got this here? All right. Okay, I've got a nice bite there, and I want to take a nice bite here, so you're going to snap this. Really, another option would've been to do it in half and half again. Okay, snap that one. Just this side or both? Just snap both of them, sorry. Okay, great. How about if I do it like that? Okay. All right, this is where I really want to - this is a little ratty on this end, but… So to me, like when I have a lot of things that are untied and a lot of clamps, it has the potential to get all twisty and annoying, but I want to be able to see both ends. So, it just depends, like this way, I can see that you're - if you kind of loosen this one, so it's not so tight… Okay. You're going to need - yes, absolutely. Just pull that all the way through for you, yeah. Should be pretty good. All right. Okay, these all look pretty good to me. This looks pretty good from a luminal discrepancy. Okay, so take this. Okay, I'll take a stitch please. So, at some point, it's nice to… Let's see. So this is all lined up, okay. I am… Yep, that goes - so we'll snap all of them. Next one, please. Okay. Okay, can we get - I don't want it quite as tight, so I can kind of see on the inside. Let's loosen that up a little bit. Just hold that up, just, or you can't really, I don't think. Yeah, just hold it that way just so I can kind of get in there. Yeah, exactly. What? I had started making it worse for a second. Yeah, you were, it's okay. But you mean well, so that counts. Okay. All right, that looks okay. It looks okay. So now we have this side. All right. That looks good. Okay. This is just to, you know - like I really am lined up, but it is nice to - let's see if you can - yeah, loosen it a little bit. Like here's one end, and now I can kind of see that I've got the other end like that. Can you - what? Oh. I don't want these stitches in my way here, okay. And then, can you loosen this one just a little bit? Take some of the tension off of that, just so… Yeah, exactly. Because then we can, yeah. Go ahead, snap that. Okay, and just, we don't want to get it, like, twisted. So, try to put them back in the order without any tension on there. Yeah, so I'm going to put that one here and put that here. And at some point, I think we want this one down here, if anything. Okay. All right, next stitch. Yep, we'll definitely need more. You'll probably need at least two more packs. Okay. All righty. Okay, and so here you can see full thickness here. All right. I'm going to want to come in. I feel like I could do a little bit better and use the curve of my hand. A little bit of a better bite on that, yep. Okay, snap that. Okay, another stitch, please. And then so I want - oh, but you want that down this way since I lined that up nicely on this last one, I should be able to - oh, look, see, this might be a tic. See there? I really, there's not that much I can do about that. See this, like I… but you want to try not to create an anastomosis to a diverticulum. Because it's weaker? Yeah, yeah. We've already committed. We certainly didn't do that on purpose, but that's what that little divot right there is. I'll see what I can do to try to… Let's see. All right. Another stitch, please. Okay, come down. The truth is, is like, once it's there, like we certainly didn't intend for that, but I'm not sure that I could do anything more about it right at this moment. Okay. I'm going to tie this. I'm going to take another stitch, please. You can cut this one, but I can see, I already can see that I want a stitch in between here, these two. See that? Stitch, please. All right, okay, so we'll start tying and then re- back. You can just kind of, I'm going to work around the other way again. So I'll probably want some intervening. See how - okay, I will take another stitch, please. Hold on, before you cut it, I'm going to just put another one right here. Okay, you can cut both of these. You can get them a little bit longer, yeah. Yep. Uh-huh. Hello, that was a little bit ratty. Okay. Now let me just see before you do that, if I want to put anything in between… I'll take another stitch, please. You want to tie this one? Sure. Go ahead, you tie this one. Okay, great, I'm going to cut both of these. Okay, you take that one. I'm going to cut that in a minute, hold on. Can you take your DeBakey and kind of push this tissue in a little bit? Yeah. All right. Okay, you can take it out. We're going to do another bite there. Another stitch there. All right, I'll take another stitch, please. Hold on. What we'll do here - see if you can push this down. I'm going to cut these, and then we'll decide later, if you we want to… Okay, go ahead and cut that. Can I have some irrigation, please? Okay, hold that that way. So it'd be nice if we can kind of push that tissue in a little bit. Don't cut this one yet. Let's use this to retract with for a second. Let me have that one. Okay, so you can cut both of those then. Makes me do think that we need a little something over here. One more stitch, please. Okay, you can tie this one. Mm-hmm. Do you have the scissors? All right, you have the scissors. Okay, great. All right, let's see what we have here. Ah, this tic makes me a little nutty, but they have that saying that "you get what you get and you don't get upset." I mean, I wouldn't have purposefully put that right there. So it would be nice to push that in a little bit, but we may have to just do that with another stitch. So take, see if you could push, see how if we could push this in like this, how nice that would be or you tie it and I'll push it in. How about that? I've got it pushed in and you tie this one. And then I'll take another stitch in a minute. Okay. Okay, great. All right, I'll take another stitch, please. Uh-huh. A little bit far. Okay, so it would be - that's a little bit far from my opinion, but it's a done deal. So what it would be nice is, I don't want this around here. Okay, you can actually cut this one, so it's not in our way. Yep. Okay, and if you could kind of push that tissue - Yes, that would be great if we can kind of - okay. I don't think that's exactly what, where, that you push it in, but that's the idea. I pushed too much? Ah, I don't know how to explain it, but maybe it wasn't you. Let's unhook these. Okay, I'll take another stitch, please. Okay, so see how they - okay, tie this one, please. Okay, great. All right. Let's get ready for the next stitches. Prep those, okay. I want to keep working in that same direction. So, take a look. What I'd love to have happen with this is when I tie this down, I kind of push this tissue in a little bit like that, if that's possible. Okay, all right, something like that will work. Okay. Worthy idea. Okay, get the next one set up to hand off to me. Do you understand what I mean by that? The next one of these. Okay, perfect. Kind of push that in a little bit. Get the next one set up and all. Okay, I'm going to take another stitch, please. See, I'm going to go in between them. with the next stitch. Fantastic. Part of me thinks I should just go into that whole tic. Maybe I should, yeah, and then kind of obliterate it. Very annoying to me, the tic. There you go. Go ahead. cut here too. Can I have another stitch, please? Okay. I'm going to kind of go beyond - this tic and kind of close it off. I'm going to give this back to you, thanks. Okay, bye tic. I'm going to tie this one. Okay, another stitch, please. You're welcome. I love to be a team player. Let me give that back. I don't think so. I'm going to take one more now and then I'm going to go all the way, like, we'll cut all of these, and then I'll look all the way around. Okay, so let's cut these. And then what I've left is I've left in the four quadrants, the ones that are the undyed. Okay, so let's take a little irrigation, and now you got a kind of a good sense, I have it everted, both the proximal and the distal. Just a couple of things like I would make as little notes of things is that I always check for hemostasis during the case, like there wasn't any active bleeding and that was super important because the rectum can bleed and it can bleed later. So we don't want it to bleed later. And that's something that you've got to watch out for. It's not that it happens commonly, but it certainly happens. And I definitely give these nice ladies, some subq heparin or some sort of DVT prophylaxis, especially those that are not that mobile because they're a clot risk. Okay, so now I'm going to go through and say, "Do I have any gaps?" All right, so I don't like that right here, so I'm going to take another stitch. Okay. And so you may need another, I don't know how many you have left, but you, yeah, you probably will need another pack. Sorry about that. Here you go. This is kind of my final check to see, and I go around again and make sure that I don't have any gaps. And the gaps would be because you have luminal discrepancy between that big dilated - let's look and see. Yeah, see, I do kind of this - do a little something here. This all looks good. Okay, all right. I'll take another stitch. Okay, cut. All righty. Let's see anything else? I think that's okay. This is okay. It's a little ratty in here, but we got it, I think. Let's see how you've got here. Looks all right. I try to get, okay, I'm pretty happy with that. So what we're going to do next is I'm going to get rid of all the hooks. All right, we are going to give her Marcaine at the end, so we want to be really careful that we don't hurt ourselves. And then we're going to push things back in, and before I cut it, so I have access - if you can help me to make me look strong here, I would appreciate it. Okay, got to kind of - yep. Yeah, okay, I feel better. It's not easy for you either. Okay, there you go. Me? Oops, too strong. Okay, let's put those through. Okay, and actually I can even take those colors. I don't want us to hook. You have to be careful when I give you these hooks back, because they're actually sharp, and I'm going to give you this back also. Okay. And now we're going to, I'm going to push it back in, so you get a sense of what it looks like back in. All right? And then I have the little hooks if I wanted to pull it back out for any reason. All right, and you can kind of see, and then sometimes I'll look on the inside also. But I think for her, you can see that this actually connection is about 2 cm up. All right, and that all looks good. Is there anything bleeding? Let's take that irrigation again. Okay, you can cut these four. I'm pretty happy with this. Yeah, that goes in. Okay. And then, yep. And then, so the anastomosis is about 2 cm. Everything tucks in nicely. And then I'll take that little, really narrow anus scope if I can, if I have something - the really narrow one, and then we'll also take the - I'll also take the local. Yep, so just take a quick look here. Okay, again, I don't really like to mess around with this too much because I don't want to - oh, I don't have a light. Like, okay. So can we have a little light that you can direct in here? I don't see anything bleeding. I'm happy with that. And you kind of can get a sense. If you can put the light in just for the - yeah. I have lighted anoscopes, but I don't think it's necessary in this case. I'm not going to hook those up.

CHAPTER 11

All right, I'm going to take this for a pudendal block. I'm going to give her, yeah. I'm going to give her 0.25% Marcaine. So I'm going to find her ischial spine. I'm going to go medial. I'm going to aspirate and then I'm going to fan out. I can give her - are these with or without epi? With. With epi. Okay, and I can give her 0 I gave her 10 already. I'm going to give her a total of 30. I'm giving her a Marcaine with some epi in it. I have another 10 cc of that. Okay, great. So we just want you to know that we're wrapping up. We're giving her the blocks. So you're going to do the same thing on the other side. Okay, you're going to find the ischial spine and you're going to go medial. Then, I like to do the washing - yep. Ischial spine, go medial. And now, uh-huh. Go ahead, nice job. Okay, medial - imagine where the nerve - okay, come down and then - yep, aspirate. Good, okay. And then you'll advance and then fan it out so that you give the full 10. All right, so you imagine the pudendal nerve coming out of Alcock's canal. Okay, and then towards the rectum, right? Okay, you can come, just be careful, like, yeah, you don't want to hurt the needle. Okay, you can come - you can advance in a little bit, fan out. I don't know, you and I are a little rough with that needle, it looks like, but - okay. Okay. It's a small needle, so it'll be a little bit hard. All right. Okay, so as far as post-op, she will keep her catheter overnight, and then it will come out tomorrow. Sometimes, some of my nice ladies have to self-cath, but sometimes that's hard for them, but other times they have no problem and they urinate on their own. She'll get a diet later, and then discharge will just depend on when she's ready. She has a couple of other medical conditions, but if she feels okay, I'll be able to send her tomorrow. That's it.

CHAPTER 12

So this is distal because this is the rectum that was out. And this is the proximal, the more like normal, inside part. Okay, so here. And so if you take a picture, this is, you know, like it's very variable. So this is about 8 cm, I'm best guessing. So yeah, this is the amount that was prolapsed out, and this is the more proximal.

CHAPTER 13

I would say two aspects or two thoughts that I have on my mind is one is the amount of prolapse that I take out is completely variable. I don't really have any idea until I get in there how much is going to be delivered to me, or how much is the patient going to deliver to me? So on this specific case, she had, I'm going to say, eyeballing at about 4 cm. worth of prolapse. And then the segment itself is about 8 or 9 cm. And essentially I'm getting above, I'm putting my hand into the abdominal cavity. So I'm going through the peritoneum that I showed you, through that pouch of Douglas. And I'm looking to see if I feel any, if I feel it looped within the lower pelvic area, which I did not. And then I delivered as much as I could, what I felt safely, because again, I cannot do anything with tension. I cannot create an anastomosis that will heal if there's any tension. So our specimen was about, you know, 8.5 to 9 cm. It retracts a little bit when it comes out. As far as like the breakdown of the operative steps, one is exposure. That's what I use the Lone Star for. There's retraction. I pull the prolapse out. I then mark or score where I'm going to create that initial dissection, which is going to go through the mucosal layer all the way through the full-thickness level of the rectum until I see the fat of the mesentery on the other side. And I do that pretty quickly because it's bloody and I want to get through that so I can get control, and then I'm going to completely evert, unravel, the rectum, so I'm on the back surface of it. And I do that all the way around, and again, it might have been a 1, 2, 3, but that's how I do it. And then I find the mesentery is the blood supply on the side of the rectum, and I make little windows and I use the LigaSure so that I can come across it, and that delivers more of the rectum to me. On this case, you clearly saw the pouch of Douglas and the peritoneum. We were able to really get a nice demonstration. I cut and opened up and that got me into the abdominal cavity. I also did something called a levatorplasty. That meant I went behind the rectum and I tightened those muscles up. That's thought to help in some cases with control, with bowel control afterwards. And so when it's available to me, I do it. When it's not, I don't. I closed the pouch of Douglas and pushed that back in. And then I created my anastomosis, which I did in the technique of creating the 4 undyed sutures of the 12, 3, 6 and 9 o'clock positions. I then went halfway in between each time and then sewed completely around, and as you could see, I used a lot of Vicryl and tried to get rid of any gaps, so that that would be kind of a sealed anastomosis, or a connection between the proximal and the distal ends of the bowel. As far as post-op care, she will go to the floor. She has a catheter that is in place. That catheter will come out in the morning. It's not uncommon, especially in the elderly ladies who have rectal prolapse to have a little bit of retention. I'll keep an eye on that. But most likely the catheter will come out. She'll get a diet. If she feels okay tomorrow, and all her numbers are good, and she can go, I anticipate for her to go home, and I have a conversation about going home before I ever do the operation. Who's helping you at home? What's that going to look like? Do you have support? If she feels good, she will go home. One other thing about this specific case is you could see - I looked for diverticulum. I saw a diverticulum, even higher up, more proximal, but I chose not to anastomose there. But when I cut down onto the bowel wall, you actually got to see a diverticulum on the inside. That was that little kind of opening. And that actually bothered me. And the way I ultimately dealt with that is I just sort of sutured that - I incorporated that into my anastomosis in some future bites. I just, I didn't need it there.