PMC9433537_01
Gross rectal prolapse occurred after each bowel motion. The picture shows a small prolapse.
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F1
Prolapse occurred with every bowel motion without any obvious cause and varied from 10 to 40 cm (Figure 1).
Fluoroscopic defecography identified extensive prolapse with eversion of the anal verge (arrows), not just protrusion of the upper rectum through the anus without eversion of the distal rectum.
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F2
Eversion of the anal verge was observed before more proximal rectum and sigmoid colon prolapsed on fluoroscopy (Figure 2).
Trocar positions. The surgeon's right and left hands should be located relatively close to each other to be able to reach the area of the levator ani complex. Sc, scope; Rt, surgeon's right hand; Lt, surgeon's left hand; Ast, assistant.
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F3
General anesthesia was induced with the patient supine and four ports (umbilical port for the scope, two lateral working ports, and a port for retraction of the rectum) were inserted, conventionally (Figure 3).
A retrorectal space was created from the peritoneal reflection to the sacral promontory extending deep into the pelvis around the levator ani complex using only blunt dissection, preventing lateral nerve injury and preserving lateral vascularity (white arrow). Rectopexy sutures were placed between the posterior wall of the rectum, the levator ani complex, the presacral fascia, and the sacral promontory (right-lower). RW, rectal wall; PRS, posterior rectal space; SP, sacral promontory; PF, presacral fascia; LM, levator ani muscle.
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F4
Its peritoneum was incised on the right side of the rectum starting from the peritoneal reflection to the sacral promontory and blunt dissection was used to expose the LAC to prevent lateral nerve injury and preserve lateral vascularity (Figure 4). All were tied extracorporeally (Figure 4).