A. STEVENSON

Hello. Good morning.

Good morning, Professor Stevenson.

Many surgeons are here in the hall waiting to watch your operation.

Good morning. Thank you for the kind invitation.

Thank you for participating in this event.

It's a nice day here in Rome.

And would you please explain the case you are going to operate?

Sure, I'd be happy to. Good morning, everyone.

This morning we're going to do a laparoscopic ventral rectopexy

on a 68-year-old lady with a complex rectocele with rectal interception.

No previous significant history other than a vaginal hysterectomy some 30 years ago.

She also has a long-term tendency towards constipation and her main symptom at present is obstructive defecation and a dull, dragging, heavy feeling in the pelvis.

If we can go to the overhead picture, we've already inserted the ports, which you can see here.

Yes, so four ports.

Four ports, all five millimetre ports.

So we've gone in first with an optical port in the right upper quadrant.

And it's important how to find where that port should go.

Working backwards with my main working port being here at the right iliac fossa.

The anterior superior iliac spine is here.

The inferior pigastric vessels will be roughly going about here.

So apparently that should be then about a hand's breadth up from that in the same line

is where I'd go in with my first port, which would be the optical port.

I can then place the 5mm port through the base of the umbilicus where the 5mm scope

can go through.

Obviously if you wanted to use a 10mm scope that would be your preference, you might just

go in there first.

But this I think gives you much better cosmesis and less pain and less risk for hernia.

The other main port here is the main one I'm going to use for suturing with my left hand

and importantly that's about two to three finger-breadths lateral and two to three finger-breadths

inferior to the umbilical port so that's not too low down that it's hard to reach and also

not too high up where that needle holder won't be able to reach down to the pelvic floor.

If we go to the laparoscopic view, to gain our exposure of the pelvis, we'll feed up

the adhesions of the omentum, where they are stuck down to the pelvic vault, and if we

have a look up here, it's been held up through this port with an endoleap placed around an

appendix of the plurica.

Let's look down again.

Now, we're also having a lot of trouble before with keeping the small bowel out of the way,

and so I've also got a second endo-loop which we really have to use, plus this on the

bloodless bald neck adjacent to the terminal ileum. We'll look down now. So I'll begin with the

section at the sacral promontory, so the bony promontory we can feel here, and let's

have a little bit more head down now please. I'll give my grasper to the

the assistant, and you can either use electrocautery for this dissection or more advanced methods

such as ultrasonic or harmonic if you needed to, but I find that it's relatively bloodless

and hopefully it'll be bloodless today, and it's going to expose the anterior surface

of the sacral promontory, which is just here, and that's where we're going to suture the

the top end of the mesh. Now this is a technique that's came more into vogue certainly in Europe

and to a lesser extent in Australia. And we've got a dolphin nose if we need it, or a mewland.

The operation I probably would have done for this lady previously would rather be an intra-anal

or what we call a STAMP procedure, or sutured trans-anal mucosectomy and placation, or some

might do a STAR procedure, which you're probably familiar with in Italy, or a resection rectopexy.

I've, in the last two years, been, for most of these sort of patients, performing a ventral

rectopexy, and usually it's a day case procedure, so most patients will go home the same day

of surgery you can come down and hold lower down. Either using permanent proline type mesh or as

you'll see today we're going to use an absorbable collagen mesh called Sergisis. Let's lift up here

now. So the patient's in lithotomy or modified lower delvy position with both arms down tucked

in by the side and the assistant surgeon who I forgot to introduce before but is Dr. Michael

Power. He's a surgeon visiting us from St. Mark's in the UK and he's standing on the patient's left

side. As you can see there she's got a very deep patch of Douglas which is typical of these

patients. You also see that in of course full thickness rectal prolapse which is the other

main indication for this type of procedure as you can see we don't

mobilize the rectum rather than to divide the peritoneum on one side of the

rectum sometimes to help define the right plane at the front it's useful to

place a probe in this case it's a swab and a rampley holder which is in the

vagina and drop your hand further good and sometimes particularly if they've

had a hysterectomy you might have some adhesions between the belt of the vagina

and the rectum now you'll notice we're starting to look up underneath so using a 30

degree laparoscope we can turn our light source around the other way 180 degrees

So it will begin to look more pap or ventral.

So we should start soaking the mesh.

Just let go where you are.

Can we go to the overhead camera again?

Just before we do that, to section a bit further,

I'm just going to show you the mesh of the overhead camera.

Thank you.

Hopefully you can see right there.

This is the surgesis.

This is an 8-ply surgesis which has been vacuum packed.

and I've just cut out the prosthesis, the shape of it, that we're going to use.

It's about three and a half centimetres at the end and that's going to be placed down on front of the rectum,

sutured onto the rectum and also to the back wall of the vagina,

then placed along that gutter that we've now made alongside the rectum

and then sutured at the top end to the sacral pulmonary.

I'm just going to soak that in saline now for five minutes and get a laparoscopic view

again.

Just cut it and soak.

That's come down a bit deeper with your grasper.

That's it.

Good.

And we continue this dissection right down to the pelvic floor, up until about a centimeter

above the level of the skin.

Typically in these patients, the sphincter length is very short, particularly in the

anterior aspect.

controversy here apart from what type of operation to do is what type of mesh to use and I've been

using the observable mesh now for the two years and they fell off and those patients will be

be presented at one of our conferences in July at the TRIPATAT meeting, which is a

big colorectal surgery meeting between the continents of United Kingdom, North America

and Australasia, with quite a big contingent from Europe, I might also add. And so we'll

be presenting the results of that but it seems to be comparable in terms of recurrence and that is

very low recurrence even with the absorbable mesh compared with the proline permanent mesh

and certainly you don't have any of the potential risks associated with permanent proline mesh

such as erosion or mesh infection as you can see we'll suddenly get very low there now

I'm going to go down. I'm going to have a feel from below now.

I'll put my finger in through the rectum.

I've got some better than.

I think I've probably gone as far as I need to go down.

So I've just got my finger now in.

Take your swab out.

So that's my finger in.

Yeah.

I can feel that there, if we go to the overhead view, so where I'm pressing there now with

my finger in through the anus, it is, if you can see there, it is about 1cm from the skin.

Yes, we see.

So it's pretty low.

So the section now is finished, let me take that mat out, we don't need the pedal.

So what we're going to do now is to maintain that view, so I'm going to use my grasper.

I'll take that one from you as well.

Yes?

Can we have the laparoscopic view, please?

Yep, laparoscopic.

Thank you.

Okay, so this is my left-hand port, so that's the right upper quadrant port

with the end of the retracted, splayed out, to lift forward on the

vedano belt. Let's come back a bit. Okay. So we've got the rectum at the back here,

vedano at the front. It's got a very floppy bladder, you can see, poking down there.

Let's go to the outside view again. Overhead camera. Two tap flips, please.

And to keep that in place, I'm going to use some tail clips on the grasper, keeping it

open, which will hopefully keep that displayed for us.

As you can see, we've got some endolubes holding up the sigmoid, the small bowel, and this

grasper being held here to give us the view of the pelvis where we need it to affect.

So if we take this through a 5mm port it's a little bit squishy, so I'm just going to

use the end of the endo-loop, which seems to be perfectly custom made for this purpose

of getting this through.

Go to the internal view now please.

So there's the mesh going through, being pushed through with this needle holder, just regular.

There was a long end there.

Okay, we can understand.

Okay, come back to the needle holder.

And then we can start suturing.

And here I just use a 3L PDS.

With my grasper holding that up, I find I need to be lateral to the grasper with that needle holder.

or otherwise you you can't get down deep enough and come in further now even with that port

pushed all the way in on the left eye like fossa i can barely i'm having to push a lot to get that

through so we're going to go in deeper now in further right in and take it down as far as we can

in the rectum. These are the two most awkward sutures to place because you're working at such

difficult angles at the extremes of your instruments. Please excuse my suturing skills but

in Australia if you're a colorectal surgeon you tend to do just colorectal surgery and so you

don't do other any other gastrointestinal surgery such as fundoplications and so on.

So you don't get to see too much apart from doing these sort of things.

Now let's come back a bit.

That's our loop.

This is a little slip knot loop that's been created by the scrub nurse Erica.

So if it doesn't work, then it was Erica that tied the knot.

It really is a long way down.

But fortunately for Erica, she can keep her job because it's worked.

You could also use a knot pusher for this, and I find once you've at least got these

first two in, which are the most difficult ones, it all works 50-well and a bit more

efficiently than using the knot pusher.

So I put two sutures in externally, which is usually enough to hold the mesh, and a

few other extra ones onto the side of the rectum.

Do we know if there are many people in the audience doing this operation at the moment?

It's one of the operations that are performed.

I have no experience with it personally.

I cannot tell you really how many in the audience perform this kind of procedure.

What's your experience with this procedure and what are your results?

functional and recurrences?

Yeah, the functional results are found to be very pleasing

for both the treatment of obstructive defecation

and also for those patients with incontinence,

particularly if they've got a degree of prolapse,

whether it be full thickness external prolapse

or early full thickness prolapse,

all these complex rectocells and of course it doesn't work in all patients and sometimes they

need to have some pelvic floor neuromodulation with a so-called nerve stimulator if we've got

associated pudendal neuropathy or a partial defect in the sphincter but I've done about 120 of these

now over the past two years. So that's roughly one a week. I'm just going to bend that

needle now to take it out. Because of the 5mm ports, sometimes the needle can get

caught trying to pull it out of the 5mm port. So I just gently bend it.

The recurrence rate so far has been about 2% and they are both in patients with

permanent mesh, probably due to technical errors. One where it pulled off the

sacral promontory and one where it had pulled off at the rectum and both have

been re-sutured, another stitch now, re-sutured laparoscopically and had no

recurrence since. But the great thing I think about this procedure compared to

what I was doing previously is the recovery of these patients. I've been

very impressed with the recovery not only the fact that they can go home the same day of surgery

even in the 91 year old patients who's the oldest one they'll go home the next day

which is very impressive then when you see them at six weeks they've usually had an early return

of a good bowel function uh unlike what i've seen with other techniques either recession rectopexy or

staff procedure and stamp and so on the recovery has been much more rapid up another couple of

stitches now a bit higher up reach and some longer needle holders no it's all right but

I remember when we were working down a narrow hole with the laparoscope turned up the other way.

If we pull back a moment with the laparoscope again you'll appreciate that again with the way we're having to operate through.

I might just clean our screen again.

So I'll just clean the lens for you, make it a bit cleaner.

Is your picture coming through okay over there?

Yes, we can see very well, thank you.

I've got one more suture to do in the rectum and then we'll secure it to the sacral

pulmonary and that's the main part of the operation essentially done where you just

put one more to the vaginal vault or occasionally if you've got a significant anterior vaginal vault

prolapse you can mobilize the rectum so mobilize the bladder from the front of the vagina and

and sometimes put in a Y-shaped graft

to cover the anterior part of the vagina as well.

and my surgical fellows certainly agree with that

when they're trying to learn this technique.

It's not just like using a simple surgical simulator

or trainer where you just stand there

with everything perfectly displayed for you.

So that will do with our attachments now to the rectum.

Typically with using a proline suture, proline mesh, you want to prevent the small bar from

attaching to the mesh, and so you close up the peritoneal over the top of the mesh, and

I believe you should also do that with the absorber mesh, mainly that it will help to

hold the mesh in the correct position, and the greater the position of the body tissues

to the mesh, the better ingrowth you're going to get with that mesh.

So I've taken my retracting device out now, I've got a grasper for you, I'll lay this

back and you come back and hold up that rectum a bit more, and that endo-loop I showed you

before onto one of the appendix of a particle of the sigmoid colon or recto-sigmoid junction.

Very useful tip to help keep exposing everything for otherwise you struggle having to

find the view all the time. So I'm just going to lay that down relatively tension free and

I'll probably cut that a bit shorter. Got some scissors, some scissors. So here's our

sacral promontory just here, so I'll cut that there. It usually works out to be about 17

centimeters in length, but I leave it at the full 20 centimeters of the mesh just to work

out approximately, because there's different size patients, but that's probably going to be about

three centimeters. Okay, so here's the cervical. So you can either staple that to the sacral

primary or suture it, which is my preference. Maybe with the new types of staples coming out

in the future, I might change my mind. But at the moment, I like to suture it. And here,

because I want this suture, I'm just using one suture, for it to last more than six weeks,

That's into the periosteum, twisting around it all the time.

coming forward, so that's nice and secure.

The Novavil, I find that the type of material seems to have less memory than proline, so

again and we'll have a short pds i'm just going to leave that one end long i'm going to suture the

the peritoneum close and tie it up to that again now if we're putting that vagina suture here's

a needle let's have a 10 mil holder you need to come out of there and once i've got this needle

in place yes okay so there's a back wall of the vagina you can see everything's very fluffy down

here now it's going to put a suture through there which will help hold up the vagina as well

i secure that onto the mesh very fluffy bladder much more so than usual so again i'm using the

come back a bit the right eye for support and the left eye for support for suturing

because i generally can't reach it down this far with the right upper quadrant port where's our

I'd like to say thank you to Stryker for their assistance with the transmission today.

Can you hear me?

Yes.

By the way, what time is it now in Brisbane?

In Brisbane, it is 10 minutes to 5 in the afternoon.

Okay, it's almost 9 here in the morning.

Uh-huh.

You'll probably want your second espresso by now.

We've been operating here since 8 o'clock this morning.

It's a long day.

It is.

What a good way to finish, huh?

Yes.

So this is going to be your last procedure for today.

It will.

And the lemon.

one mesh in place and it's going to secure the peritoneum over the top of that which will help

to keep it all in the right position and to increase the position of tissue to the synthetic

to the bio-absorbable mesh is that mesh expensive i'm sure in europe it's very cheap by the time it

to us over here it's a bit more expensive but uh it's probably what 500 euro but uh much lower

we do have uh someone from cook bio design here with us today who supplied the mesh

and uh maybe they can tell us what how much it is in europe uh i could not get back to it from that

that. Why can't I see that? It's so floppy. I'm going to try and reach you here. If you

can lift forward, I'm going to have to, because I can't. It's so floppy, floppy.

Can't reach.

going to get my assistant to help lift up the bladder, which we wouldn't normally need

need to do. Okay, I'll just come down.

Once we get across the front here we'll be alright.

Again we're working at the very limit of our

instruments with the very deep

pelvis which makes it that much more

difficult. I could just swap over and use bariatric

instruments but I find them just as tricky.

regardless, until now.

Can you just lift up there?

let's come back a bit, find my needle, unfortunately I have a bit of a hematoma there in the peritoneum

overlying the front of the rectum, but hopefully that's secured it, another suture just there,

get involved. Just trying to find the peritoneal edge there. Everything that wants to flop down

but it'll probably all settle once we take the tension off all the tissues, I suspect.

So you can see our small bowel is turning out of the way nicely, rotate your hand a

bit, that's better.

We're on the home stretch now, we'll come around the corner, sounds like a horse race,

that's how you can get John Lomley to do these, that's how you can get John Lomley to do these,

telling us like horse racing.

towards you a bit, that's it.

Just press in there, you can.

Now come out of the way, okay.

Now I can release our,

so there's our finished product.

I'll just show you there with the,

hold that, sorry, did I stab you?

As you can see, she doesn't have that deep patch

of Douglas anymore.

She didn't have a very big fat pad there, but if I do, sometimes I'll excise that patch,

that big fat pad, what some people call a douglasectomy.

And so that's it, and we've had to mobilise the cecum and ternolilium here to allow the

small bowel to stay out of the pelvis, and now we need to release these endo-loops.

So it's a one-hour procedure?

That's approximately one hour. I think the average time at the moment is 70 minutes.

And this lady is going to go home when?

She'll probably go home this evening.

I'll take that out.

The main criteria is that they're comfortable and that their bladder is functioning.

So you used four 5mm ports so the pain will be minimal.

Yes, pain is usually not a major feature after this operation. Sometimes I do get a bit of

periosteal pain, but not immediately. Can you come off the head down too, please? Sucker.

Look in a bit. That's the operation complete. A big, fluffy sigmoid can hang down in there

there again. And as you can see, a very long, redundant sigmoid. And that endo-loop was

very useful to hold it out of the way. Otherwise, you'd be struggling all the time to keep it

out of there.

That's a nice trick.

Now let's take this, suck the gas and fluid out from over the liver. And the gas

off, please. Go to the overhead camera. And gas off. And we go to the monitor cam.

So we're all done here. Certainly happy to have any questions from the audience if you have time.

There is no chance now to ask questions because we're in a different room.

But we appreciated very much these procedures and we thank you very much for being with us this morning.

And on behalf of Professor Giorgio Palazzini and the whole audience, thank you very much.

You're welcome and thank you very much for the kind invitation and good luck for the rest of the conference.

Thank you. Have a good evening.

Thank you. You too.