Laparoscopic Rectopexy

Anesthesia Implications

Position: Supine, Lithotomy, Trendelenburg, airplaned right, arms tucked
Time: 2-4 hours (long)
Blood Loss: Low (10-50 ml)
Post-op Pain: Moderate (3-6)
Maintenance Paralytic: Yes

Approach – GETT with paralytic.

Antibiotic – Ertapenem 1g or surgeon preference

Pain – This is a particularly painful procedure intraoperatively so consider using longer acting narcotics like dilaudid to curb the hemodynamic responses.

Tucked Arms (general considerations): Consider a second IV – once the procedure has started, it’s going to be VERY difficult to handle IV issues – especially if your only IV has problems. Ensure the IV is running and monitors are still functioning after tucking the patient’s arms

Laparoscopic cases (general considerations): The patient’s peritoneum is insufflated (which is called a pneumoperitoneum), and instrumentation will be inserted into the abdomen. General anesthesia, ETT tube, and paralytics are necessary. Some of the procedures are rather short, so make sure the timing is right to reverse the paralytic. The pressure in peritoneum affects the organs of that space. Anything more than 10 mmHg will begin to alter hemodynamics. Cardiac output is decreased and SVR is increased. Peak inspiratory pressures rise. Renal vessels will be compressed, which reduces flow to the kidneys, and activates the renin angiotensin aldosterone system (RAAS). Reduced blood to the kidney means reduced urine output. Peak inspiratory and plateau pressures will also increase. The gas used to insufflate the peritoneum is CO2 – so, as you might guess, hypercarbia can develop – and with it, acidosis. You’ll see this sometimes reflected in the end-tidal CO2. This is all adding to the stress response we try to avoid in anesthesia.

Long procedure (general considerations): Procedures anticipated to last longer than 2 hours generally require a urinary catheter. Also consider checking lines and positioning regularly as the risks of infiltration and nerve damage are increased with procedure time. Consider an IV fluid warmer and a forced air warmer to keep the patient euthermic.

Rectopexy is performed to treat rectal prolapse. Rectal prolapse occurs when the rectum protrudes from the anus. This can be caused by weakening of pelvic floor muscles, increased intra-abdominal pressure  (chronic coughing, obesity, etc), or chronic constipation.