Laparoscopic rectal prolapse surgery combined with short hospital stay is safe in elderly and debilitated patients

Laparoscopic ventral mesh rectopexy in the oldest old is safe: the race is run

BACKGROUND

Laparoscopic ventral mesh rectopexy (LVMR) is considered to be the gold standard for managing rectal prolapse. Nevertheless, concerns have been expressed about the use of this procedure in elderly patients. The aim of the current study was to examine the perioperative safety of primary LVMR operations in the oldest old in comparison to younger individuals and to assess our hospital policy of offering LVMR to all patients, regardless of age and morbidity.

METHODS

A retrospective study analysed demographic information, operation notes, meshes utilised, operation times, lengths of hospital stay (LOS) and American Society of Anesthesiologists (ASA) scores of patients who underwent LVMR at Elisabeth-TweeSteden Hospital between 2012 and 2023.

RESULTS

Eighty-seven female patients underwent LVMR. Nineteen patients were 80 years of age or older (OLD group); the remaining 65 patients were under the age of 80 (YOUNG group). The difference between the groups in terms of age was statistically significant. ASA scores were not significantly different. No mortality was observed. There was no statistically significant difference between the groups in terms of LOS, operation time or morbidity. Moreover, the postoperative morbidity profile was excellent in both groups.

CONCLUSION

LVMR seems to be a safe operation for the "oldest old" patients with comorbidity, despite a single-centre, retrospective trial with limited follow-up. The present study suggests abandoning the dogma that "frail patients with rectal prolapse are not suitable for laparoscopic ventral mesh rectopexy."

Perioperative Outcomes for Combined Ventral Rectopexy With Sacrocolpopexy Compared to Perineal Rectopexy With Vaginal Apical Suspension

OBJECTIVES

To describe and compare perioperative complications in women undergoing combined ventral rectopexy with sacrocolpopexy compared with perineal rectopexy with vaginal apical suspension.

METHODS

Current Procedural Terminology codes were used to identify women in the National Surgical Quality Improvement Program database who underwent ventral rectopexy with sacrocolpopexy or perineal rectopexy with vaginal apical suspension from 2006 to 2015. Perioperative complication was defined as any of the following within 30 days of surgery: death, return to the operating room, transfusion, or vascular, wound, respiratory, infectious, or renal morbidity. Secondary outcomes included length of hospital stay, operative time, blood loss, readmission, and rate of urinary tract infections. Modified Poisson regression was used to estimate the adjusted relative risks of complication associated with surgical approach, abdominal versus perineal.

RESULTS

Of the 273 women included, 240 (88%) underwent surgery with an abdominal approach, and 33 (12%) underwent surgery with a perineal approach. Perioperative complications occurred in 24 (9%) patients; 19 (8%) in the abdominal group and 5 (15%) in the perineal group. The age-adjusted risk of perioperative complications was not significantly different between those with a perineal approach compared with those with an abdominal approach (adjusted relative risk, 1.78; 95% confidence interval, 0.73-4.33).

CONCLUSIONS

Patients in this database who underwent surgery with a vaginal/perineal approach were not more likely to have a postoperative complication after adjusting for age compared with those undergoing an abdominal approach. Larger studies are needed to determine a more precise estimate of the impact of surgical approach on rates of perioperative complications.

Perineal Rectosigmoidectomy Revisited

Objective

The aim of this study was to evaluate the long-term results of perineal rectosigmoidectomy.

Background

Multiple surgical options are available for rectal prolapse perineal rectosigmoidectomy (Altemeier procedure) is the procedure of choice in elderly patients and those with multiple comorbidities.

Methods

Retrospective review was performed of all patients undergoing perineal rectosigmoidectomy from 1998 to 2008.

Results

Of 128 patients, 125 (98%) were women; with mean age 74 years. Mean operating time was 76 minutes. Hemostasis was achieved using ultrasonic scalpel or clamp and tie technique in equal numbers. Ultrasonic scalpel use resulted in shorter operative times (57.9 versus 94.7 minutes, respectively, P < 0.0001,) and estimated blood loss (18.8 versus 73 mL, respectively, P < 0.0001) compared to clamp-tie technique. Recurrence was seen in 23 (18%) patients. Recurrence was more after a handsewn anastomosis compared to a stapled anastomosis. Complications occurred in 3 patients (2%: 1 experienced major bleeding, 1 experienced perineal abscess, and 1 experienced postoperative ileus).

Conclusions

Perineal rectosigmoidectomy is associated with low morbidity and mortality. In addition, the minimal discomfort to patient, short length of stay and improvement in quality of life makes this a suitable operation for the elderly.

Getting to the bottom of treatment of rectal prolapse in the elderly: Analysis of the National Surgical Quality Improvement Program (NSQIP)

BACKGROUND

Many approaches to treat rectal prolapse exists, yet little is known regarding their safety in the elderly.

METHOD

NSQIP (2008-2014) was queried to identify patients ≥ 70 years who underwent open rectopexy (OR), laparoscopic rectopexy (LR) and perineal rectosigmoidectomy (PR). Patients were selected using NSQIP's estimated probability of morbidity of ≥50^th percentile. Outcomes were 30-day mortality and a composite: mortality, septic shock and organ space abscess and fascial dehiscence.

RESULTS

Overall, 1361 patients underwent OR(18%), LR(15%) and PR(67%) with no difference in outcomes among 3 approaches. After adjustment of other factors, the composite was associated with PR [OR 2.5, CI 1.1, 5.7] and not with older age [OR 1.3, (CI) 0.7, 2.4]. From 2008 to 2014, LR increased from 11% to 19%; and PR decreased from 75% to 72%.

CONCLUSIONS

All 3 surgical approaches carry low morbidity among the sick, elderly. PR remains the predominant approach nationally. A paradigm shift accepting the safety of abdominal approaches is needed. There should also be less focus on age in the decision-making process of surgical treatment.

One decade of rectal prolapse surgery: a national study

PURPOSE

We aimed to investigate the development of common procedures used as treatment for rectal prolapse over a decade and to determine if the choice of primary operation affects the reoperation rate.

METHODS

This is a retrospective analysis of operative data from a National Data Registry, Landspatientregisteret (LPR), from the period of January 1, 2004 to December 31, 2014. All hospitalized surgical treatments are registered in LPR.

RESULTS

Sixteen hundred and twenty-five patients with rectal prolapse underwent 1834 operations. There were 94% women and mean age at surgery was 71.6 ± 18.1 years, with no difference over the 11 years. The types of operations performed differed (p < 0.0001), with an increase in overall number of operations and increasing use of laparoscopic procedures. There were 209 reoperations, of which 129 patients were primarily operated with a perineal procedure. The mean age at reoperation was 72.8 ± 17.3 years. The most frequently used reoperation was laparoscopic rectopexy. The overall reoperation rate was 16%: 10% for both open and laparoscopic rectopexy, and for perineal procedures 26% (p < 0.001). The overall 30-day mortality was 2.1% and there was no difference in mortality between the procedures (p = 0.23).

CONCLUSIONS

The overall number of rectal prolapse operations was increasing. There was a clear trend towards extended use of laparoscopic rectopexy both as primary procedure and as reoperation. The highest reoperation rates were for the perineal procedures.

Optimizing Treatment for Rectal Prolapse

Rectal prolapse is associated with debilitating symptoms and leads to both functional impairment and anatomic distortion. Symptoms include rectal bulge, mucous drainage, bleeding, incontinence, constipation, tenesmus, as well as discomfort, pressure, and pain. The only cure is surgical. The optimal surgical repair is not yet defined though laparoscopic rectopexy with mesh is emerging as a more durable approach. The chosen approach should be individually tailored, taking into account factors such as presence of pelvic floor defects and coexistence of vaginal prolapse, severe constipation, surgical fitness, and whether the patient has had a previous prolapse procedure. Consideration of a multidisciplinary approach is critical in patients with concomitant vaginal prolapse. Surgeons must weigh their familiarity with each approach and should have in their armamentarium both perineal and abdominal approaches. Previous barriers to abdominal procedures, such as age and comorbidities, are waning as minimally invasive approaches have gained acceptance. Laparoscopic ventral rectopexy is one such approach offering relatively low morbidity, low recurrence rates, and good functional improvement. However, proficiency with this procedure may require advanced training. Robotic rectopexy is another burgeoning approach which facilitates suturing in the pelvis. Successful rectal prolapse surgeries improve function and have low recurrence rates, though it is important to note that correcting the prolapse does not assure functional improvement.

High-grade hemorrhoids requiring surgical treatment are common after laparoscopic ventral mesh rectopexy

Purpose

To describe patients developing grade III and IV hemorrhoids requiring surgery after laparoscopic ventral mesh rectopexy (LVMR) and to explore the relationship between developing such hemorrhoids and recurrence of rectal prolapse after LVMR.

Methods

All consecutive patients receiving LVMR at the Meander Medical Centre, Amersfoort, the Netherlands, between 2004 and 2013 were analyzed. Kaplan–Meier estimates were calculated for recurrences.

Results

A total of 420 patients underwent LVMR. Sixty-five of these patients (actuarial 5-year incidence 24.3, 95 % confidence interval (CI) 18.6–30.0) developed symptomatic grade III/IV hemorrhoids requiring stapled or excisional hemorrhoidectomy. Re-do surgery for recurrent grade III/IV hemorrhoids was required for 15 of the 65 patients (actuarial 5-year recurrence rate 40.6, 95 % CI 23.2–58.0) after the primary hemorrhoidectomy. Three of the 65 patients developed an external rectal prolapse (ERP) recurrence and eight an internal rectal prolapse (IRP) recurrence. This generated a 5-year recurrence rate of 25.3 % (95 % CI 0–53.9) for ERP recurrence and 24.4 % (95 % CI 9.1–39.7) for IRP recurrence. The rest of the LVMR cohort not receiving additional surgery for hemorrhoids (n = 355) showed significantly lower actuarial 5-year ERP (0.8 %, p = 0.011) and IRP (11 %, p = 0.020) recurrence rates.

Conclusion

High-grade hemorrhoids requiring surgery may be common after LVMR. The development of high-grade hemorrhoids after LVMR might be considered a predictor of rectal prolapse recurrence.

Safety of laparoscopic ventral rectopexy in the elderly: results from a nationwide database

BACKGROUND

Laparoscopic ventral rectopexy is an established procedure in the treatment of posterior pelvic organ prolapse. It is still unclear whether this procedure can be performed safely in the elderly.

OBJECTIVE

This study aimed to assess the effects of age on the outcome of laparoscopic ventral rectopexy performed for patients with pelvic organ prolapse.

DESIGN

This study was a retrospective cohort analysis with data from a national registry.

SETTINGS

The study was conducted in a tertiary care setting.

PATIENTS

Patients undergoing laparoscopic ventral rectopexy were identified from discharge summaries. Patients were stratified according to age, including patients <70 (group A) and ≥ 70 (group B) years old.

MAIN OUTCOME MEASURES

Variables analyzed included sex, age, diagnosis, associated pelvic organ prolapse, comorbidities, length of stay, complications (Clavien-Dindo scale), and mortality.

RESULTS

Among 4303 patients (98.2% women) who underwent a laparoscopic ventral rectopexy, 1263 (29.4%) were >70 years old (mean age, 76.2 ± 5.0 years). Main diagnoses were vaginal vault prolapse (53.0% [group A] vs 47.0% [group B]; p value not significant) and rectal prolapse (17.7 vs 26.8%; p value not significant). Comorbidity was significantly increased in group B (mean length of stay, 5.6 ± 3.6 vs 4.7 ± 1.8 days; p < 0.001) and minor complications (8.4% vs 5.0%; p < 0.001) were significantly increased in group B, whereas major complications were not different (group A, 0.7%; group B, 0.9%; p = 0.40) after univariate analysis. Multivariate analysis found no significant differences between groups. The subgroup analysis of patients >80 years old (n = 299) showed no differences. Each group had 1 postoperative mortality.

LIMITATIONS

Limitations of the study include its retrospective design, lack of prestudy power calculation, possible inaccuracy of an administrative database, and selection bias.

CONCLUSIONS

Laparoscopic ventral rectopexy appears to be safe in select elderly patients.

Clinical outcomes of perineal proctectomy among patients of advanced age

BACKGROUND

Rectal prolapse occurs primarily in older patients who often have significant comorbidities. With the aging population, increasing numbers of elderly patients are presenting with rectal prolapse. The perineal approach is preferred for these patients because it involves less perioperative risk than an abdominal procedure, but the outcomes of this procedure in elderly patients are unknown.

OBJECTIVE

The aim of this study was to examine whether clinical outcomes after perineal proctectomy are similar among elderly patients versus patients of younger age.

DESIGN

This study was a retrospective review.

SETTING

This study was conducted in mixed academic and private practice; the operations were performed at 16 hospitals.

PATIENTS

Patients who had perineal proctectomy for rectal prolapse from 1994 to 2012 were grouped according to age: <70 (group A), 70 to 79 (group B), 80 to 89 (group C), and ≥90 years (group D).

INTERVENTIONS

Perineal proctectomy with or without concurrent levatorplasty was performed.

MAIN OUTCOME MEASURES

The primary outcomes measured were postoperative complications, recurrence, and survival after perineal proctectomy.

RESULTS

Four hundred patients underwent 518 perineal proctectomies: group A, N = 113; group B, N = 113; group C, N = 208; and group D, N = 84. The immediate and late complication rates were 5.6% and 3.5% and did not vary by age. Recurrence was 22.6% and was significantly different between groups, with the lowest recurrence in group D, 14.3% (p = 0.007). Reoperation after recurrence was less likely in group D. The main type of reoperation was perineal proctectomy (41.5%), but, for group D, recurrence was usually managed nonoperatively (58.3%). Median survival after operation was more than 4 years in the advanced age group.

LIMITATIONS

Retrospective data, which did not allow analysis of patients with rectal prolapse who did not undergo surgery, were used in this study.

CONCLUSIONS

When selected appropriately, patients 90 years of age or older have outcomes similar to younger patients; therefore, age alone should not be a contraindication to surgery. In addition, elderly patients have a median survival of more than 4 years after surgery, so the operative risk can be worth the benefit accrued.

Laparoscopic ventral rectopexy in an elderly population with external rectal prolapse: clinical and anal manometric results

AIM

We report the clinical and anal manometric results of elderly patients treated with laparoscopic ventral rectopexy (LVR) for full-thickness rectal prolapse.

METHOD

From March 2009 to June 2012, patients were consecutively included. A modified laparoscopic Orr-Loygue procedure with posterior mobilisation was used. The patients were evaluated preoperatively, 2 months postoperatively and after 1 year. We registered Wexner incontinence scores and laxative uses by a questionnaire and performed simple anal manometry.

RESULTS

A total of 46 patients underwent operation, all women. The median age was 83 years (range 34-99), median prolapse size was 8 cm (range 2-15), and 30 % had previous prolapse surgery. The median operative time was 135 min (range 90-215), and the median length of stay was 2 days (range 1-14). The 30-day morbidity rate was 15 %, and there were two (4 %) deaths within 30 days. There was a significant reduction in incontinence scores after 2 months and 1 year. The anal resting pressures improved from 10 cm H(2)O slightly to 16 cm H(2)O after 2 months, significantly, and still significant after 1 year at 13 cm H(2)O. There were no changes in the use of laxatives. The median follow-up time was 1.5 years (range 0.5-3), and there were two prolapse recurrences (4 %) in this period.

CONCLUSIONS

Laparoscopic ventral rectopexy with posterior mobilisation seems to be effective and relatively well tolerated, although not without mortality in elderly debilitated patients. It improves incontinence. With increased life-year expectance, these patients may benefit from a lower risk of recurrence compared with perineal procedures.

Laparoscopic Rectopexy for Rectal Prolapse: Will it be the Gold Standard?

A review of the current literature is presented regarding the surgical management of full thickness rectal prolapse, comparing laparoscopic rectopexy with open abdominal operations and perineal procedures. Outcome measures include length of stay, short- and long-term outcomes and financial burdens. Current evidence suggests that laparoscopic rectopexy as treatment for full thickness rectal prolapse is a safe alternative to the other options.

Laparoscopic rectopexy for rectal prolapse to reduce surgical-site infections and length of stay

BACKGROUND

Rectal prolapse is commonly seen in patients with significant co-morbidities. Multiple approaches have been described, including the use of laparoscopy. The purpose of this study was to determine if laparoscopic approaches for repair of rectal prolapse are associated with less short-term morbidity than open approaches.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent laparoscopic or open rectopexy (R) or sigmoid resection and rectopexy (SR + R) between 2005 and 2008. Co-morbidities analyzed included diabetes, body mass index, chronic obstructive pulmonary disease, hypertension, cardiac (history of congestive heart failure, myocardial infarction, peripheral vascular disease, previous percutaneous cardiac intervention or surgery), and neurologic disorder (history of transient ischemic attack or cerebrovascular accident). Postoperative complications analyzed included surgical-site infections (SSIs), pneumonia, reintubation, pulmonary embolus, stroke, myocardial infarction, and sepsis. The χ (2) or t test/ANOVA were used to assess significance for categoric and continuous variables, respectively. Logistic regression analysis was used to determine risk factors for morbidity after rectal prolapse repair.

RESULTS

Altogether, 685 patients underwent surgical treatment of rectal prolapse. Most patients underwent open SR + R (open: 247 SR + R, 193 R; laparoscopic: 161 SR + R, 84 R). All patients had similar co-morbidity profiles. Patients undergoing laparoscopic R were significantly older (mean age 61.4 years) than those in the other three groups (p = 0.04). Operating time ranged from 128 min (open R) to 185 min (laparoscopic SR + R; p < 0.001). Open SR + R and open R were associated with significantly more morbidity than laparoscopic SR + R and R [odds ratio (OR) 0.42, 95 % confidence interval (CI) 0.22-0.83, p = 0.01]. Comparing all four procedures, there was a trend to decreased overall morbidity with laparoscopic R, but without statistical significance (OR 0.31, 95 % CI 0.07-1.40, p = 0.13). Length of hospital stay (LOS) and SSI rates were significantly lower with laparoscopic R than with the other three procedures.

CONCLUSIONS

Patients who undergo laparoscopic rectopexy have a shorter LOS and lower SSI rate than patients who undergo other abdominal procedures for repair of rectal prolapse. Further study is necessary to determine the long-term outcomes from laparoscopic rectopexy, but in high-risk patients the laparoscopic approach can decrease perioperative risk.

DeloRes trial: study protocol for a randomized trial comparing two standardized surgical approaches in rectal prolapse - Delorme's procedure versus resection rectopexy

Background

More than 100 surgical approaches to treat rectal prolapse have been described. These can be done through the perineum or transabdominally. Delorme’s procedure is the most frequently used perineal, resection rectopexy the most commonly used abdominal procedure. Recurrences seem more common after perineal compared to abdominal techniques, but the latter may carry a higher risk of peri- and postoperative morbidity and mortality.

Methods/Design

DeloRes is a randomized, controlled, observer-blinded multicenter trial with two parallel groups. Patients with a full-thickness rectal prolapse (third degree prolapse), considered eligible for both operative methods are included. The primary outcome is time to recurrence of full-thickness rectal prolapse during the 24 months following primary surgery. Secondary endpoints are time to and incidence of recurrence of full-thickness rectal prolapse during the 5-year follow-up, duration of surgery, morbidity, hospital stay, quality of life, constipation, and fecal incontinence. A meta-analysis was done on the basis of the available data on recurrence rates from 17 publications comprising 1,140 patients. Based on the results of a meta-analysis it is assumed that the recurrence rate after 2 years is 20% for Delorme’s procedure and 5% for resection rectopexy. Considering a rate of lost to follow-up without recurrence of 30% a total of 130 patients (2 x 65 patients) was calculated as an adequate sample size to assure a power of 80% for the confirmatory analysis.

Discussion

The DeloRes Trial will clarify which procedure results in a smaller recurrence rate but also give information on how morbidity and functional results compare.

Trial registration

German Clinical Trial Number DRKS00000482

Rectal prolapse in the elderly: trends in surgical management and outcomes from the American College of Surgeons National Surgical Quality Improvement Program database

BACKGROUND

Full thickness rectal prolapse (FTRP) is managed with an abdominal or perineal operation. Traditionally, the approach has been determined by patient age and comorbidities. Our aim was to determine operative trends and outcomes for repair of FTRP in elderly patients using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database.

STUDY DESIGN

We queried the ACS NSQIP database from 2006 to 2009 for patients with FTRP who were 70 years of age or older. Patients were grouped according to type of surgical repair: laparoscopic (LR), open (OR), or perineal (PR) technique. We reviewed demographics, operative trends of surgical technique, and short-term outcomes for each group.

RESULTS

A total of 816 patients were analyzed; 596 (73%) PR, 130 (16%) OR, and 90 (11%) LR patients. Patients who received OR and LR had lower mean American Society of Anesthesiologists (ASA) scores than PR patients (2.6, 2.5, and 2.7, respectively, p < 0.001). The percentage of LR and OR procedures decreased as age increased by decade; the inverse was seen for PR (p < 0.001). The distribution of operative techniques has not changed from year to year. Length of stay was significantly shorter for LR (3.77 days) and PR (3.44 days) patients vs OR patients (6.23 days) (p = 0.01). Complication rates were 2.22%, 8.72%, and 12.31% for LR, PR, and OR, respectively (p = 0.021). Open surgery was the only factor associated with an increased complication rate, with an odds ratio of 6.29 (95% CI 1.38 to 28.6, p < 0.02).

CONCLUSIONS

Despite the appeal of perineal proctectomy in the elderly and debilitated patient, the approach to FTRP is slowly evolving in the era of laparoscopic surgery. Laparoscopic repair of FTRP in the elderly is associated with improved short-term outcomes when compared with OR and PR.

Hospital discharge criteria following colorectal surgery: a systematic review

AIM

The aim of this study was to identify and synthesize the hospital discharge criteria that have been used in the colorectal surgery literature.

METHODS

A systematic literature search was conducted using eight bibliographic databases. Searches were limited to English language journal articles published between January 1996 and October 2009. Primary research applying hospital discharge criteria following colorectal surgery was included. Study selection was made independently by two reviewers. Discharge criteria were extracted from each included study.

RESULTS

The 156 studies identified by the search strategy described 70 different sets of criteria to indicate readiness for discharge. The majority of studies applied a combination of three or four criteria; those most frequently cited were tolerance of oral intake (80%), return of bowel function (70%), adequate pain control (44%) and adequate mobility (35%). End-points employed to determine the achievement of criteria were generally poorly defined.

CONCLUSION

A variety of hospital discharge criteria were applied in the colorectal surgery literature. Development of standardized criteria will allow more accurate comparison of results between studies assessing hospital length of stay or other discharge-related outcome measures.

Outcome of laparoscopic rectopexy versus perineal rectosigmoidectomy for full-thickness rectal prolapse in elderly patients

BACKGROUND

The balance between abdominal and perineal approaches for rectal prolapse is always the higher morbidity but better outcome in the former setting. Therefore, perineal approaches have been preferred for the treatment of full-thickness rectal prolapse (FTRP) in elderly patients. However, laparoscopic rectopexy with or without resection also may be used for elderly patients and may confer the same benefits.

PURPOSE

The objective of this study was to evaluate safety and efficacy of laparoscopic rectopexy compared with perineal rectosigmoidectomy for FTRP in elderly patients.

METHODS

Between July 2000 and June 2009, eight consecutive patients (8 women; mean age, 71 (range, 65-77) years) with FTRP underwent laparoscopic rectopexy (LAP group). During the same period, 143 patients underwent perineal rectosigmoidectomy (PRS group). A total of 123 patients were selected who underwent perineal rectosigmoidectomy (117 women; mean age, 80.7 (range, 66-98) years).

RESULTS

Three patients (37.5%) in the LAP group and 29 patients (23.6%) in the PRS group had undergone previous operations for rectal prolapse. The mean follow-up periods were 6.9 months and 12.8 months, respectively. In the LAP group, operative time was longer (166.5 vs. 73.5 minutes; p > 0.05) and bleeding loss was more (101.7 vs. 31.6; p < 0.05), whereas the length of hospitalization was same between the two groups (5.4 vs. 5.3 days; p > 0.05). Postoperative complications included an incisional hernia in the LAP group (12.5%) and urinary retention (4.8%), anastomotic disruption (2.4%), urinary tract infection (1.6%), and atelectasis (1.6%) in the PRS group (13.8%). Recurrences were 1 (12.5%) in the LAP group and 14 (11.4%) in the PRS group.

CONCLUSIONS

Laparoscopic rectopexy is a safe and feasible procedure in elderly patients with FTRP but results in increased operative time.

Common transabdominal surgical options for rectal prolapse

Rectal prolapse is a troublesome anorectal disorder. Surgical procedures for rectal prolapse contain transabdominal and transperineal approaches. There are hundreds of transabdominal procedures currently available for treatment of the disease, such as Ripstein procedure, Wells procedure, Orr procedure, Nigro procedure, anterior resection, Frykman-Goldberg procedure, and Roscoe Graham procedure. Laparoscopic repair represents the latest advance in surgical treatment of rectal prolapse. As each procedure has its strength and weakness, personalized selection of appropriate procedure can greatly improve surgical outcome. Individualized diagnosis and treatment plan may represent a new direction for transabdominal surgical treatment of rectal prolapse.

Multimedia manuscript. Laparoscopic rectopexy with posterior mesh fixation

OBJECTIVE

The purpose of this multimedia article is to present a technique of laparoscopic rectopexy with fixation of the rectum to the sacrum using a short strip of mesh.

METHODS

The technique is presented in a video clip.

RESULTS

The laparoscopic rectopexy procedure is usually performed using four ports. First, the upper rectum is mobilized on its right side, and dissection posterior to the rectum is performed all the way down to the level of the pelvic floor. Anterior mobilization is performed next, and the rectovaginal septum is dissected all the way down to the level of the pelvic floor. A short strip of mesh, approximately 5 cm × 2 cm in diameter, is introduced through the right lower quadrant port. The mesh is placed vertically on the sacrum from the level of the sacral promontory downward, and secured to the sacrum using endo-tackers, which should be applied below the promontory and adjacent to the midline to avoid injury to the hypogastric nerves. The mesorectum is then secured to the mesh in four points using absorbable sutures. Applying adequate sutures directly to the presacral fascia using the relatively small needles that can go through the ports may be a difficult task. Suturing to the mesh, however, is very easy, and in our opinion may be considered the main advantage of the posterior mesh technique. Ten female patients (age range, 26-84 years) underwent rectopexy using this technique. At a mean follow-up of 2.2 years, two had recurrent prolapse-one of which, the only patient in whom absorbable tackers were used-had in-house recurrence and refixation. Complications included one patient with mild pelvic pain, which spontaneously resolved in 3 weeks.

CONCLUSION

The presented technique may ease fixation of the rectum to the sacrum and potentially improve results.

Open vs laparoscopic repair of full-thickness rectal prolapse: a re-meta-analysis

OBJECTIVE

A re-meta-analysis of available data within the published literature comparing laparoscopic rectopexy (LR) with open repair (OR).

METHOD

We searched MEDLINE, EMBASE, CINAHL, PubMed and the Cochrane databases from January 1990 to October 2008. We searched the following MESH terms: 'laparoscopy', 'prolapse' and 'rectal prolapse'. We used the following text words: 'rectopexy', 'haemorrhoids', 'minimally invasive' and 'keyhole surgery'. The bibliography of selected trials and a Cochrane review was scrutinized and relevant references obtained. Selected trials were analysed to conduct a meta-analysis.

RESULTS

Twelve comparative studies on 688 patients qualified for the review. There were 330 patients in LR group and 358 in the OR group. LR takes longer to perform compared with OR. This difference was statistically significant [random effects model: standardized mean difference (SMD) 1.63, 95% CI (1.14-2.12), z = 6.56, P < 0.001]. There was a significant reduction in hospital stay between LR vs OR [random effects model: SMD -1.75, 95% CI (-2.45 to -1.05), z = -4.90, P < 0.001]. There was no statistical difference relating to morbidity, constipation, incontinence or mortality between the two groups.

CONCLUSION

Laparoscopic rectopexy is a safe and effective modality and is comparable to OR, however, there is still a paucity of randomized controlled trials within the literature regarding this subject. Until these trials are conducted, we would advise caution in deriving absolute conclusions.

Tailored surgery for internal and external rectal prolapse: functional results of 268 patients operated upon by a single surgeon over a 21-year period*

OBJECTIVE

Many procedures are used to treat internal (IRP) and external rectal prolapse (ERP). We report the outcome of surgery tailored in accordance with an evolving Unit algorithm over a 21-year period.

METHOD

Two hundred and sixty-eight patients (151 IRP and 117 ERP) are reported. Perineal procedures (Delorme's mucosectomy, Altemeier's perineal rectosigmoidectomy) were used in frail elderly patients with ERP with abdominal sacrorectopexy or the Frykman-Goldberg procedure in fit patients. In IRP, prolapsectomy was most common with anterior hemi-Delorme's procedures for rectocele and levatorplasty for coincident faecal incontinence. Clinical and functional outcome was assessed over a median of 61 months (range 4-184 months).

RESULTS

Postoperative mortality was 0.4%. For ERP, a perineal procedure was carried out in 75 (61.4%) cases with a 7.2% complication rate, postoperative incontinence in 20 (26.7%), constipation in four (5.3%) and recurrence in 12 (16%). For 42 abdominal procedures, the complication rate was 5% with incontinence in 7.1%, constipation in eight (19%) and recurrence in five (11.9%). A perineal operation was used in 89.4% of patients with IRP with incontinence in 10.6%, persistent constipation in 48 (52.7%) and recurrence in 25 (27.5%). The overall incontinence rate was 11% following abdominal and 24% following perineal procedures (P < 0.05). Recurrence of ERP was significantly higher following a perineal operation (P < 0.05).

CONCLUSION

Tailored surgery for ERP achieves satisfactory results in terms of recurrence and functional outcome. For patients with IRP, perineal procedures are associated with a high incidence of recurrence and residual evacuatory difficulty.

Prolapse of the rectum, long-term results of surgical treatment

AIMS

This study evaluates patency and functional results of abdominal and perineal treatment approaches to prolapse of the rectum.

METHODS

A database search identified patients operated upon for prolapse of the rectum. The operations were abdominal or perineal approaches. The patient's records were reviewed, patients alive were contacted, and a self-report form evaluated functional results. Patients were followed until the prolapse recurred.

RESULTS

A primary operation for prolapse of the rectum was performed in 56 patients. Median age was 59 years (range 20-87) and 78 (40-91) for abdominal and perineal approaches, respectively (p < 0.001). The average length of the prolapses was 8.7 cm (2-25) and 8.6 cm (2-15) for abdominal or perineal approaches. All prolapses treated with a Thiersch's operation recurred within a few months and all prolapses treated with the Delorme's operation recurred within 5 years, whereas the 5-year patency of the abdominal approach was 93% (p < 0.001). No prolapses recurred after mesh rectopexy and the 5-year patency of resection rectopexy was 86%. The abdominal approaches improved stool evacuation and constipation significantly, and anal leakage improved somewhat (p = 0.065). The median hospital stay was 11 (4-20) and 7 (2-155) days after abdominal and perineal approaches (p = 0.003). Complications occurred in 20% of patients.

CONCLUSIONS

The patency of abdominal approach to prolapse of the rectum is better than that of perineal repairs. The abdominal approaches also have a favorable effect on constipation and anal insufficiency. Perineal approaches should be reserved for patients with a very short life expectancy.

Robot-assisted laparoscopic rectovaginopexy for rectal prolapse: a prospective cohort study on feasibility and safety

Robotic systems may be particularly supportive for procedures requiring careful pelvic dissection and suturing in the Douglas pouch, as in surgery for rectal prolapse. Studies reporting robot-assisted laparoscopic rectovaginopexy for rectal prolapse, however, are scarce. This prospective cohort study evaluated the outcome of this technique up to one year after surgery. From January 2005 to June 2006, 15 consecutive patients with a rectal prolapse, either with or without a concomitant rectocele or enterocele, underwent robot-assisted laparoscopic rectovaginopexy with support of the da Vinci robotic system. A prospective cohort study was performed on operating times, blood loss, intra-operative and post-operative complications, and outcome at a minimum of one year after surgery. Median age at time of operation was 62 years (33-72) and median body mass index 24.9 (20.9-33.9). Median robot set-up time was 10 min (3-15) and median skin-to-skin operating time was 160 min (120-180). No conversions to open surgery were necessary. No in-hospital complications occurred and there was no mortality. Median hospital stay was four days (2-9). During one year follow-up, two patients needed surgical reintervention. One patient was operated for recurrent enterocele and rectocele one week after surgery. In another patient an incisional hernia at the camera port occurred three months after surgery. At one year after surgery, 87% of patients claimed to be satisfied with their postoperative result. Robot-assisted laparoscopic rectovaginopexy proved to be an effective technique with favourable outcomes in most patients in this prospective series. The operating team experienced the support of the robotic system as beneficial, especially during the dissection of the rectovaginal plane and suturing in the Douglas pouch.