Focus on abdominal rectopexy for full-thickness rectal prolapse: meta-analysis of literature

Mesh Rectopexy or Resection Rectopexy for Rectal Prolapse; Is There a Gold Standard Method: A Systematic Review, Meta-Analysis and Trial Sequential Analysis

(1) Background: Rectal prolapse is a benign condition that mainly affects females and the elderly. The most common symptoms are constipation and incontinence. The treatment of choice is surgical, but so far, there has been no gold standard method. The aim of this study is to compare the two most common intrabdominal procedures utilized for treating rectal prolapse: the resection rectopexy and the mesh rectopexy. (2) Methods: In this study, we conducted a thorough systematic review and meta-analysis of the available literature and compared the two different approaches regarding their complication rate, recurrence rate, and improvement of symptoms rate. (3) Results: No statistically significant difference between the two methods was found regarding the operating time, the length of stay, the overall complication rate, the surgical site infection rate, the cardiopulmonary complication rate, the improvement in constipation and incontinence rates, and the recurrence rate. (4) Conclusions: Our study revealed that mesh rectopexy and resection rectopexy for rectal prolapse have similar short- and long-term outcomes. As a result, the decision for the procedure used should be individualized and based on the surgeon's preference and expertise.

Rectal Prolapse Pathological Features: Findings in Patients With Outlet Obstruction Treated With Stapled Transanal Rectal Resection

BACKGROUND

Obstructed defecation syndrome is a common multifactorial disease for which treatment is based primarily on clinic presentation for the lack of reliable instrumental and anatomopathological criteria.

OBJECTIVE

The study aimed to analyze the pathological findings of the resected rectal specimens after stapled transanal rectal resection in patients affected by outlet obstruction.

DESIGN

Retrospective cohort study.

SETTINGS

University hospital.

PATIENTS

Patients who underwent rectal resection for obstructed defecation syndrome due to internal rectal prolapse were included.

INTERVENTIONS

Specimens of patients with obstructed defecation syndrome were analyzed through conventional histology and morphometric image analysis and compared with those of rectal specimens excised for oncological diseases.

MAIN OUTCOME MEASURES

Analysis of the anatomopathological impairments underlying rectal prolapse.

RESULTS

From January 2017 to December 2020, 46 specimens from the stapled transanal rectal resection group were compared with 40 specimens from the control group. In the stapled transanal rectal resection group, conventional histology revealed 34 samples (73.9%) had moderate- to severe-grade fibrosis with moderate-grade nerve degeneration in 33 cases (71.7%). In the control group, conventional histology revealed the absence of fibrosis in 31 specimens (77.5%), whereas the absence of nerve degeneration was detected in 37 specimens (92.5%). In the stapled transanal rectal resection group, morphometric image analysis showed severe-grade fibrosis in 25 cases (54.4%) compared to only low-grade fibrosis in 11 cases (27.5%).

LIMITATIONS

The small sample size and the retrospective design of the study were limitations. Moreover, there was no chance to use specimens from healthy volunteers as the control group.

CONCLUSIONS

Stapled transanal rectal resection specimens showed a higher rate of fibrosis and nerve dysplasia, an important parameter that is typically not considered preoperatively and could lead patients with rectal prolapse to the best treatment approach. See Video Abstract at http://links.lww.com/DCR/B928 .

CARACTERSTICAS ANATOMOPATOLGICAS EN EL PROLAPSO DE RECTO HALLAZGOS EN PACIENTES CON OBSTRUCCIN DEL TRACTO DE SALIDA TRATADOS CON RESECCIN RECTAL TRANSANAL CON GRAPAS

ANTECEDENTES:El síndrome de obstrucción del tracto de salida, es una afección multifactorial común, cuyo tratamiento está basado principalmente en la presentación clínica, ésto, debido a la falta de criterios confiables tanto instrumentales como anatomopatológicos.OBJETIVO:Analizamos los hallazgos histopatológicos de las piezas de resección rectal obtenidas por vía transanal mediante grapas, realizadas en pacientes que presentaban obstrucción del tracto de salida.DISEÑO:Este fue un estudio de cohorte retrospectivo.AJUSTE:El escenario fue un hospital universitario.PACIENTES:Aquellos sometidos a resección rectal por síndrome obstructivo del tracto de salida causada por un prolapso rectal interno.INTERVENCIONES:Los especímenes de pacientes con síndrome obstructivo defecatorio fueron analizados mediante histología convencional y análisis de imágenes morfométricas, comparados con especímenes rectales resecados por enfermedad oncológica.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario se concentró en la investigación de las deficiencias anatomopatológicas subyacentes del prolapso rectal interno.RESULTADOS:Desde enero de 2017 hasta diciembre de 2020, se compararon 46 especímenes del grupo de resección rectal transanal con grapas con 40 especímenes del grupo de control. En histología convencional, el grupo de resección rectal transanal con grapas, 34 muestras (73,9%) presentaron un grado de fibrosis moderada-severa con un grado moderado de degeneración neurógena en 33 casos (71,7%). En el grupo control, la histología convencional reveló ausencia de fibrosis en 31 especímenes (77,5 %), mientras que la ausencia de degeneración neurógena se detectó en 37 controles (92,5 %). En el grupo de resección rectal transanal con grapas, el análisis de imágenes morfométricas mostró fibrosis moderada y fibrosis severa en 19 (41,3%) y 25 (54,4%) casos, respectivamente. En el grupo control, el análisis de imágenes morfométricas mostró solo un bajo grado de fibrosis en 11 casos (27,5%). Se encontró una diferencia significativa en todos los grados de fibrosis y displasia neurógena entre los grupos en las evaluaciones de análisis de imagen morfométrica e histología convencional (p < 0,001).LIMITACIONES:El pequeño tamaño de la muestra y el diseño retrospectivo del estudio. Además, no existe la posibilidad de utilizar un grupo de control con muestras de voluntarios sanos.CONCLUSIONES:Los especímenes de resección rectal transanal con grapas mostraron una mayor tasa de fibrosis y displasia neurógena, parámetro importante que actualmente no está considerado antes de la operación y en un futuro muy cercano podría orientar a los pacientes con prolapso rectal interno hacia un mejor enfoque de tratamiento. Consulte Video Resumen en http://links.lww.com/DCR/B928 . (Traducción-Dr. Xavier Delgadillo ).

Robotic-assisted rectosigmoid resection rectopexy with natural orifice specimen extraction (NOSE): technical notes, short-term results, and functional outcome

PURPOSE

Rectosigmoid resection rectopexy has been established as an effective therapy for obstructive defecation syndrome. The addition of the NOSE-technique provides an even less invasive approach avoiding minilaparotomy, but can be technically challenging. Application of a robotic platform has been proposed to facilitate the specimen extraction and fashioning of the intracorporeal anastomosis and has been proven to be effective in left-sided colectomies.

METHODS

After establishing laparoscopic rectosigmoid-resection-rectopexy with NOSE, we modified our technique by addition of the robotic platform. Whenever robotic capacity was available, elective patients scheduled for rectosigmoid resection rectopexy for obstructive defecation syndrome were operated robotically assisted. Demographic and intraoperative data were prospectively collected. Follow up was assessed using the Wexner constipation score, Wexner incontinence score, and Altomare ODS score.

RESULTS

The NOSE-RRR technique was completed in all 31 patients. The mean operative time was 166 min (range 67-230). No conversion was required. The median hospital stay was 5 days (range 3-28). Four patients had minor complications (Clavien I). Two patients were reoperated (Clavien IIIb). Functional scores improved significantly postoperatively. Mean Wexner incontinence score was 7.1 preoperatively, 6.9 after 1 month, and decreased significantly to 3.93 after 3 months (p < 0.001). Mean Altomare ODS score was 17.47 preoperatively and 6.93/5.03 after 1/3 months (p < 0.001). Wexner constipation score (12.83) also showed a significant improvement after 1/3 months (6.97/6.67; p < 0.001).

CONCLUSION

NOSE-RRR can be performed safely with a low rate of manageable complications. The technique provides a significant improvement for ODS-Symptoms.

Outcomes for men undergoing rectal prolapse surgery - a systematic review

AIM

Rectal prolapse is considered rare in men but the prevalence can be high in certain populations. It is unclear which surgical approach offers lower recurrence rates and better functional outcomes in men. The aim of this work was to determine the recurrence rates, complications and functional outcomes after prolapse surgery in men.

METHOD

The MEDLINE, EMBASE and Scopus databases were systematically searched to identify studies on outcomes following surgical management of full-thickness rectal prolapse in men (over 18 years of age) published between 1951 and September 2022. Outcomes of interest included recurrence rate after surgery, bowel function, urinary function, sexual function and postoperative complications.

RESULTS

Twenty-eight studies involving 1751 men were included. Two papers focused exclusively on men. Twelve studies employed a mixture of abdominal approaches, ten employed perineal approaches and six compared both. The recurrence rate varied across studies, ranging from 0% to 34%. Sexual and urinary function were poorly reported, but the incidence of dysfunction appears low.

CONCLUSION

The outcomes of rectal prolapse surgery in men are poorly studied with small sample sizes and variable outcomes reported. There is insufficient evidence to recommend a specific repair approach based on the recurrence rate and functional outcomes. Further studies are required to identify the optimal surgical approach for rectal prolapse in men.

Mesh safety in pelvic surgery: Our experience and outcome of biological mesh used in laparoscopic ventral mesh rectopexy

BACKGROUND

Laparoscopic ventral mesh rectopexy (LVMR) continues to be a popular treatment option for rectal prolapse, obstructive defecation/faecal incontinence and rectoceles. In recent years there have been concerns regarding the safety of mesh placements in the pelvis.

AIM

To assess the safety of the mesh and the outcome of the procedure.

METHODS

Eighty-six patients underwent LVMR with Permacol (Biological) mesh from 2012 to 2018 at University Hospital Wishaw. Forty were treated for obstructive defecation secondary to prolapse, rectocele or internal rectal intussusception, 38 for mixed symptoms obstructive defecation and incontinence, 5 for pain and bleeding secondary to full thickness prolapse and 3 with symptoms of incontinence. Questionnaires for the calculation of Wexner scores for constipation and incontinence were completed by the patients who were followed up in the clinic 12 wk after surgery and again in 6-12 mo. The average review of their notes was 18.3 ± 4.2 mo.

RESULTS

The median Wexner scores for constipation pre-operatively and post-operatively were 14.5 [Interquartile range (IQR): 10.5-18.5] and 3 (IQR: 1-6), respectively, while the median Wexner score for faecal incontinence was 11 (IQR: 7-15) and 2 (IQR: 0-5), respectively (P < 0.01). There were 4 (4.6%) recurrences, 2 cases that presented with erosion of a suture through the rectum and one with diskitis. No mesh complications or mortalities were recorded.

CONCLUSION

LVMR using a Permacol mesh is a safe and effective procedure for the treatment of obstructive defecation/faecal incontinence, rectal prolapse, rectoceles and internal rectal prolapse/intussusception.

Update on Robotic Rectal Prolapse Treatment

Rectal prolapse is a condition that can cause significant social impairment and negatively affects quality of life. Surgery is the mainstay of treatment, with the aim of restoring the anatomy and correcting the associated functional disorders. During recent decades, laparoscopic abdominal procedures have emerged as effective tools for the treatment of rectal prolapse, with the advantages of faster recovery, lower morbidity, and shorter length of stay. Robotic surgery represents the latest evolution in the field of minimally invasive surgery, with the benefits of enhanced dexterity in deep narrow fields such as the pelvis, and may potentially overcome the technical limitations of conventional laparoscopy. Robotic surgery for the treatment of rectal prolapse is feasible and safe. It could reduce complication rates and length of hospital stay, as well as shorten the learning curve, when compared to conventional laparoscopy. Further prospectively maintained or randomized data are still required on long-term functional outcomes and recurrence rates.

Surgical Treatment of Rectal Prolapse in the Laparoscopic Era; A Review of the Literature

Rectal prolapse is associated with debilitating symptoms including the discomfort of prolapsing tissue, mucus discharge, hemorrhage, and defecation disorders of fecal incontinence, constipation, or both. The aim of treatment is to eliminate the prolapse, correct associated bowel function and prevent new onset of bowel dysfunction. Historically, abdominal procedures have been indicated for young fit patients, whereas perineal approaches have been preferred in older frail patients with significant comorbidity. Recently, the laparoscopic procedures with their advantages of less pain, early recovery, and lower morbidity have emerged as an effective tool for the treatment of rectal prolapse. This article aimed to review the current evidence base for laparoscopic procedures and perineal procedures, and to compare the results of various techniques. As a result, laparoscopic procedures showed a relatively low recurrence rate than the perineal procedures with comparable complication rates. Laparoscopic resection rectopexy and laparoscopic ventral mesh rectopexy had a small advantage in the improvement of constipation or the prevention of new-onset constipation compared with other laparoscopic procedures. However, the optimal surgical repair has not been clearly demonstrated because of the significant heterogeneity of available studies. An individualized approach is recommended for every patient, considering age, comorbidity, and the underlying anatomical and functional disorders.

Surgical Treatment of Rectal Prolapse: A 10-Year Experience at a Single Institution

Purpose

Methods

Results

Conclusion

Rectal-prolapse repair in men is safe, but outcomes are not well understood

Introduction

Rectal prolapse is a condition that occurs infrequently in men and there is little literature guiding treatment in this population. The purpose of this study was to evaluate the surgical approach and outcomes of rectal-prolapse repair in men.

Methods

A retrospective multicenter review was conducted of consecutive men who underwent rectal-prolapse repair between 2004 and 2014. Surgical approaches and outcomes, including erectile function and fecal continence, were evaluated.

Results

During the study period, 58 men underwent rectal-prolapse repair and the mean age of repair was 52.7 ± 24.1 years. The mean follow-up was 13.2 months (range, 0.5–117 months). The majority of patients underwent endoscopic evaluation (78%), but few patients underwent anal manometry (16%), defecography (9%) or ultrasound (3%). Ten patients (17%) underwent biofeedback/pelvic-floor physical therapy prior to repair. Nineteen patients (33%) underwent a perineal approach (most were perineal proctosigmoidectomy). Thirty-nine patients (67%) underwent repair using an abdominal approach (all were suture rectopexy) and, of these, 77% were completed using a minimally invasive technique. The overall complication rate was 26% including urinary retention (16%), which was more common in patients undergoing the perineal approach (32% vs. 8%, P = 0.028), urinary-tract infection (7%) and wound infection (3%). The overall recurrence rate was 9%, with no difference between abdominal and perineal approaches. Information on sexual function was missing in the majority of patients  both before and after surgery (76% and 78%, respectively).

Conclusion

 Rectal-prolapse repair in men is safe and has a low recurrence rate; however, sexual function was poorly recorded across all institutions. Further studies are needed to evaluate to best approach to and functional outcomes of rectal-prolapse repair in men.

Long-term outcomes of robotic ventral mesh rectopexy for external rectal prolapse

INTRODUCTION

Nowadays in Europe, laparoscopic ventral mesh rectopexy is the gold standard treatment of external rectal prolapse (ERP). The benefits of robot ventral mesh rectopexy (RVMR) are not clearly defined. The primary objective of the study was to evaluate the long-term results of RVMR. The secondary objective was to determine predictive factors of recurrence.

DESIGN

Monocentric, retrospective study. Data, both pre-operative and peri-operative, were collected, and follow-up data were assessed prospectively by a telephone questionnaire. The study was performed in a tertiary referral center.

METHODS

Between August 2007 and August 2017, we evaluate all consecutive patients who underwent RVMR for ERP by three different surgeons. The primary outcome was the recurrence rate perceived by patients. Secondary outcome were functional results based on Knowles-Eccersley-Scott-Symptom score for constipation and Wexner score for incontinence, compared before and after surgery.

RESULTS

During the study period 96 patients (86 women) underwent RVMR. The mean age was 62.3 years (range 16-90). Twelve patients had a history of ERP repair. Sixty-nine patients were analyzed for long-term outcomes with a mean follow-up of 37 months (range 2.3-92 months). Recurrence rate was 12.5%. After surgery, constipation was significantly reduced: 44 patients were constipated before surgery versus 23 after surgery. Six patients described de novo constipation (6.25%). Fecal incontinence was significantly reduced: 59 patients were incontinent before surgery versus 14 after surgery. No predictive factor for recurrence was identified after multivariate analysis. No mesh related complications were related.

CONCLUSIONS

In conclusion, RVMR presents good long-term functional result and a recurrence rate similar to LVMR as published in the literature. The rate of mesh related complications seems lower.

Consensus Statement of the Italian Society of Colorectal Surgery (SICCR): management and treatment of complete rectal prolapse

Rectal prolapse, rectal procidentia, "complete" prolapse or "third-degree" prolapse is the full-thickness prolapse of the rectal wall through the anal canal and has a significant impact on quality of life. The incidence of rectal prolapse has been estimated to be approximately 2.5 per 100,000 inhabitants with a clear predominance among elderly women. The aim of this consensus statement was to provide evidence-based data to allow an individualized and appropriate management and treatment of complete rectal prolapse. The strategy used to search for evidence was based on application of electronic sources such as MEDLINE, PubMed, Cochrane Review Library, CINAHL and EMBASE. The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by the American College of Gastroenterology's Chronic Constipation Task Force. Five evidence levels were defined. The recommendations were graded A, B, and C.

Retrospective case-matched study between reduced port laparoscopic rectopexy and conventional laparoscopic rectopexy for rectal prolapse

Introduction:

Reduced port laparoscopic Well's procedure (RPLWP) is a novel technique used to overcome the limitations of single-incision laparoscopic surgery. The aim of this study was to compare outcomes between RPLWP and conventional laparoscopic Well's procedure (CLWP) and to investigate the learning curve of RPLWP.

Patients and Methods:

From January 2006 to March 2017, a retrospective review of a prospectively maintained laparoscopic surgery database was performed to identify patients had undergone CLWP and RPLWP. From these patients, each of 10 cases were manually matched for age, sex, body mass index. From January 2006 to March 2015, CLWP was used for all procedures whereas, from April 2015, RPLWP was routinely performed as a standard procedure for rectal prolapse.

Results:

No significant differences were observed between the two groups in terms of operating time, blood loss, intraoperative complications, and conversion to CLWP or open rectopexy. Based on the postoperative outcomes, the hospital stay was significantly shorter in the RPLWP group. The estimated learning curve for RPLWP was fitted and defined as y = 278.47^e-0.064x with R²= 0.838; therefore, a significant decrease in operative time was observed by using the more advanced surgical procedure.

Conclusions:

RPLWP is an effective, safe, minimally invasive procedural alternative to CLWP with no disadvantage for patients when a skilled surgeon performs it.

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.

Robot-Assisted Ventral Mesh Rectopexy for Rectal Prolapse: A 5-Year Experience at a Tertiary Referral Center

BACKGROUND

Laparoscopic ventral mesh rectopexy is being increasingly performed internationally to treat rectal prolapse syndromes. Robotic assistance appears advantageous for this procedure, but literature regarding robot-assisted ventral mesh rectopexy is limited.

OBJECTIVE

The primary objective of this study was to assess the safety and effectiveness of robot-assisted ventral mesh rectopexy in the largest consecutive series of patients to date.

DESIGN

This study is a retrospective cross-sectional analysis of prospectively collected data.

SETTINGS

The study was conducted in a tertiary referral center.

PATIENTS

All of the patients undergoing robot-assisted ventral mesh rectopexy for rectal prolapse syndromes between 2010 and 2015 were evaluated.

MAIN OUTCOME MEASURES

Preoperative and postoperative (mesh and nonmesh) morbidity and functional outcome were analyzed. The actuarial recurrence rates were calculated using the Kaplan-Meier method.

RESULTS

A total of 258 patients underwent robot-assisted ventral mesh rectopexy (mean ± SD follow-up = 23.5 ± 21.8 mo; range, 0.2 - 65.1 mo). There were no conversions and only 5 intraoperative complications (1.9%). Mortality (0.4%) and major (1.9%) and minor (<30 d) early morbidity (7.0%) were acceptably low. Only 1 (1.3%) mesh-related complication (asymptomatic vaginal mesh erosion) was observed. A significant improvement in obstructed defecation (78.6%) and fecal incontinence (63.7%) were achieved for patients (both p < 0.0005). At final follow-up, a new onset of fecal incontinence and obstructed defecation was induced or worsened in 3.9% and 0.4%. The actuarial 5-year external rectal prolapse and internal rectal prolapse recurrence rates were 12.9% and 10.4%.

LIMITATIONS

This was a retrospective study including patients with minimal follow-up. No validated scores were used to assess function. The study was monocentric, and there was no control group.

CONCLUSIONS

Robot-assisted ventral mesh rectopexy is a safe and effective technique to treat rectal prolapse syndromes, providing an acceptable recurrence rate and good symptomatic relief with minimal morbidity. See Video Abstract at http://links.lww.com/DCR/A427.

Surgery for constipation: systematic review and practice recommendations: Results II: Hitching procedures for the rectum (rectal suspension)

AIM

To assess the outcomes of rectal suspension procedures (forms of rectopexy) in adults with chronic constipation.

METHOD

Standardised methods and reporting of benefits and harms were used for all CapaCiTY reviews that closely adhered to PRISMA 2016 guidance. Main conclusions were presented as summary evidence statements with a summative Oxford Centre for Evidence-Based Medicine (2009) level.

RESULTS

Eighteen articles were identified, providing data on outcomes in 1238 patients. All studies reported only on laparoscopic approaches. Length of procedures ranged between 1.5 to 3.5 h, and length of stay between 4 to 5 days. Data on harms were inconsistently reported and heterogeneous, making estimates of harm tentative and imprecise. Morbidity rates ranged between 5-15%, with mesh complications accounting for 0.5% of patients overall. No mortality was reported after any procedures in a total of 1044 patients. Although inconsistently reported, good or satisfactory outcome occurred in 83% (74-91%) of patients; 86% (20-97%) of patients reported improvements in constipation after laparoscopic ventral mesh rectopexy (LVMR). About 2-7% of patients developed anatomical recurrence. Patient selection was inconsistently documented. As most common indication, high grade rectal intussusception was corrected in 80-100% of cases after robotic or LVMR. Healing of prolapse-associated solitary rectal ulcer syndrome occurred in around 80% of patients after LVMR.

CONCLUSION

Evidence supporting rectal suspension procedures is currently derived from poor quality studies. Methodologically robust trials are needed to inform future clinical decision making.

Age and cellular context influence rectal prolapse formation in mice with caecal wall colorectal cancer xenografts

In patients with rectal prolapse is the prevalence of colorectal cancer increased, suggesting that a colorectal tumor may induce rectal prolapse. Establishment of tumor xenografts in immunodeficient mice after orthotopic inoculations of human colorectal cancer cells into the caecal wall is a widely used approach for the study of human colorectal cancer progression and preclinical evaluation of therapeutics. Remarkably, 70% of young mice carrying a COLO320DM caecal tumor showed symptoms of intussusception of the large bowel associated with intestinal lumen obstruction and rectal prolapse. The quantity of the COLO320DM bioluminescent signal of the first three weeks post-inoculation predicts prolapse in young mice. Rectal prolapse was not observed in adult mice carrying a COLO320DM caecal tumor or young mice carrying a HT29 caecal tumor. In contrast to HT29 tumors, which showed local invasion and metastasis, COLO320DM tumors demonstrated a non-invasive tumor with pushing borders without presence of metastasis. In conclusion, rectal prolapse can be linked to a non-invasive, space-occupying COLO320DM tumor in the gastrointestinal tract of young immunodeficient mice. These data reveal a model that can clarify the association of patients showing rectal prolapse with colorectal cancer.

Short term outcome of laparoscopic ventral rectopexy for rectal prolapse

Objective:

To find out the short term outcomes of effectiveness and safety of laparoscopic ventral rectopexy for rectal prolapse.

Methods:

It was a descriptive case series study of 31 consecutive patients of rectal prolapse in Colorectal division of Ward 2, Department of General surgery, Jinnah Post Graduate Medical Center, Karachi, from November 2009 to November 2015. These patients were admitted through outpatient department with complains of something coming out of anus, constipation and per rectal bleeding. All patients were clinically examined and baseline investigations were done. All patients underwent laparoscopic repair with ventral mesh placement on rectum.

Results:

Among 31 patients, mean age was 45 years range (20 - 72). While females were 14(45%) and males 17(55%). We observed variety of presentations, including solitary rectal ulcers (n=4) and rectocele (n=3) but full thickness rectal prolapse was predominant(n=24). All patients had laparoscopic repair with mesh placement. Average hospital stay was three days. Out of 31 patients, there was one (3.2%) recurrence. Port site minor infection in 3(9.7%) patients, while conversion to open approach was done in two (6.4%), postoperative ileus observed in two (6.4%) patients. one(3.2%) patient developed intractable back pain and mesh was removed six weeks after the operation. one(4.8%) patient complained of abdominal pain off and on postoperatively. No patient developed denovo or worsening constipation while constipation was improved in 21 patients (67%). Sexual dysfunction such as dysperunia in females and impotence in males was not detected in follow up.

Conclusions:

This study provides the limited evidence that nerve sparing laparoscopic ventral rectopexy is safe and effective treatment of external and symptomatic internal rectal prolapse. It has better cosmetic and functional outcome as advantages of minimal access and comparable recurrence rate.

Current status of laparoscopic and robotic ventral mesh rectopexy for external and internal rectal prolapse

External and internal rectal prolapse with their affiliated rectocele and enterocele, are associated with debilitating symptoms such as obstructed defecation, pelvic pain and faecal incontinence. Since perineal procedures are associated with a higher recurrence rate, an abdominal approach is commonly preferred. Despite the description of greater than three hundred different procedures, thus far no clear superiority of one surgical technique has been demonstrated. Ventral mesh rectopexy (VMR) is a relatively new and promising technique to correct rectal prolapse. In contrast to the abdominal procedures of past decades, VMR avoids posterolateral rectal mobilisation and thereby minimizes the risk of postoperative constipation. Because of a perceived acceptable recurrence rate, good functional results and low mesh-related morbidity in the short to medium term, VMR has been popularized in the past decade. Laparoscopic or robotic-assisted VMR is now being progressively performed internationally and several articles and guidelines propose the procedure as the treatment of choice for rectal prolapse. In this article, an outline of the current status of laparoscopic and robotic ventral mesh rectopexy for the treatment of internal and external rectal prolapse is presented.

Long-term Outcome After Laparoscopic Ventral Mesh Rectopexy: An Observational Study of 919 Consecutive Patients

OBJECTIVE

This multicenter study aims to assess long-term functional outcome, early and late (mesh-related) complications, and recurrences after laparoscopic ventral mesh rectopexy (LVR) for rectal prolapse syndromes in a large cohort of consecutive patients.

BACKGROUND

Long-term outcome data for prolapse repair are rare. A high incidence of mesh-related problems has been noted after transvaginal approaches using nonresorbable meshes.

METHODS

All patients treated with LVR at the Meander Medical Centre, Amersfoort, the Netherlands and the University Hospital Leuven, Belgium between January 1999 and March 2013 were enrolled in this study. All data were retrieved from a prospectively maintained database. Kaplan-Meier estimates were calculated for recurrences and mesh-related problems.

RESULTS

919 consecutive patients (869 women; 50 men) underwent LVR. A 10-year recurrence rate of 8.2% (95% confidence interval, 3.7-12.7) for external rectal prolapse repair was noted. Mesh-related complications were recorded in 18 patients (4.6%), of which mesh erosion to the vagina occurred in 7 patients (1.3%). In 5 of these patients, LVR was combined with a perineotomy. Both rates of fecal incontinence and obstructed defecation decreased significantly (P < 0.0001) after LVR compared to the preoperative incidence (11.1% vs 37.5% for incontinence and 15.6% vs 54.0% for constipation).

CONCLUSIONS

LVR is safe and effective for the treatment of different rectal prolapse syndromes. Long-term recurrence rates are in line with classic types of mesh rectopexy and occurrence of mesh-related complications is rare.

Laparoscopic rectopexy is feasible and safe in the emergency admission setting

AIM

External rectal prolapse may require emergency admission in the elderly and comorbid population. We report the safety and efficacy of laparoscopic ventral rectopexy in patients having an emergency admission with external rectal prolapse.

METHOD

A retrospective analysis was performed of a prospective database of all rectopexies performed from 2006. Outcome and follow-up data were assessed.

RESULTS

Of 812 rectopexies performed, 28 were included for analysis. The mean length of hospital stay was 13.0 days. All operations were completed successfully and without intra-operative complications. Four patients developed a postoperative complication. Two patients developed a recurrence of prolapse.

CONCLUSION

Laparoscopic correction of rectal prolapse following emergency admission is both feasible and safe. It can be considered for both recurring cases and cases with multiple comorbidities.

Laparoscopic surgery for rectal prolapse and pelvic floor disorders

Pelvic floor disorders are different dysfunctions of gynaecological, urinary or anorectal organs, which can present as incontinence, outlet-obstruction and organ prolapse or as a combination of these symptoms. Pelvic floor disorders affect a substantial amount of people, predominantly women. Transabdominal procedures play a major role in the treatment of these disorders. With the development of new techniques established open procedures are now increasingly performed laparoscopically. Operation techniques consist of various rectopexies with suture, staples or meshes eventually combined with sigmoid resection. The different approaches need to be measured by their operative and functional outcome and their recurrence rates. Although these operations are performed frequently a comparison and evaluation of the different methods is difficult, as most of the used outcome measures in the available studies have not been standardised and data from randomised studies comparing these outcome measures directly are lacking. Therefore evidence based guidelines do not exist. Currently the laparoscopic approach with ventral mesh rectopexy or resection rectopexy is the two most commonly used techniques. Observational and retrospective studies show good functional results, a low rate of complications and a low recurrence rate. As high quality evidence is missing, an individualized approach is recommend for every patient considering age, individual health status and the underlying morphological and functional disorders.

Laparoscopic posterior mesh rectopexy for rectal prolapse is a safe procedure in older patients: A prospective follow-up study

BACKGROUND AND AIMS

The aim of this study is to examine the clinical and functional outcome of laparoscopic posterior rectopexy in a consecutive series of adult patients with full-thickness rectal prolapse.

MATERIAL AND METHODS

Preoperative data on demography, life-style practices, medication, comorbidity, and previous surgery for rectal prolapse were ascertained from patient charts. Information on operative procedure, and pre- and postoperative complications were recorded. Short- and long-term follow-up were done after a median of 60 days and 2 years after surgery.

RESULTS

Between 1 February 2009 to 1 June 2012, 81 laparoscopic posterior rectopexies were done. Male-to-female ratio was 4:77, median age 73 [57-80.5] years and median ASA Grade 2. Conversion to open surgery was done in 6.2%, the median operating time was 82 min [66 - 102] and median length of hospital stay was 2 days [2-5.7]. Minor and major complications were seen in 5.3% and 14.8%, respectively. The 30-day mortality rate was 1.2%. Constipation or incontinence improved or disappeared in 65.2% and 74.4%, respectively. The cumulated recurrence rate was 11.1% after a median observation time of 2 years.

CONCLUSION

Laparoscopic posterior rectopexy is a safe and well-tolerated procedure in older patients and can be done with acceptable complications and recurrence rates and short hospital stays. Laparoscopic posterior rectopexy seems to improve bowel function in many patients.

The role of synthetic and biologic materials in the treatment of pelvic organ prolapse

Pelvic organ prolapse is a significant medical problem that poses a diagnostic and management dilemma. These diseases cause serious morbidity in those affected and treatment is sought for relief of pelvic pain, rectal bleeding, chronic constipation, obstructed defecation, and fecal incontinence. Numerous procedures have been proposed to treat these conditions; however, the search continues as colorectal surgeons attempt to find the procedure that would optimally treat these conditions. The use of prosthetics in the repair of pelvic organ prolapse has become prevalent as the benefits of their use are realized. While advances in biologic mesh and new surgical techniques promise improved functional outcomes with decreased complication rates without de novo symptoms, the debate concerning the best prosthetic material, synthetic or biologic, remains controversial. Furthermore, laparoscopic ventral mesh rectopexy has emerged as a procedure that could potentially fill this role and is rapidly becoming the procedure of choice for the surgical treatment of pelvic organ prolapse.

European Association of Endoscopic Surgeons (EAES) consensus statement on the use of robotics in general surgery

Following an extensive literature search and a consensus conference with subject matter experts the following conclusions can be drawn: 1. Robotic surgery is still at its infancy, and there is a great potential in sophisticated electromechanical systems to perform complex surgical tasks when these systems evolve. 2. To date, in the vast majority of clinical settings, there is little or no advantage in using robotic systems in general surgery in terms of clinical outcome. Dedicated parameters should be addressed, and high quality research should focus on quality of care instead of routine parameters, where a clear advantage is not to be expected. 3. Preliminary data demonstrates that robotic system have a clinical benefit in performing complex procedures in confined spaces, especially in those that are located in unfavorable anatomical locations. 4. There is a severe lack of high quality data on robotic surgery, and there is a great need for rigorously controlled, unbiased clinical trials. These trials should be urged to address the cost-effectiveness issues as well. 5. Specific areas of research should include complex hepatobiliary surgery, surgery for gastric and esophageal cancer, revisional surgery in bariatric and upper GI surgery, surgery for large adrenal masses, and rectal surgery. All these fields show some potential for a true benefit of using current robotic systems. 6. Robotic surgery requires a specific set of skills, and needs to be trained using a dedicated, structured training program that addresses the specific knowledge, safety issues and skills essential to perform this type of surgery safely and with good outcomes. It is the responsibility of the corresponding professional organizations, not the industry, to define the training and credentialing of robotic basic skills and specific procedures. 7. Due to the special economic environment in which robotic surgery is currently employed special care should be taken in the decision making process when deciding on the purchase, use and training of robotic systems in general surgery. 8. Professional organizations in the sub-specialties of general surgery should review these statements and issue detailed, specialty-specific guidelines on the use of specific robotic surgery procedures in addition to outlining the advanced robotic surgery training required to safely perform such procedures.

Ten-year follow up after laparoscopic suture rectopexy for full-thickness rectal prolapse

AIM

Studies have shown that recurrence rates of full-thickness rectal prolapse (FTRP) 5 years after surgery can quadruple at 10 years. This study aimed to evaluate the impact of laparoscopic suture rectopexy for FTRP on recurrence rates and functional outcome at a median follow up of 10 years.

METHOD

Prospectively collected data for patients who underwent laparoscopic suture rectopexy for FTRP between 1993 and 2006 were analysed. Laparoscopic rectopexy consisted of circumferential mobilization of the rectum down to the levator followed by suture suspension to promontory. Patients with preexisting constipation or who were unfit for general anaesthesia were not included. Incontinence, quality of life and constipation were assessed by validated scores. Recurrence-free curves were generated using the Kaplan-Meier method.

RESULTS

One hundred and seventy-nine patients with a median age of 62 (15-93) years including 174 women and five men underwent laparoscopic suture rectopexy. There was no mortality. The 30-day complication rate was 4% (partial transection of the left ureter, pneumonia, urinary tract infection, urinary retention, superficial surgical site infection). Data on 172 patients (96%) were available at follow up. There were 10 recurrences of FTRP at 5-year follow up giving a crude recurrence rate of 6%. The actuarial 10-year recurrence rate was 20% (95% CI, 10.8-20.1). Follow-up continence (P < 0.0001) and quality of life were better than preoperatively: lifestyle (P < 0.001), coping (P < 0.001), self-perception (P < 0.005), embarrassment (P < 0.06). Constipation was unchanged.

CONCLUSION

Laparoscopic suture rectopexy led to few complications, a recurrence rate of 20%, improved continence and quality of life with no worsening of constipation at 10 years.

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.

Long-term outcome of robotic-assisted laparoscopic rectopexy for full-thickness rectal prolapse in elderly patients

AIM

Full-thickness rectal prolapse is common in the elderly, but there are no particular practice guidelines for its surgical management. We evaluated retrospectively the perioperative and long-term clinical results and function in elderly and younger patients with complete rectal prolapse after robotic-assisted laparoscopic rectopexy (RALR).

METHOD

Seventy-seven patients who underwent RALR between 2002 and 2010 were divided into Group A (age < 75 years, n = 59) and Group B (age > 75 years, n = 18). Operative time, intra- and postoperative complications, length of hospital stay, short-term and long-term outcomes, recurrence rate and degree of satisfaction were evaluated.

RESULTS

There was no significant difference between the groups regarding operation time, conversion, morbidity or length of hospital stay. At a median follow-up of 51.8 (5-115) months, there was no difference in the improvement of faecal incontinence, recurrence and the degree of satisfaction.

CONCLUSION

Robotic-assisted laparoscopic rectopexy is safe in patients aged over 75 years and gives similar results to those in patients aged < 75 years.

Laparoscopic resection rectopexy versus laparoscopic ventral rectopexy for complete rectal prolapse

BACKGROUND

Laparoscopic resection rectopexy (LRR) and laparoscopic ventral rectopexy (LVR) are favored for the treatment for rectal prolapse (RP) in the USA and Europe, respectively. This study aims to compare these two surgical techniques.

METHODS

All patients who underwent LRR because of RP between January 2000 and January 2012 at Cleveland Clinic Florida (Weston, FL, USA) were identified, and all relevant characteristics were entered in a database. This same analysis was also conducted for all patients who underwent LVR in the Meander Medical Center (Amersfoort, the Netherlands) between January 2004 and January 2012. These two cohorts were retrospectively compared with regard to complications, functional results and recurrence.

RESULTS

Twenty-eight patients (all female, mean age 50.1 years) were included in the LRR cohort at a mean follow-up of 57 (range 2-140; standard deviation (SD) ± 41.2) months. The LVR group consisted of 40 patients (36 females and 4 males) with a mean age of 67.0 years and a mean follow-up of 42 (range 2-82; SD ± 23.8) months. A significant reduction in constipation was observed in both cohorts after surgery: 57 versus 21% after LRR and 55 versus 23% after LVR (both P < 0.05). The incidence of incontinence also significantly decreased in both groups: 15% after LVR (55% before surgery) and 4% after LRR (61 % before surgery). Direct comparison of these two techniques showed a trend to significance (P = 0.09). Significantly, more complications occurred after LRR (n = 9: 1 major, 8 minor) then after LVR (n = 3: 2 major, 1 minor) (P < 0.05).

CONCLUSIONS

Both LVR and LRR are effective for the treatment for RP. Although both techniques offer significant improvements in functional symptoms, continence may be better after LRR. However, LRR also had a higher complication rate then did LVR.

Laparoscopy for pelvic floor disorders

Surgical treatment of pelvic floor disorders has significantly evolved during the last decade, with increasing understanding of anatomy, pathophysiology and the minimally-invasive 'revolution' of laparoscopic surgery. Laparoscopic pelvic floor repair requires a thorough knowledge of pelvic floor anatomy and its supportive components before repair of defective anatomy is possible. Several surgical procedures have been introduced and applied to treat rectal prolapse syndromes. Transabdominal procedures include a variety of rectopexies with the use of sutures or prosthesis and with or without resection of redundant sigmoid colon. Unfortunately there is lack of one generally accepted standard treatment technique. This article will focus on recent advances in the management of pelvic floor disorders affecting defecation, with a brief overview of contemporary concepts in pelvic floor anatomy and different laparoscopic treatment options.

Changing approaches to rectal prolapse repair in the elderly

Aim: The abdominal approach to rectal prolapse is associated with lower rates of recurrence but a higher chance of complications and has been traditionally reserved for younger patients. However, longer life expectancy and wider use of laparoscopic techniques necessitates another look at the abdominal approach in older patients.

Methods: This was a retrospective review of data from patients undergoing abdominal repair of rectal prolapse between 2005 and 2011.

Results: Forty-six abdominal repairs (laparoscopic or open suture rectopexy, sigmoidectomy and rectopexy and low anterior resection) were performed during the study period. Twenty-nine repairs (63%) were performed in patients under the age of 70 (average age 51) and 17 (37%) in patients older than 70 (average age 76; range 71–89). Most of the cases performed during the initial 3 years of the study were via laparotomy. However, in the last 4 years, the laparoscopic approach was used in 83% of younger patients and 69% of older patients. Average length of stay was 2.6 days for younger and 3.8 days for older patients. Both groups had similar rates of re-admission: 20% vs 23%. The rate of wound infection was higher in the younger patients (5% vs nil). However, rates of urinary tract infection, two instances (10%) vs four (30%), urinary retention, one instance (5%) vs two (15.4%), ileus, one instance (5%) vs two (15.4%) were higher in the older group.

Conclusion: Wider use of laparoscopy has precipitated a change in the approach to rectal prolapse in older patients. Although associated with a slightly higher rate of post-operative complications, the abdominal approach to rectal prolapse is feasible, safe and effective in patients older than 70 years.

[Pelvic floor disorders from the surgeon's viewpoint]

Pelvic floor disorders present very differently with regard to symptoms and manifestation. Both diagnostic and treatment options require specific experience and an interdisciplinary approach. Diagnostic work-up is primarily based on medical history, physical examination and procto-rectoscopy. Furthermore, endosonography and perineal sonography have also gained importance. In almost all cases following these basic examinations conservative therapy options should be considered. As the interdisciplinary concept is very important, for careful diagnosis of pelvic floor disorders it became crucial to find an adequate form of treatment. Every decision for surgical therapy should not only focus on the results of previous examinations but should also consider the individual situation of each patient. In pelvic floor disorders a large variety of symptoms are confronted with a vast number of different and often highly specific procedures. The decisions on who to treat and how to treat are not only based on individual patient requests and desires but also on the experience and preference of the surgeon.

Long-term outcomes of robot-assisted laparoscopic rectopexy for rectal prolapse

BACKGROUND

Robot-assisted laparoscopic rectopexy for total rectal prolapse is safe and feasible. Small series proved clinical and functional short-term results comparable with conventional laparoscopy. No long-term results have been reported yet.

OBJECTIVE

The primary objective of the study was to evaluate long-term functional and anatomic results of robot-assisted laparoscopic rectopexy. The secondary objective was to evaluate the learning curve of this procedure.

DESIGN

Monocentric study data, both preoperative and perioperative, were collected prospectively, and follow-up data were assessed by a telephone questionnaire.

SETTINGS

The study was performed in an academic center by 3 different surgeons.

PATIENTS

We evaluated all of the consecutive patients who underwent a robot-assisted laparoscopic rectopexy between June 2002 and August 2010.

INTERVENTION

Rectopexy was performed with 2 anterolateral meshes or with 1 ventral mesh, and in 9 patients a sigmoidectomy was associated with rectopexy.

MAIN OUTCOME MEASURES

The actuarial recurrence rate was evaluated using the Kaplan-Meier method.

RESULTS

During the study period, 77 patients underwent a robot-assisted laparoscopic rectopexy, and the mean age was 59.9 years (range, 23-90 y). Average operating time was 223 minutes (range, 100-390 min); the learning curve was completed after 18 patients were seen. Two patients died of causes unrelated to surgery at 5 and 24 months. There were 5 conversions (6%) to open procedure. Overall morbidity was low and concerned only 8 patients (10.4%). Mean follow-up time was 52.5 months (range, 12-115 mo). Recurrences have been observed in 9 patients (12.8%). Preoperatively, 24 (34%) of the patients had constipation. Postoperatively, constipation disappeared for 12 (50%) of 24 and constipation appeared for 11 (24%) of 46 patients. Fecal incontinence decreased after surgery from Wexner score 10.5 to 5.1 of 20.

LIMITATIONS

There was a lack of standardization of the surgical procedure. The study was monocentric. Seven patients (9%) were lost to follow-up.

CONCLUSIONS

Long-term results of robot-assisted laparoscopic rectopexy are satisfying. Further studies comparing robot-assisted and conventional laparoscopy, including cost-effectiveness, are needed.

Hand-assisted laparoscopic suture rectopexy for complete rectal prolapse complicated by a solitary ulcer and obstructed defecation: a case report and review of the literature

Introduction

Solitary rectal ulcer syndrome is a condition in which an ulcer occurs in the rectum. There is evidence that solitary rectal ulcer syndrome is associated with rectal prolapse either overt or occult and that stopping complete rectal prolapse may lead to rapid healing of the solitary rectal ulcer. A huge variety of operative techniques have been described in the literature to correct this condition. We present the case of a patient who underwent hand-assisted laparoscopic suture rectopexy for complete rectal prolapse complicated by a solitary ulcer and obstructed defecation.

Case presentation

A 32-year-old Caucasian woman presented to our institute complaining of having had difficulty with her bowel movements, a rectal prolapse and pain in the anal area for one and a half years. She was checked in hospital for suspected rectal carcinoma, however, the examination revealed rectal ulceration. A diagnosis of complete rectal prolapse complicated by a solitary ulcer and obstructed defecation was established. The symptoms persisted so a hand-assisted laparoscopic suture rectopexy was performed. After six months of follow-up, her bowel movements had improved, she was experiencing no pain and the rectal ulcer had healed.

Conclusion

A hand-assisted laparoscopic suture rectopexy is a feasible and safe surgical treatment of rectal prolapse with solitary rectal ulcer syndrome, providing complete recovery for patients with solitary rectal ulcer syndrome.

Internal Delorme's procedure for rectal outlet obstruction

AIM

The outcome of the internal Delorme's procedure (IDP) for obstructed defaecation was assessed.

METHOD

From October 2001 to March 2009, 167 patients with obstructed defaecation associated with rectal intussusception were operated on. Patients were selected on the basis of validated constipation and continence scores, clinical examination and defaecography. Seventy-six patients were treated by the IDP alone and 91 patients were treated by the IDP with a levatorplasty. Before surgery and after a mean ± SD follow up of 3.0 ± 1.5 years, patients were assessed using the Cleveland Clinic Incontinence and Constipation Score (CCIS and CCCS), the Obstructed Defecation Score (ODS), faecal urgency and the Patient Assessment of Constipation Quality of Life (PAC-QoL) questionnaire.

RESULTS

Seventeen (10.2%) patients developed a postoperative complication including fissure-in-ano (4.2%), proctalgia (3.0%), suture-line dehiscence with stenosis (1.8%) and Clostridium difficile colitis (1.2%). Faecal urgency changed from 22% to 17.6% (P = 0.754). Tenesmus fell from 53.9% to 17.1% (P < 0.001). The CCCS and the ODS fell by 50% or more in 82.6% and 73.7% of the patients, respectively. The CCIS did not worsen significantly in patients who remained incontinent, and 45.7% of the previously incontinent patients regained normal continence. The CCCS decreased from 11 to 3 (P < 0.001) in the patients treated by the IDP and from 12 to 3 (P < 0.001) in the patients treated by the IDP with levatorplasty. The overall recurrence rate was 5.4%. The PAC-QoL showed a reduction of anxiety/depression and of physical and psychological discomfort (P < 0.001).

CONCLUSION

The IDP is an effective and safe option for rectal outlet obstruction caused by rectal intussusception with excellent function and patient satisfaction.

Rectal prolapse

CASE REPORT

A 56-year-old male presented to the emergency department with a feeling of heaviness and a protruding mass at the anal verge associated with pruritus in this area. The patient did not feel any pain and did not report experiencing faecal incontinence. Physical examination resulted in the visual diagnosis of a total rectal prolapse. Immediate manual repositioning through gentle pressure succeeded and the patient was scheduled for an elective laparoscopic ventral rectopexy.

DISCUSSION

Total rectal prolapse, or full-thickness rectal prolapse (procidentia), is defined as protrusion of the rectum beyond the anus. The entire rectal wall can be palpated in the externalized tissue exhibiting circular plication. Thus, a less distinct rectal prolapse can be distinguished visually from an anal mucosal prolapse as the latter shows stellate plication. Symptomatic patients having difficulties in reduction, substantial incontinence or obstructed defecation are to be referred for consideration of surgery.

Laparoscopic low ventral rectocolpopexy (LLVR) for rectal and rectogenital prolapse: surgical technique and functional results

BACKGROUND

Laparoscopic ventral rectopexy limits the risk of autonomic nerve damage, and the colpopexy allows correction of a concomitant prolapse of the middle compartment. The aim of this study is to describe a modified laparoscopic ventral rectocolpopexy procedure with a low approach to the sacral hollow (laparoscopic low ventral rectocolpopexy: LLVR). We propose this technique to manage combined rectogenital prolapse.

METHODS

Between November 2006 and June 2009, all patients with symptomatic rectal prolapse associated with genital prolapse and/or enterocele underwent LLVR. Demographics, results of imaging studies, mortality, morbidity, and functional outcome were retrospectively analyzed.

RESULTS

Thirty patients underwent LLVR: two patients suffered from a full-thickness rectal prolapse while 28 had symptomatic recto-anal intussusception. The mean operating time was 94 ± 39 minutes. Conversion to laparotomy was never needed. Hospital stay ranged between 2 and 14 days (mean of 5 ± 2.5 days). No mortality was recorded and only two complications occurred (6.6%): one trocar site incisional hernia and one vaginal suture erosion in a patient who had concomitant hysterectomy. After a mean follow-up of 13.9 months, constipation was completely resolved or improved in 92.8% patients. Significant reduction in the mean Altomare obstructed defecation score (14.7-5.6; p < 0.05) was recorded. Preoperative incontinence improved after the procedure in all patients affected. No new cases of postoperative constipation or fecal incontinence were registered. Only one case of recurrence in a patient with recto-anal intussusception was recorded (3.4%), after 19 months.

CONCLUSIONS

Laparoscopic low ventral rectocolpopexy is safe and associated with very low morbidity. In the medium term, it provides good result for prolapse and associated symptoms.