Functional results after laparoscopic rectopexy for rectal prolapse

European Society of Coloproctology guidance on the use of mesh in the pelvis in colorectal surgery

This is a comprehensive and rigorous review of currently available data on the use of mesh in the pelvis in colorectal surgery. This guideline outlines the limitations of available data and the challenges of interpretation, followed by best possible recommendations.

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.

The association between a positive lactulose methane breath test and rectocele in constipated patients

OBJECTIVES

Rectocele with constipation might be related to methane (CH4) producing intestinal bacteria. We investigated the breath CH4 levels and the clinical characteristics of colorectal motility in constipated patients with rectocele.

METHODS

A database of consecutive female outpatients was reviewed for the evaluation of constipation according to the Rome III criteria. The patients underwent the lactulose CH4 breath test (LMBT), colon marker study, anorectal manometry, defecography and bowel symptom questionnaire. The profiles of the lactulose breath test (LBT) in 33 patients with rectocele (with size ≥ 2 cm) and 26 patients with functional constipation (FC) were compared with the breath test results of 30 healthy control subjects.

RESULTS

The mean size of rectocele was 3.52 ± 1.06 cm. The rate of a positive LMBT (LMBT+) was significantly higher in patients with rectocele (33.3%) than in those with FC (23.1%) or healthy controls (6.7%) (p = 0.04). Breath CH4 concentration was positively correlated with rectosigmoid colon transit time in rectocele patients (γ = 0.481, p < 0.01). A maximum high pressure zone pressure > 155 mmHg was a significant independent factor of LMBT+ in rectocele patients (OR = 8.93, 95% CI = 1.14-71.4, p = 0.04).

CONCLUSIONS

LMBT+ might be expected in constipated patients with rectocele. Moreover, increased rectosigmoid colonic transit or high anorectal pressure might be associated with CH4 breath levels. Breath CH4 could be an important therapeutic target for managing constipated patients with rectocele.

Primary and repeated perineal stapled prolapse resection

BACKGROUND

Previous studies of the outcome after perineal stapled prolapse resection (PSPR) have included a limited number of patients with a short follow-up and high recurrence rates. The present study was designed to assess the initial results, complications, recurrence rate, and outcomes up to 4 years after PSPR, as well as the need for a repeated procedure.

METHODS

Fifty-four consecutive patients with rectal prolapse (mean age 77.2 years, range 46-93 years; n = 3 men) were selected for PSPR between May 2009 and February 2015. Prolapse length was measured at baseline and after surgery. Patients were asked to grade intensity of symptoms as a satisfaction score of 1-10, 10 representing being symptom-free.

RESULTS

The mean operation time was 45.3 min (SD = 17.5, range 25-95 min). The mean rectal prolapse length was reduced significantly from 9.5 cm (SD = 5.0, range 4-30 cm) to 1.2 cm (SD = 2.6, range 0-10 cm; p < 0.0001). Bleeding requiring surgical intervention occurred in two patients (3.7%). Postoperative satisfaction score increased from a mean of 2.2 (SD = 0.9) to a mean of 6.4 (SD = 2.8, p ≤ 0.0001). After a mean follow-up of 13.4 months (SD = 14.1), six patients with recurrence underwent a new PSPR and five patients underwent colostomy, mainly because of incontinence, resulting in a recurrence rate of 20.4%. There were no complications after redo PSPR, and after a median of 10-month follow-up (range 6-37), there were no recurrences.

CONCLUSIONS

PSPR is a rather new surgical procedure for external rectal prolapse. Immediate complications are few and not serious. Although recurrences can be treated with a second PSPR, the operation may only be the best option for old and fragile patients with comorbidities and a short life expectancy.

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.

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.

In patients with rectoceles and obstructed defecation syndrome, surgery should be the option of last resort

BACKGROUND

The indications for operation in patients with obstructed defecation syndrome (ODS) with rectocele are not well defined.

METHODS

A total of 90 female patients with ODS and rectocele were prospectively evaluated and treated with fiber supplements and biofeedback training. Univariate and multivariate regression was used to determine factors predictive of failing medical management.

RESULTS

Obstructive symptoms were the most prevalent presenting complaint (82.2%). Ultimately, 71.1% of patients responded to medical management and biofeedback. Multivariate regression analysis suggested that the presence of internal intussusception was associated with a lower chance of undergoing surgery to address ODS symptoms [odds ratio 0.18; P = .05], whereas inability to expel balloon, contrast retention on defecography, and splinting were not (P ≥ .15).

CONCLUSION

Rectoceles with concomitant intussusception in patients with ODS appear to portend a favorable response to biofeedback and medical management. We argue that all patients considered for surgery for rectoceles because of ODS should first undergo appropriate bowel retraining.

Rectal prolapse and intussusception

Rectal prolapse continues to be problematic for both patients and surgeons alike, in part because of increased recurrence rates despite several well-described operations. Patients should be aware that although the prolapse will resolve with operative therapy, functional results may continue to be problematic. This article describes the recommended evaluation, role of adjunctive testing, and outcomes associated with both perineal and abdominal approaches.

Are rectoceles the cause or the result of obstructed defaecation syndrome? A prospective anorectal physiology study

AIM

To determine the relationship between obstructed defaecation syndrome (ODS) and rectoceles.

METHOD

From December 2007 to November 2011, all female patients with ODS were prospectively evaluated with full interview, clinical examination and anorectal physiology testing. The characteristics of patients with and without rectoceles were compared, and logistic regression was utilized to identify factors predictive of patients having a rectocele beyond the introitus.

RESULTS

Of 239 patients with ODS, 90 (mean age: 52.3 ± 1.7 years) had a rectocele. Patients with rectoceles (R+) had a similar prevalence of incomplete emptying compared with patients with no rectocele (R-) (P ≥ 0.21), but only R+ patients reported splinting with defaecation (36.7% vs 0%; P < 0.0001). Anorectal manometry measurements, including mean resting pressure, maximum resting pressure and maximum squeeze pressure, were similar between groups (P ≥ 0.12). There were also no significant differences in rectal compliance (maximum tolerated volume) or rectal sensitivity (volume of first sensation) (P ≥ 0.65). R+ patients had greater difficulty expelling a 60 cm(3) balloon (70.1% R+ patients vs 57.5% R- patients; P = 0.05), but the prevalence of pelvic floor dyssynergia, as quantified by nonrelaxation on electromyography (EMG) testing, was similar to that of R- patients (P = 0.49). Logistic regression suggested that only difficulty with balloon expulsion was associated with higher odds of having a rectocele (OR = 3.00; P = 0.002), whereas mean resting pressure, EMG nonrelaxation and symptoms of incomplete emptying were not (P ≥ 0.12).

CONCLUSION

Rectoceles are not associated with an increased severity of ODS-type symptoms, anorectal abnormalities or pelvic floor dyssynergia in patients with ODS. This suggests that rectoceles may be the result, rather than the cause, of ODS.

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

BACKGROUND

Laparoscopic rectopexy to treat full-thickness rectal prolapse has proven short-term benefits, but there are few long-term follow-up and functional outcome data available. Using meta-analysis techniques, this study was designed to evaluate long-term results of open and laparoscopic abdominal procedures to treat full-thickness rectal prolapse in adults.

METHODS

A literature review was performed using the National Library of Medicine's PubMed database. All articles on abdominal rectopexy patients with a follow-up longer than 16 months were considered. The primary end point was recurrence of rectal prolapse, and the secondary end points were improvement in incontinence and constipation. A random effect model was used to aggregate the studies reporting these outcomes, and heterogeneity was assessed.

RESULTS

Eight comparative studies, consisting of a total of 467 patients (275 open and 192 laparoscopic), were included. Analysis of the data suggested that there is no significant difference in recurrence, incontinence and constipation improvement between laparoscopic abdominal rectopexy and open abdominal rectopexy. Considering non-comparative trials, the event rate for recurrence was similar in open and laparoscopic suture rectopexy studies and in open and laparoscopic mesh rectopexy trials. Improvement in constipation after the intervention was not statistically significant except for open mesh repair; postoperative improvement in incontinence was statistically significant after laparoscopic procedures and open mesh rectopexy.

CONCLUSIONS

Laparoscopic abdominal rectopexy is a safe and feasible procedure, which may compare equally with the open technique with regard to recurrence, incontinence and constipation. However, large-scale randomized trials, with comparative, strong methodology, are still needed to identify outcome measures accurately.

The relationship between internal rectal prolapse and internal anal sphincter function

AIM

Faecal incontinence is commonly seen in patients with internal rectal prolapse (IRP), although the mechanism is not clear. This study assessed the relationship between IRP and anal sphincter function.

METHOD

Patients both with IRP diagnosed on proctography and those with external rectal prolapse (ERP) were identified from a prospective database generated from a tertiary referral pelvic floor clinic. The results of anorectal manometry were analysed, and the relationship between sphincter pressure and grade of prolapse was assessed.

RESULTS

A total of 515 patients were identified with clinical evidence of ERP or proctographic evidence of internal and external prolapse. There were 88 with grade 5 or external prolapse [mean maximal resting pressure (MRP) 28.5 (standard error 2.1) mmHg], 156 with grade 4 prolapse [44.0 (1.8) mmHg], 153 with grade 3 prolapse [49.2 (1.6) mmHg], 88 with grade 2 prolapse [56.2 (2.1) mmHg] and 29 patients with grade 1 rectal prolapse [56.8 (4.5) mmHg]. There was a significant reduction in the mean MRP with increasing grade of prolapse from grade 2 to 5. By contrast, there was no relationship between prolapse grade and mean maximal squeeze pressure, except in patients with ERP, in whom the squeeze pressure was significantly lower compared with patients with IRP.

CONCLUSION

This is the first large-scale study to show the relationship between internal prolapse and MRP. The observation that squeeze pressure is unchanged suggests that the effect of internal prolapse on continence occurs mainly through a reduction in internal anal sphincter tone.

Surgical treatment of rectal prolapse

Rectal prolapse is defined as a protrusion of the rectum beyond the anus. Although rectal prolapse was recognized as early as 1500 BC, the optimal surgical procedure is still debated. The varied operative procedures available for treating rectal prolapsed can be confusing. The aim of treatment is to control the prolapse, restore continence, and prevent constipation or impaired evacuation. In elderly and high-risk patients, perineal approaches, such as Delorme's operation and Altemeier's operation, have been preferred, although the incidence of recurrence and the rate of persistent incontinence seem to be high when compared with transabdominal procedures. Abdominal operations involve dissection and fixation of the rectum and may include a rectosigmoid resection. From the late twentieth century, the laparoscopic procedure has been applied to the treatment of rectal prolapse. Current laparoscopic surgical techniques include suture rectopexy, stapled rectopexy, posterior mesh rectopexy with artificial material, and resection of the sigmoid colon with colorectal anastomosis with or without rectopexy. The choice of surgery depends on the status of the patient and the surgeon's preference.

The Altemeier procedure for rectal prolapse: an operation for all ages

PURPOSE

Perineal rectosigmoidectomy was the most popular operation performed for rectal prolapse in the first half of the 20th century. However, high recurrence rates relegated it to a back-up role for elderly or other high-risk patients who were not candidates for an abdominal operation. Recent series (combined with levatorplasty = Altemeier procedure) revealed excellent results across a broader spectrum of patients and inspired this ongoing consecutive series of cases.

METHODS

This is a review of 103 (99 women) consecutive patients (mean age, 68.9 y; range, 20-97 y) who underwent the Altemeier procedure between 2000 and 2009. Patients were placed in the prone jackknife position: 93 patients (90%) with the use of general anesthesia and 10 patients (10%) with the use of spinal anesthesia. The mean follow-up was 43 months (range, 3 mo to 10 y).

RESULTS

The mean time for the operation was 97.7 minutes (range, 50-180 min) with a mean 7.2 cm of rectum resected (range, 2.5-26.7 cm). The mean blood loss was 66.9 mL (range, 0-350 mL). The mean time to tolerating a diet was 2.3 days (100% within 4 d) and mean postoperative length of hospital stay was 4.2 days (93% within 6 d). There was no mortality, minimal morbidity (14%), and no recurrence. Preoperative constipation (61% of patients) improved in 94% and preoperative fecal incontinence (47% of patients) improved in 85%, whereas 15% developed new onset of seepage or incontinence to flatus.

CONCLUSIONS

The Altemeier procedure for rectal prolapse provided excellent results across all age groups with minimal morbidity, allowing for short hospital stays and periods of convalescence. To this point, there has been no evidence of recurrence in this group of patients, pending longer periods of follow-up, especially among patients from the younger age groups.

Stapled transanal rectal resection for symptomatic intussusception: morphological and functional outcome

INTRODUCTION

Stapled transanal rectal resection (STARR) was developed to correct intussusception causing obstructed defecation. Some patients, however, do not profit from this operation as anticipated. We aimed to study the relationship between functional outcome and rectal morphology after STARR.

METHODS

Fifteen consecutive female patients with median age of 64 years [interquartile range (IQR) 58-71 years] were studied before and after STARR. All patients had symptoms of obstructed defecation preoperatively. Pre- and postoperative workup consisted of standardized interview (including Wexner score) with physical examination including procto- and rectoscopy, anorectal manometry, and magnetic resonance (MR) defecography. Median follow up was 18 months (IQR 16-22 months).

RESULTS

STARR was technically successful in all 15 patients without intra- or postoperative complications. Median (IQR) Wexner score of fecal incontinence was 0 (0-0) before and 3 (0-4.5) after surgery (p < 0.05). While all patients had repetitive incomplete defecation preoperatively, this symptom was present in seven patients postoperatively (p < 0.01). Third-degree intussusception was diagnosed during MR defecography in all patients preoperatively. After surgery, no patient had third-degree intussusception but one patient had first-degree and one patient had second-degree intussusception (p < 0.05). Size of rectocele was reduced from 2.9 cm (2.0-3.8 cm) to 0.8 cm (0.6-1.9 cm) (p < 0.05). Sphincter pressures were unchanged during anorectal manometry; however, first sensation during balloon distension in the rectum decreased from 50 ml (40-83 ml) before surgery to 30 ml (25-40 ml) after surgery (p < 0.05).

CONCLUSION

Stapled transanal rectal resection (STARR) achieved a high rate of morphological correction of intussusception; however, symptoms of obstructed defecation were not improved to the same extent, which warrants exploration in future studies.

Recurrence and functional results after open versus conventional laparoscopic versus robot-assisted laparoscopic rectopexy for rectal prolapse: a case-control study

PURPOSE

This study was designed to evaluate recurrence and functional outcome of three surgical techniques for rectopexy: open (OR), laparoscopic (LR), and robot-assisted (RR). A case-control study was performed to study recurrence after the three operative techniques used for rectal procidentia. The secondary aim of this study was to examine the differences in functional results between the three techniques.

MATERIALS AND METHODS

All consecutive patients who underwent a rectopexy between January 2000 and September 2006 enrolled in this study. Peri-operative data were collected from patient records and functional outcome was assessed by telephonic questionnaire.

RESULTS

Eighty-two patients (71 females, mean age 56.4 years) underwent a rectopexy for rectal procidentia. Nine patients (11%) had a recurrence; one (2%) after OR, four (27%) after LR, and four (20%) after RR. RR showed significantly higher recurrence rates when controlled for age and follow-up time compared to OR, (p = 0.027), while LR showed near-significant higher rates (p = 0.059). Functional results improved in all three operation types, without a difference between them.

CONCLUSIONS

LR and RR are adequate procedures but have a higher risk of recurrence. A RCT is needed assessing the definitive role of (robotic assistance in) laparoscopic surgery in rectopexy.

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.

Robot-assisted vs. conventional laparoscopic rectopexy for rectal prolapse: a comparative study on costs and time

PURPOSE

Laparoscopic rectopexy has become one of the most advocated treatments for full-thickness rectal prolapse, offering good functional results compared with open surgery and resulting in less postoperative pain and faster convalescence. However, laparoscopic rectopexy can be technically demanding. Once having mastered dexterity, with robotic assistance, laparoscopic rectopexy can be performed faster. Moreover, it shortens the learning curve in simple laparoscopic tasks. This may lead to faster and safer laparoscopic surgery. Robot-assisted rectopexy has been proven safe and feasible; however, until now, no study has been performed comparing costs and time consumption in conventional laparoscopic rectopexy vs. robot-assisted rectopexy.

METHODS

Our first 14 cases of robot-assisted laparoscopic rectopexy were reviewed and compared with 19 patients who underwent conventional laparoscopic rectopexy in the same period.

RESULTS

Robot-assisted laparoscopic rectopexy did not show more complications. However, the average operating time was 39 minutes longer, and costs were euro 557.29 (or: dollars 745.09) higher.

CONCLUSION

Robot-assisted laparoscopic rectopexy is a safe and feasible procedure but results in increased time and higher costs than conventional laparoscopy.

Surgical management of rectal prolapse

This article reviews the pathogenesis, clinical presentation and surgical management of rectal prolapse. Full-thickness prolapse of the rectum causes significant discomfort because of the sensation of the prolapse itself, the mucus that it secretes, and because it tends to stretch the anal sphincters and cause incontinence. Treatment of rectal prolapse is primarily surgical. Perineal surgical repairs are well tolerated, but are generally associated with higher recurrence rates. Abdominal repairs involve fixing the rectum to the sacrum by using either mesh or sutures, and tend to have the lowest recurrence rates. If significant preoperative constipation is present, a sigmoid resection can be performed at the time of rectopexy. For many patients, diarrhea and incontinence improve after surgery. Laparoscopic repair of rectal prolapse has similar morbidity and recurrence rates to open surgery, with attendant benefits of reduced length of hospital stay, postoperative pain and wound complications.

Laparoscopic Rectopexy without Resection: A Worthwhile Treatment for Rectal Prolapse in Patients without Prior Constipation

Anterior resection with rectopexy is considered by many to be the best operation for rectal prolapse. It is feared that if sigmoid redundancy created by rectal mobilization is not resected, colonic motility (specifically constipation) could be disabling. We contend that resection is not necessary in patients without preexisting constipation. We tested this hypothesis using a laparoscopic approach to minimize hospital stay. Twelve patients were treated (eight women); mean age was 45 years (range, 25–82 years). No patient had preexisting constipation; one had irritable bowel syndrome. Three patients had prior prolapse operations. Full rectal mobilization was undertaken down to the levator hiatus; neither the mesenteric vessels nor the lateral ligaments were divided. Rectopexy to the presacral fascia was done with one to two Nurolon sutures on either side of the rectum. There were no complications; mean hospital stay was 4 days. Mean follow up was 32 months (range; 3–75 months); there have been no recurrences. Only the patient with irritable bowel syndrome developed significant constipation. We conclude: 1) rectopexy can be safely done laparoscopically, 2) resection is not required in the absence of prior constipation, and 3) rectal mobilization and rectopexy does not predispose to future constipation in these selected patients.

Technical and functional results after laparoscopic rectopexy to the promontory for complete rectal prolapse. Prospective study in 54 consecutive patients

INTRODUCTION

Laparoscopic rectopexy for complete rectal prolapse offers short-term advantages compared with operations performed by laparotomy. The aim of this prospective study was to report technical and functional outcome after laparoscopic rectopexy to the promontory in consecutive patients operated on by a single surgeon.

PATIENTS AND METHODS

From May 1996 to July 2004, 54 consecutive patients (47 women), median age 53 years (range: 16-84 years), underwent laparoscopic rectopexy to the promontory for complete rectal prolapse. Preoperative evaluation included physical examination, dynamic videoproctography and, in patients with constipation, colonic transit time (with radiopaque markers). Postoperative evaluation included the same examinations and a simple global quality-of-life questionnaire.

RESULTS

Conversion to laparotomy was required for three patients during the learning curve. Median duration of operation was 157 minutes (range: 50-370). There was no mortality and morbidity was 5.5% (brachial plexus palsy in two patients and urinary tract infection in one). Median hospital stay was 3.5 days (range: 1-11). There were 4 recurrences (7.4%). Functional outcome at 12 months showed the presence of constipation in 20.3% of patients (persistence in eight and de novo in three) and the presence of outlet obstruction in 25.9% of patients (persistence in six and de novo in eight). Anal continence improved in 72.4% of the 29 patients who complained of this symptom. The global quality-of-life questionnaire showed a satisfactory result in 96% of patients.

CONCLUSION

Laparoscopic rectopexy to the promontory is a safe and efficient procedure to treat complete rectal prolapse; morbidity is low. Functional outcome is at least equivalent to that obtained with open procedures in terms of continence, constipation and outlet obstruction.

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

BACKGROUND

We report the results of patients treated from January 2000 to June 2004 for full-thickness rectal prolapse with trans-abdominal surgery in Helsinki.

METHODS

Sixty-five of 75 patients were treated laparoscopically, with a 6% conversion rate. Ten patients were operated on openly. Half of the patients were scored as American Society for Anesthesiologists III or IV.

RESULTS

The operation time was similar in the laparoscopic and the open rectopexy procedures (p = 0.15), whereas laparoscopic resection rectopexy was more time-consuming compared to the open procedure (p = 0.007). Intraoperative bleeding during laparoscopic surgery was minimal in comparison to open surgery (p = 0.006). Patients treated laparoscopically had a shorter median hospital stay than those treated with an open procedure (rectopexy, 3 and 7 days, respectively; resection rectopexy, 4 and 7.5 days, respectively) (p < 0.00001). There was no mortality and minor morbidity. During follow-up, there were two prolapse recurrences. All surgical techniques improved fecal continence considerably. Eighty-four percent of rectopexy patients and 92% of resection rectopexy patients considered the surgical outcome to be excellent or good.

CONCLUSIONS

Both rectopexy and resection rectopexy cure prolapse with good results and can be performed safely in older and debilitated patients. The laparoscopic approach enables a shortened hospital stay and is well tolerated in elderly patients.

Long-term outcome after laparoscopic and open surgery for rectal prolapse: a case-control study

BACKGROUND

Laparoscopic repair (LR) of rectal prolapse is potentially associated with earlier recovery and lower perioperative morbidity, as compared with open transabdominal repair (OR). Data on the long-term recurrence rate and functional outcome are limited.

METHODS

Perioperative data on rectal prolapse in relation to all LRs performed between December 1991 and April 2004 were prospectively collected. The LR patients were matched by age, gender, and procedure type with OR patients who underwent surgery during the same period. Patients with previous complex abdominal surgery or a body mass index exceeding 40 were excluded from the study. Data on recurrence rate, bowel habits, continence, and satisfaction scores were collected using a telephone survey.

RESULTS

A total of 111 patients (age, 56.8 +/- 18.1 years; female, 87%) underwent attempted LR. An operative complication deferred repair in two cases. Among the 111 patients, 42 had posterior mesh fixation, and 67 had sutured rectopexy (32 patients with sigmoid colectomy for constipation). Eight patients (7.2%) had conversion to laparotomy. Matching was established for 86 patients. The LR patients had a shorter hospital stay (mean, 3.9 vs 6.0 days; p < 0.0001). The 30-day reoperation and readmission rates were similar for the two groups. The rates for recurrence requiring surgery were 9.3% for LR and 4.7% for OR (p = 0.39) during a mean follow-up period of 59 months. An additional seven patients in each group reported possible recurrence by telephone. Postoperatively, 35% of the LR patients and 53% of the OR patients experienced constipation (p = 0.09). Constipation was improved in 74% of the LR patients and 54% of the OR patients, and worsened, respectively, in 3% and 17% (p = 0.037). The postoperative incontinence rates were 30% for LR and 33% for OR (p = 0.83). Continence was improved in 48% of the LR patients and 35% of the OR patients, and worsened, respectively, in 9% and 18% (p = 0.22). The mean satisfaction rates for surgery (on a scale of 0 to 10) were 7.3 for the LR patients and 8.1 for the OR patients (p = 0.17).

CONCLUSIONS

The hospital stay is shorter for LR than for OR. Both functional results and recurrent full-thickness rectal prolapse were similar for LR and OR during a mean follow-up period of 5 years.

Robotic-assisted pelvic organ prolapse surgery

BACKGROUND

This study describes technical aspect and short-term results of pelvic organ prolapse surgery using the da Vinci robotic system.

METHODS

During a 1-year period, 18 consecutive patients with pelvic organ prolapse were operated on using the da-Vinci system. Clinical data were prospectively collected and analyzed.

RESULTS

All but one procedure was successfully completed robotically (95%). Performed procedures were colpohysteropexy (n = 12), mesh rectopexy (n = 2), or sutured rectopexy combined with sigmoid resection (n = 4). Average setup time was 21 min and significantly decreased with experience. Mean operative time was 172 min (range, 45-280). There were no mortality and no specific morbidity due to the robotic approach. Mean hospital stay was 7 days. At 6 months, all patients were free of pelvic organ prolapse and stated that they were satisfied with anatomical and functional results.

CONCLUSION

Our experience indicates that using the da-Vinci robotic system is feasible, safe, and effective for the treatment of pelvic organ prolapse.

Early Outcomes of Laparoscopic Procedures Performed on Military Personnel With Total Rectal Prolapse and Follow-up

Total rectal prolapse is a disorder frequently associated with constipation and anal incontinence. The aim of this study was to evaluate the outcomes of the complications, pain management, hospital stay, constipation, and anal functions of the patients undergoing 2 types of laparoscopic surgical approaches. In this study, 33 patients underwent either laparoscopic rectopexy or hand-assisted laparoscopic resection rectopexy. Preoperative colonic transit time, defecation, postoperative pain scoring, pre-postoperative evaluation of the anal function, and the changes in constipation and relating symptoms were assessed. Postoperative evaluation had been performed at the sixth week and the twelfth month. Median operation time was 137 minutes for rectopexy and 230 minutes for resection rectopexy group. Median postoperative hospital stay was 3 days for patients with rectopexy and 7 days for patients with resection rectopexy. Patients needed painkillers in short postoperative period for pain management in both groups. Continence was improved in 11 of 13 patients (84.6%) in a year after laparoscopic surgery. In 15 patients (45.5%), preoperative constipation either remained in the same or became worse in 7 (21.1%) in a year after surgery. No patient developed recurrence in the median follow-up period, which was about 15 months. Laparoscopic rectopexy and resection rectopexy in the young aged patients working the Army are carried out with less morbidity rate. We eliminated the total prolapse and cure incontinence in almost all patients. In addition to constipation was reduced by laparoscopic surgical approaches in a short time hospitalization with short time painkiller need.

Robotic assisted rectopexy

BACKGROUND

During the last 3 years, robotic surgery has had a considerable impact on minimally invasive surgery in a wide range of specialties. This study describes the surgical technique and preliminary results of our first 6 cases of robotic assisted suture rectopexy.

METHODS

During a period of 13 months 6 patients with full thickness rectal prolapse were operated on with the da Vinci surgical system. All patients were considered suitable for a suture rectopexy. Setting-up time, procedure time, patient recovery, and hospital stay were recorded and compared with the current literature.

RESULTS

All operations were completed successfully using the robotic system. There were no major complications and no deaths. Mean setting-up time was 28 minutes, mean operation time was 127 minutes, and mean hospital stay was 6 days. At 3 to 6 months of follow-up all patients are in good health, with no signs of recurrence and no reports of constipation.

CONCLUSIONS

Robotic assisted suture rectopexy is feasible and safe and apparently meets accepted standards of laparoscopic surgery.