Laparoscopic Rectopexy

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Laparoscopic Rectopexy

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Rectal prolapse is a debilitating condition that affects 1% of people older than 60 years. Surgical approaches to its treatment include a perineal approach and an abdominal approach. [1] Laparoscopic rectopexy was initially described in the early 1990s and has since become the abdominal procedure of choice for rectal prolapse. [2] This review describes three of the current laparoscopic approaches in the management of rectal prolapse and rectocele.

Once rectal prolapse is diagnosed, surgical repair is indicated to prevent worsening fecal incontinence and discomfort.

Laparoscopic rectopexy has been recommended as the first option for rectal prolapse. [3]

Abdominal rectopexy yields low recurrence rates (< 5%) and some improvement of incontinence. However, this approach can cause constipation and does not resolve existing constipation, [4, 5] possibly owing to rectal denervation after the posterolateral dissection of the rectum.

In contrast, perineal approaches, including Altemeier and Delorme procedures, are associated with a higher recurrence rate but lower morbidity than open abdominal approaches. Although these are considered safer operations, with the rate of recurrence approaching 18% and minimal improvement in continence, better alternatives have been investigated. [4]

The small incisions, lack of anastomosis, and low recurrence rates of the minimally invasive approach have reduced the morbidity of the abdominal approach without affecting efficacy. In a randomized control trial, laparoscopic rectopexy had fewer complications, shorter length of hospital stay, and decreased in pain compared with open abdominal rectopexy. [6] In addition, it was comparable to perineal procedures in terms of morbidity.

Compared with the classic open posterior rectopexy, laparoscopic rectopexy has similar functional outcomes with respect to constipation. Satisfactory long-term results have been reported with laparoscopic “ventral” rectopexy, and new constipation is prevented because of the lack of posterior dissection. [7, 8, 9, 10, 3]

In a prospective study of 224 patients who underwent laparoscopic ventral mesh rectopexy, McLean et al assessed long-term clinical outcomes, patient-reported functional and quality-of-life outcomes, and urinary and sexual dysfunction. [11]  No mortality was reported. The overall complication rate was 10.7%, mesh-related morbidity was 0.45%, and vaginal suture-related morbidity was 1.33%. The overall recurrence rate was 11.4%. Significant improvements in patient-reported functional outcomes were seen for both constipation and fecal incontinence symptoms.Significant improvements in quality-of-life outcomes persisted in patients with constipation, fecal incontinence and prolapse.

Madbouly et al compared functional outcomes, recurrence rates, and quality of life for laparoscopic ventral rectopexy (n = 41) versus laparoscopic Wells rectopexy (n = 33) in patients with complete rectal prolapse. [12]  Both procedures successfully and safely corrected prolapse and prevented recurrence, though laparoscopic ventral rectopexy was associated with significantly longer operating time and length of stay. Laparoscopic ventral rectopexy appeared to be more suitable for patients with a high constipation score and abnormal perineal descent.

Compared with the results of laparoscopic rectopexy, the results of robotic rectopexy have been similar in terms of length of stay, postoperative pain, recurrence rates, and mortality. In contrast, robotic rectopexy has been associated with a longer operating time and higher costs. [13, 14, 15, 16]  However, a randomized controlled trial that included 30 patients reported no significant difference in operating time between robot-assisted and conventional laparoscopic ventral rectopexy. [17]

Stein EA, Stein DE. Rectal procidentia: diagnosis and management. Gastrointest Endosc Clin N Am. 2006 Jan. 16 (1):189-201. [Medline].

Berman IR. Sutureless laparoscopic rectopexy for procidentia. Technique and implications. Dis Colon Rectum. 1992 Jul. 35 (7):689-93. [Medline].

Keskin M, Gönüllü D, Karip B, Balik E, Bulut MT. Laparoscopic Rectopexy: First Option for Rectal Prolapse?. Chirurgia (Bucur). 2016 Mar-Apr. 111 (2):131-7. [Medline]. [Full Text].

Tou S, Brown SR, Nelson RL. Surgery for complete (full-thickness) rectal prolapse in adults. Cochrane Database Syst Rev. 2015 Nov 24. 2:CD001758. [Medline].

Madiba TE, Baig MK, Wexner SD. Surgical management of rectal prolapse. Arch Surg. 2005 Jan. 140 (1):63-73. [Medline].

Solomon MJ, Young CJ, Eyers AA, Roberts RA. Randomized clinical trial of laparoscopic versus open abdominal rectopexy for rectal prolapse. Br J Surg. 2002 Jan. 89 (1):35-9. [Medline].

D’Hoore A, Cadoni R, Penninckx F. Long-term outcome of laparoscopic ventral rectopexy for total rectal prolapse. Br J Surg. 2004 Nov. 91 (11):1500-5. [Medline].

Boons P, Collinson R, Cunningham C, Lindsey I. Laparoscopic ventral rectopexy for external rectal prolapse improves constipation and avoids de novo constipation. Colorectal Dis. 2010 Jun. 12 (6):526-32. [Medline].

Bjerke T, Mynster T. Laparoscopic ventral rectopexy in an elderly population with external rectal prolapse: clinical and anal manometric results. Int J Colorectal Dis. 2014 Oct. 29 (10):1257-62. [Medline].

Maeda Y, Vaizey CJ, Warusavitarne J. Response to: Consensus on ventral rectopexy: report of a panel of experts. Colorectal Dis. 2014 Sep. 16 (9):739. [Medline].

McLean R, Kipling M, Musgrave E, Mercer-Jones M. Short- and long-term clinical and patient-reported outcomes following laparoscopic ventral mesh rectopexy using biological mesh for pelvic organ prolapse: a prospective cohort study of 224 consecutive patients. Colorectal Dis. 2018 May. 20 (5):424-436. [Medline].

Madbouly KM, Youssef M. Laparoscopic Ventral Rectopexy Versus Laparoscopic Wells Rectopexy for Complete Rectal Prolapse: Long-Term Results. J Laparoendosc Adv Surg Tech A. 2018 Jan. 28 (1):1-6. [Medline].

Wong MT, Meurette G, Rigaud J, Regenet N, Lehur PA. Robotic versus laparoscopic rectopexy for complex rectocele: a prospective comparison of short-term outcomes. Dis Colon Rectum. 2011 Mar. 54 (3):342-6. [Medline].

Heemskerk J, de Hoog DE, van Gemert WG, Baeten CG, Greve JW, Bouvy ND. Robot-assisted vs. conventional laparoscopic rectopexy for rectal prolapse: a comparative study on costs and time. Dis Colon Rectum. 2007 Nov. 50 (11):1825-30. [Medline]. [Full Text].

Mehmood RK, Parker J, Bhuvimanian L, Qasem E, Mohammed AA, Zeeshan M, et al. Short-term outcome of laparoscopic versus robotic ventral mesh rectopexy for full-thickness rectal prolapse. Is robotic superior?. Int J Colorectal Dis. 2014 Sep. 29 (9):1113-8. [Medline].

Faucheron JL, Trilling B, Barbois S, Sage PY, Waroquet PA, Reche F. Day case robotic ventral rectopexy compared with day case laparoscopic ventral rectopexy: a prospective study. Tech Coloproctol. 2016 Oct. 20 (10):695-700. [Medline].

Mäkelä-Kaikkonen J, Rautio T, Pääkkö E, Biancari F, Ohtonen P, Mäkelä J. Robot-assisted vs laparoscopic ventral rectopexy for external or internal rectal prolapse and enterocele: a randomized controlled trial. Colorectal Dis. 2016 Oct. 18 (10):1010-1015. [Medline].

Munz Y, Moorthy K, Kudchadkar R, Hernandez JD, Martin S, Darzi A, et al. Robotic assisted rectopexy. Am J Surg. 2004 Jan. 187 (1):88-92. [Medline].

Pucher PH, Mayo D, Dixon AR, Clarke A, Lamparelli MJ. Learning curves and surgical outcomes for proctored adoption of laparoscopic ventral mesh rectopexy: cumulative sum curve analysis. Surg Endosc. 2017 Mar. 31 (3):1421-1426. [Medline].

Felt-Bersma RJ, Tiersma ES, Cuesta MA. Rectal prolapse, rectal intussusception, rectocele, solitary rectal ulcer syndrome, and enterocele. Gastroenterol Clin North Am. 2008 Sep. 37 (3):645-68, ix. [Medline].

Wong M, Meurette G, Abet E, Podevin J, Lehur PA. Safety and efficacy of laparoscopic ventral mesh rectopexy for complex rectocele. Colorectal Dis. 2011 Sep. 13 (9):1019-23. [Medline]. [Full Text].

Tsunoda A, Takahashi T, Ohta T, Kusanagi H. A novel technique of introducing the mesh at the distal dissection while performing laparoscopic ventral rectopexy. Colorectal Dis. 2016 Sep. 18 (9):O334-6. [Medline].

van Iersel JJ, Formijne Jonkers HA, Paulides TJC, Verheijen PM, Draaisma WA, Consten ECJ, et al. Robot-Assisted Ventral Mesh Rectopexy for Rectal Prolapse: A 5-Year Experience at a Tertiary Referral Center. Dis Colon Rectum. 2017 Nov. 60 (11):1215-1223. [Medline].

Leandro Feo, MD Resident Physician, Department of General Surgery, Hahnemann University Hospital, Drexel University College of Medicine

Leandro Feo, MD is a member of the following medical societies: American College of Surgeons

Disclosure: Nothing to disclose.

David E Stein, MD Chief, Division of Colorectal Surgery, Associate Professor, Department of Surgery, Director, Mini-Medical School Program, Drexel University College of Medicine; Chief, Division of Colorectal Surgery, Department of Surgery, Hahneman University Hospital; Consultant, Merck; Consultant, Ethicon Endo-Surgery; Consultant, Health Partners; Consultant, Cook Surgical

David E Stein, MD is a member of the following medical societies: American College of Surgeons, American Society of Colon and Rectal Surgeons, Association for Surgical Education, Pennsylvania Medical Society, Society for Surgery of the Alimentary Tract, Crohn’s and Colitis Foundation of America

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Merck<br/>Serve(d) as a speaker or a member of a speakers bureau for: Merck.

Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS Professor of General and Gastrointestinal Surgery and Senior Consultant Surgeon, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), India

Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS is a member of the following medical societies: American College of Gastroenterology, American College of Surgeons, American Society of Colon and Rectal Surgeons, Royal College of Physicians and Surgeons of Glasgow, Royal College of Surgeons of Edinburgh, Royal College of Surgeons of England

Disclosure: Nothing to disclose.

The Chief Editor would like to acknowledge the assistance of Dr Mohsina Subair, Postgraduate Resident, Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Pondicherry, India, in updating the review of this article.

Laparoscopic Rectopexy

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