Surg Endosc (2003) 17: 99–103 DOI: 10.1007/s00464-002-8511-9
Springer-Verlag New York Inc. 2002

Clinically based management of rectal prolapse Comparison of the laparoscopic Wells procedure and laparoscopic resection with rectopexy K. M. Madbouly, A. J. Senagore, C. P. Delaney, H. J. Duepree, K. M. Brady, V. W. Fazio Department of Colorectal Surgery and the Minimally Invasive Surgery Center, Cleveland Clinic Foundation, 9500 Euclid Ave, Desk A-111, Cleveland, OH 44195, USA Received: 10 January 2002/Accepted: 12 June 2002/Online publication: 4 October 2002

Abstract Background: Laparoscopic repair of rectal prolapse offers the potential of lower recurrence rates for transabdominal repair coupled with the advantages of minimally invasive colorectal surgery. There have been no direct comparisons of the laparoscopic Wells procedure (LWP) and laparoscopic resection with rectopexy (LRR). This study is the first to make a direct comparison of outcomes from laparoscopic LRR and LWP repairs using a selected, symptom-based choice of operative procedure. Methods: Consecutive patients presenting with complete rectal prolapse were evaluated by clinical history of the degree of constipation, diarrhea, or incontinence. Patients with a history of constipation or normal bowel habits with normal continence underwent LRR, whereas those with diarrhea or anal incontinence underwent LWP. The collected data included age, gender, operative time, length of hospital stay (LOS), operative blood loss, complications, and postoperative symptoms of constipation or diarrhea. Continence was scored using the Cleveland Clinic scoring system. Results: Of the 24 patients, 11 underwent LRR and 13 had LWP. The patients in both groups were predominantly, female (LRR, 9/1; LWP, 10/2). The LRR patients were significantly younger (48.6 vs 63.9 years p < 0.001). Both operative time and LOS were significantly longer in the RR group (operative time, 128.5 ± 80.6 min vs 69.9 ± 13.4 min; LOS, 3.6 ± 3.1 days vs 2.2 ± 1.03 days). All patients in the LRR group had constipation preoperative, and no patients were incontinent clinically. Preoperatively, 7 of the 13 patients in the LWP group had preoperative diarrhea, and 1 patient had clinical constipation. A five patients experienced clinical symptoms of fecal incontinence, manifested in different degrees. Postoperative complications occurred

Correspondence to: A. J. Senagore

only in the LRR group (1 case of abdominal wall hematoma and 2 cases of prolonged ileus). During a mean follow-up period of 18.1 months, there were no recurrences; 10 of the 11 LRR patients had correction of constipation; and 4 of 5 of the incontinent LWP patients had improvement in their symptoms. Constipation developed in one LWP patient. Conclusions: Clinical assessment of preoperative bowel function and continence allows accurate selection of the appropriate laparoscopic technique for repair of rectal prolapse without the added expense of anal physiologic testing. Although LRR may be associated greater morbidity than LWP, both procedures offer good functional outcome, with short LOS and low recurrence rates. Key words: Rectal prolapse — Laparoscopic rectopexy — Wells procedure Rectal prolapse is a distressing condition that has long fascinated surgeons, as evidenced by the multitude of proposed operative approaches for its correction. In the patient with complete rectal prolapse, all layers of the rectal wall profrude through the anal sphincter complex [23]. In addition, approximately 75% of patients with rectal prolapse experience anal incontinence, and 25% to 50% of these patients will have significant constipation [18, 23, 25, 28]. Anal incontinence associated with rectal prolapse has been attributed to abnormal bowel motility and low resting anal pressure resulting from continuous rectoanal inhibition or pudendal neuropathy [14, 19, 26]. Conversely, Metcalf and Loening-Baveke [28] reported their belief that it is the increase in external anal sphincter electromyographic activity that causes outlet obstruction and constipation. Finally, Madoff [24] suggested that slow colonic transit time, a common finding with rectal prolapse, is the primary factor, and that it coincides with development of constipation. Because of the frequently contradictory results from anorectal and

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Fig. 1. Clinical algorithm for choosing a laparoscopic approach to rectal prolapse.

colonic physiologic testing in this patient population, it is difficult to support the superiority of testing over clinical evaluation based on history and physical examination. The sequential aims of surgical treatment of prolapse are to eradicate the external prolapsing of the rectum, improve continence, and improve bowel function. Optimally, the goal should be to restore normal anatomic configuration and improve the functional outcome. The potential advantage of abdominal procedures is fixation of the rectum in a more appropriate anatomic location without sacrifice of the compliant rectal reservoir. In addition, these approaches generally are considered superior because of the lower recurrence rates, improvement in symptoms, and better functional results [2, 11, 17, 31]. Perineal approaches that either eradicate the rectal ampulla with a colonanal anastomosis or plicate the prolapse are felt to be superior in older, high-risk patients because of less surgical trauma [12, 22]. It is clear, however, that these procedures typically are associated with higher recurrence rates [12, 22]. Laparoscopic management of rectal prolapse was first introduced by Berman [4] in 1992. Laparoscopic access may provide a means of pairing the reduction in surgical stress associated with a perineal approach and the low recurrence rates achieved with abdominal repair of the prolapse. Even when a laparoscopic approach is selected, a choice must be made between a rectopexy with suture or artificial material and a sigmoid colectomy with or without rectopexy [9, 31]. There has been little discussion in the literature regarding criteria for selection of either approach. The purpose of this study was to assess the clinical outcome and functional results of a clinically based approach to the selection of either a laparoscopic posterior rectopexy using mesh (Wells procedure) or a laparoscopic sigmoid colectomy with suture rectopexy.

Patients and methods A retrospective review of data from a prospectively accrued database of consecutive patients (March 1999 to April 2001) presenting to the Cleveland Clinic Department of Colorectal Surgery with rectal prolapse was performed. The patients were divided into two groups the basis of the laparoscopic procedure performed: Wells procedure (LWP) or resection with suture rectopexy (LRR). Data on recurrence and current functional status were updated by chart review and telephone survey. All the patients were assessed preoperatively by clinical examination, with particular attention focussed on the degree of continence, constipation, or diarrheal symptoms. Assessment of anal incontinence was performed using the Cleveland Clinic scoring system [13]. The patients were judged to have constipation if they had two or

fewer bowel movement per week or strained for more than 25% of their defecations. Confirmation of the prolapse was achieved by examination after a Fleets enema had been administered and the patient had strained on a commode. Digital rectal examination was performed to assess the degree of resting tone, and to identify any anal sphincter defects. Patients with normal bowel habits or constipation without symptoms of anal incontinence underwent
Operative techniques All the patients underwent surgery in the modified lithotomy position, with Dan–Allen stirrups used to abduct the legs and limit hip flexion. All the patients had general anesthesia. An open approach was used to place the umbilical trocar (10 mm). Pneumoperitoneum was maintained at 12 mmHg throughout the operation. For LWP cases, a 5-mm trocar was placed in the right iliac fossa lateral to the rectus sheath, and a second 5mm trocar was placed in the same line just above the level of the umbilicus. For L-RR cases, a 12-mm trocar was used in the right iliac fossa to allow introduction of the endoscopic linear stapler. In both procedures, a 5-mm trocar was placed in the left iliac fossa for the assistant. In all cases, rectal mobilization was performed using a medial approach to identify the left ureter and allow entry to the retrorectal space. However the marginal artery was preserved in all the patients. Only the posterior 60% of the rectum was mobilized down to the pelvic floor, preserving both the hypogastric sympathetic plexus and the lateral stalks. Limited mobilization of the left colon was performed, allowing for fixation of the colon to help support the repair of the prolapse. In LWP cases, a 5 · 5-cm piece of polypropylene mesh (Atrium, Menlo Park, CA, USA) was inserted behind the mobilized rectum and fixed to the sacral promontory using the hernia stapler (EndoUniversal, United States Surgical Corporation, Norwalk, CT, USA). (Two or three polypropylene sutures) were placed on either side of the rectum to allow attachment of the mesh to the mesorectum at the side of the rectum and provide fixation. The pelvic peritoneum was not closed over the repair, and no drain was inserted. In LRR cases, a similar approach was used for rectosigmoid mobilization. The rectosigmoid junction was divided using an endoscopic linear stapler across peritonealized rectum. Only sigmoidal branch vessels were divided. The sigmoid colon was exteriorized via a 3- to 4-cm muscle splitting incision at the site of the left lower quadrant port. The sigmoid was divided extracorporeally, and the 28-mm PCEEA (Auto Suture, United States Surgical Corporation, Norwalk, CT, USA) anvil was inserted. The bowel was returned to the abdominal cavity, the fascia closed, and the pneumoperitoneum reestablished. The circular stapler was inserted transanally, and the anastomosis was completed. The rectum then was fixed high onto the presacral fascia by 2 to 4 polypropylene sutures. The pelvic peritoneum was not closed, and no drains were inserted. Postoperatively, all the patients were allowed full liquids with advancement to a general diet as tolerated. Discharge criteria included adequate oral analgesia, tolerance of three solid meals, and passage of flatus or stool.

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Results During the study period, 24 patients underwent laparoscopic treatment of complete rectal prolapse. All the patients had overt prolapse of the rectum through the anus while straining. The gender ratio was 21 females to 3 males. The male-to-female ratio in the LWP group was 2 to 11, as compared with 1 to 10 in the LRR group. The ages ranged from 21 to 88 years (mean, 52.64 ± 21.32 years) for the entire group. However, the LRR patients were significantly younger (LRR, 48.6 ± 19.17 years; LWP, 63.99 ± 19.96 years; p < 0.001). Two patients in the LRR group had concomitant sigmoid diverticular disease, which was resected, whereas two patients in the LWP group underwent synchronous procedures: one laparoscopic total abdominal hysterectomy and one anal sphincteroplasty. Constipation was a major problem for all the LRR patients, whereas only one of the LWP patients (7.7%) had preoperative constipation. Diarrhea was present in 6 of the 13 patients in the LWP group. There were no continence problems in any of the LRR patients. In the LWP group, one patient experienced a range from incontinence to solid stools (Cleveland Clinic score, 18), two patients had frequent leakage of liquid stools (Cleveland Clinic score, 8), and two patients had infrequent leakage of liquid stools (Cleveland clinic score, 6). The clinical data are shown in Table 1. Operative results In two cases, one in each group, the procedure was converted to open surgery. The conversion was because of presacral bleeding in one case and extensive adhesions from prior surgery in the other case. There was no significant difference in estimated blood loss between the groups (LRR, 87.72 ± 61.69 ml; LWP, 69.91 ± 13.45 ml). The mean operative time was significantly longer in the LRR group (LRR, 128.5 ± 80.6 min; LWP, 69.91 ± 13.4 min; p < 0.001). Postoperative complications occurred in three LRR patients: two cases of prolonged ileus and one case of abdominal wall hematoma. There were no perioperative complications in the LWP group. The length of hospital stay was significantly longer in the LRR group (LRR, 3.6 ± 3.1 days; LWP, 2.2 ± 1.03 days). The mean follow-up period was 18.1 months (range, 6–30 months). There were no recurrent prolapses in either group, and no patients in either group developed postoperative constipation. However, one LWP patient with preoperative constipation continued to be constipated after surgery. Continence scores returned to normal in four or five LWP patients with preoperative continence problems. One patient with a score of 18 required an anal sphincter repair.

Discussion Laparoscopy has been proposed as a feasible and effective procedure for treatment of complete rectal pro-

Table 1. Clinical data of the patients in both groups

Mean age (years) Gender ratio (M/F) ASA score <2 >2 Previous pelvic surgery BMI <25 >25 Constipation Continence problems

Resection rectopexy

Wells rectopexy

48.6 ± 19.17 2: 11

63.99 ± 19.96 1:10

9 4 7

7 4 4

9 4 13 0

10 1 1 5

ASA, American Society of Anesthesiology; BMI, body mass index

lapse [4]. Studies comparing the same laparoscopic and open surgical approach for rectal prolapse have demonstrated that laparoscopy confers benefits related to postoperative pain, length of hospital stay, and return of bowel function [1, 5]. These benefits are obtained while similar clinical and functional results are achieved [6]. Current laparoscopic surgical techniques include posterior suture [21] or stapled [10] rectopexy, posterior rectopexy using artificial material (mesh) [16], and resection of the sigmoid and upper rectum with or without suture rectopexy [32]. The use of foreign material for fixation adds the potential benefit of a greater degree of rectal fixation. However, it poses a potential risk if used with resection should an anastomotic complication occur. Therefore, mesh rectopexy generally is not performed with bowel resection. Suture rectopexy is technically less demanding and avoids the risk of foreign material, but there is a higher recurrence rate and a similar risk of postoperative constipation [15, 32]. In general, resection rectopexy achieves the best results in terms of recurrence and avoidance of postoperative constipation. However, it adds the risks of anastomotic complications and longer hospital stays [20, 32]. The Wells rectopexy has gained popularity because it is simple and easily accomplished, but reportedly is associated with a high incidence of new post-operative constipation [5, 16]. Constipation is believed to occur because of an exaggerated sigmoid loop and kinking resulting from fixation of the segment. Fibrotic structuring of the bowel is a potential risk as well [1, 27]. Currently, no absolute criteria exist for choosing the best procedure to use with any given patient who has rectal prolapse. The goal is to achieve the best possible functional outcome with the least morbidity and risk of recurrence. A variety of physiologic and radiographic investigations have been used for the preoperative assessment of these patients including anal manometry, pudendal nerve terminal motor latency, colonic transit studies, defecography, and anal endosonography. The cost benefit of these investigations remains undefined. The results obtained from studies using these expensive assessments do not provide evidence that the outcome is superior. Actually, Boccasanta [5] found that the statistically significant improvement in anal pressures postoperatively was of no clinical significance in terms of symptom resolution.

102 Table 2. Results from laparoscopic correction of rectal prolapse Study

Lap procedure

Operative time (min)

Blood loss (ml)

Conversion (%)

LOS (days)

Solomon [29] Stevenson [30] Bruch [7] Xynos [32]

Mesh rectopexy LRR Suture rectopexy and LRR LRR

— — — —

14 0 1.4 —

6.3 5 15 4.7

Kellokumpu [20]

LRR, suture rectopexy

—

—

Darzi [10] Current study

LRR, suture rectopexy, mesh rectopexy LRR, LWP

198 185 227 130 225 in LRR, 150 in suture rectopexy LRR, 133 Suture rectopexy, 106.5 Mesh rectopexy, 113.5 128 in LRR, 80 in LWP

— LRR, 87 LWP, 69.91

No 9

5 LRR, 3.6 Suture rectopexy, 2.6 Mesh rectopexy, 2.7 LRR, 3.6 LWP, 2.3

Lap, laparoscopic; LOS, length of hospital stay; LRR, laparoscopic resection with rectopexy; LWP, laparoscopic Wells procedure

Table 3. Functional outcome after laparoscopic correction of rectal prolapse

Study

Lap procedure

Improvement of preop constipation (%)

Solomon [29] Stevenson [30] Caronia [8] Bruch [7] Xynos [32]

Mesh rectopexy LRR Suture rectopexy Suture rectopexyand LRR LRR

— 64 0 76 100

Kellokumpu [20]

LRR, suture rectopexy

68

Daerzi [10] Current study

LRR, suture rectopexy, mesh rectopexy LRR, LWP

LRR, 100 in Suture rectopexy, 0 in Mesh rectopexy 95

Development of postop constipation (%)

Improvement of preop incontinence (%)

Recurrence (%)

— 0 0 0 0 Suture rectopexy, 6 LRR, 12 LRR, 0/18 in Suture rectopexy, 25 Mesh rectopexy, 32 0

— 70 100 64 70

0 7 0 0 0

100

7

in Mesh rectopexy, 100 Suture rectopexy 75 LRR, 80 80

0 0

Lap, laparoscopic; LRR, laparoscopic resection with rectopexy; LWP, laparoscopic Wells procedure

In the current study, we used two laparoscopic techniques: Wells mesh rectopexy and resection rectopexy. The results of this clinically based choice of operation demonstrated that both laparoscopic resection rectopexy and Wells rectopexy effectively and safely cure prolapse in this patient population. This occurred although 33% of the patients had an American Society of Anesthesiology (ASA) rating of 3, indicating significant comorbidity. In addition, the operative times approximated 1 h for the LWP group and 2 h for LRR group. The operative selection criteria achieved correction of anal in continence in 80% of the symptomatic patients and no instance of new onset constipation. Our data differ somewhat from those of Darzi et al. [10], who reported one de novo incontinence after LRR and only a 20% rate of in-continence improvement. Xynos et al. [32], despite the use of extensive physiologic testing, still found that 40% of cases needed postoperative anal sphincteroplasy for incontinence after LRR. It therefore appears that clinical identification of significant incontinence symptoms may be predictive of poor functional results after LRR. Constipation improved in 100% of the patients after LRR, and the sole LWP patient with both constipation and incontinence remained functionally unchanged after surgery. Kessler et al. [21] on had 6% incontinence and 15% obstructed defection after suture rectopexy. Zittel

et al. [33] identified a similar incidence of evacuation problems after suture rectopexy, although there were no postoperative incontinence cases. We strongly believe that division of the lateral rectal ligaments results in parasympathatic denervation and leads directly to evacuation problems. This contention is supported by the persistence of constipation in 18% of patients after LRR, with division of lateral stalk in the publication by Darzi et al. [10]. Bruch et al. [7] also found that preservation of the lateral ligaments leads to significant improvement of constipation after both LRR and suture rectopexy, as compared with lateral ligament dissection. Tables 2 and 3 show the operative and functional outcomes of various laparoscopic approaches for rectal prolapse. The results in the current study compare favorably in terms of operative time, complications, length of stay, and functional improvement after surgery. Conclusion In the current study, both LRR and LWP successfully corrected the prolapse and avoided recurrence during the follow-up period. As compared with laparoscopic LWP, LRR was associated with longer operative times and length of stay. However, both operations compare favorably with published results for either approach performed by laparotomy. The use of clinical criteria for

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selection of the operative approach appears to result in good functional outcome in terms of both constipation and in-continence symptoms. Preservation of the lateral rectal ligaments and avoidance of injury to the hypogastric nerves also may play a role in the good functional results. Therefore, laparoscopic repair of rectal prolapse can be performed on the basis of clinical evaluation, with the expectation of good clinical outcome. References 1. Baker R, Senagore AJ, Luchtefeld M (1995) Laparoscopic-assisted vs open resection: rectopexy offers excellent results. Dis Colon Rectum 38: 199–201 2. Bartolo CC (1996) Rectal prolapse. Br J Surg 83: 3–5 3. Benoist S, Taffinder N, Gould S, Chang A, Darzi A (2001) Functional results two years after laparoscopic rectopexy. Am J Surg 182: 168–173 4. Berman IR (1992) Sutureless laparoscopic rectopexy for procidentia: technique and implications. Dis Colon Rectum 35: 689–693 5. Boccasanta P (1999) Laparotomic vs laparoscopic rectopexy in complete rectal prolapse. Dig Surg 16: 415–419 6. Boccasanta P, Rosati R, Venturi M, Montorsi M, Cioffi U, De Simone M, Strinna M, Peracchia A (1998) Comparison of laparoscopic rectopexy with open technique in the treatment of complete rectal prolapse: clinical and functional results. Surg Laparosc Endosc 8: 460–465 7. Bruch HP, Herold A, Schiedeck T, Schwandner O (1999) Laparoscopic surgery for rectal prolapse and outlet obstruction. Dis Colon Rectum 42: 1189–1195 8. Caronia FP (1999) Laparoscopic rectopexy: our experience in the treatment of complete rectal prolapse. Giornale di Chirurgia 20: 311–313 9. Circco WC, Brown AC (1993) Anterior resection for the treatment of rectal prolapse: a 20-year experience. Am Surg 59: 265–269 10. Darzi A, Henry MM, Guillou PJ, Shorvon P, Monson JR (1995) Stapled laparoscopic rectopexy for rectal prolapse. Surg Endosc 9: 301–303 11. Duthie GS, Bartolo DC (1992) Abdominal rectopexy for rectal prolapse: a comparison of techniques. Br.J Surg 79: 107–113 12. Eu K-W, Seow-Choen F (1997) Functional problems in adult rectal prolapse and controversies in surgical treatment [review] Br J Surg 84: 904–911 13. Giordano P, Wexner SD (2001) The assessment of fecal incontinence in women [review] J Am Coll Surg 193: 397–406 14. Gordon PH (1999) Rectal procidentia. In: Gordon PH, Nivatvongs S (eds) Principles and practice of surgery for the colon, rectum, and anus. Quality Medical Publishers, St Louis, Missouri 15. Heah SM, Hartley JE, Hurley J, Duthie GS, Monson JR (2000) Laparoscopic suture rectopexy without resection is effective treatment for full-thickness rectal prolapse. Dis Colon Rectum 43: 638–643

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