Tech Coloproctol (2006) 10:318–322 DOI 10.1007/s10151-006-0300-3 O R I G I N A L A RT I C L E

E.G.G. Verdaasdonk • J.M. Bueno de Mesquita • L.P.S. Stassen

Laparoscopic rectovaginopexy for rectal prolapse

Received: 10 January 2006 / Accepted: 15 March 2006 / Published online: 27 November 2006

Abstract Background Open rectovaginopexy is an effective procedure for the treatment of both rectal prolapse and anterior rectocele. This study investigates our results of laparoscopic rectovaginopexy (LRVP). Methods A consecutive series of 14 patients (median age, 73 years; range 24–92) with rectal prolapse was planned for LRVP. Pre-, per- and postoperative parameters were recorded. Followup was performed at the outpatients’ clinic. Results The median length of hospital stay was 6 days (range, 3–14). There was one fatal cerebrovascular accident 14 days postoperatively; this patient was excluded from further analysis. Median follow-up was 7 months (range, 0.75–38). During follow-up, 11 of 13 patients (85%) experienced resolution or major improvement of their symptoms. Anal incontinence was diminished in 9 of 13 cases (69%). Constipation improved in 2 of 3 patients (66%). These three patients experienced a combination of both anal incontinence and constipation, preoperatively. Recurrence occurred in 2 patients (15%). Two others had a minor residual mucosal prolapse. No patients reported symptoms

E.G.G. Verdaasdonk () • J.M. Bueno de Mesquita L.P.S. Stassen Department of Surgery Reinier de Graaf Group Delft, The Netherlands E-mail: [email protected]

suggestive of operation-induced constipation or dyspareunia. Conclusions LRVP is feasible, and seems to be an effective procedure for rectal prolapse. No operationinduced constipation was observed in this series. Taking into account the age and co-morbidities of these patients, morbidity and mortality may be considered acceptable. Key words Rectal prolapse • Anterior rectocele Laparoscopic • Rectovaginopexy • Rectocolpopexy

•

Introduction Complete rectal prolapse that causes obstructed defecation can be a socially disabling condition. Little is known about the exact incidence of rectal prolapse. Currently, there is no ideal technique considering the diversity of procedures [1]. A Cochrane review on surgical treatment of rectum prolapse in adults revealed that the small sample size of reported trials together with their methodological weaknesses severely limit the development of practice guidelines [2]. Classically, an abdominal approach is used. Such a procedure consists of rectopexy with or without sigmoid resection. This technique may lead to operation-induced constipation in which damage to the pelvic autonomic nerves may play a role [3–6]. Moreover, as the condition is commonly observed in the elderly patient, there is an increased risk for per- and postoperative morbidity. Therefore, perineal procedures such as the Altemeier and the Delorme procedures have gained popularity. Unfortunately, these have a high recurrence rate compared to transabdominal procedures and should be reserved for high-risk or elderly patients [7–9]. The transabominal laparoscopic repair of rectal prolapse is an alternative that results in reduction of hospital stay and morbidity. In this procedure, a minimally invasive approach is combined with a conventional intra-abdominal rectopexy [10].

E.G.G. Verdaasdonk et al.: Laparoscopic rectovaginopexy

In 1999, Silvis et al. [4] described an interesting procedure for the treatment of both rectal prolapse and anterior rectocele: the (open) rectovaginopexy (RVP). This technique avoided dorsolateral mobilization of the rectum in order not to endanger the nerves, which resulted in long-term relief of constipation. Laparoscopic rectovaginopexy (LRVP) combines the advantages of RVP with those of a minimally invasive approach. D’Hoore et al. [11] described the first series of patients treated with laparoscopic ventral rectopexy and reported a low recurrence rate of the prolapse and no new onset or increase of constipation. This study is the second report of a nerve-preserving, laparoscopic, mesh procedure for rectum prolapse. The goals of the new technique are: effective correction of the rectal prolapse, avoiding iatrogenic constipation and maintaining the advantages of minimally invasive surgery (i.e. low morbidity). The present study was conducted to analyse the results of LRVP of the first 14 patients treated with this procedure in our hospital.

Materials and methods From June 2000 to May 2005, the study enrolled all patients planned for LRVP for complete rectal prolapse. Pre-, per- and postoperative parameters were collected. These parameters included: general patient data, medical history, symptoms before and after surgery, medication, results of diagnostic tests, physical examination and complications. Patients were analyzed on an intention to treat basis. Follow-up was performed at the outpatients’ clinic unless the patient’s condition prevented this. During follow-up, symptoms were evaluated. Special attention was paid to the occurrence of new symptoms such as abdominal pain, constipation and dyspareunia. Continence was assessed on a scale of 1 to 4 according to Parks [12]. Grade 1 is normal continence, grade 2 is incontinence to mucus or flatus, grade 3 is incontinence for liquid stool, and grade 4 is incontinece for solid stool. In this study, Parks grades 2–4 were considered as incontinence. Improvement of clinical symptoms was defined as a correction of the prolapse, a decline in the Parks grade for incontinence, or a reduction or disappearance of constipation. Adverse effects were defined as worsening of symptoms or occurrence of new symptoms.

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2

a

b

a

3 1

b

Fig. 1a, b Use of Prolene mesh for rectovaginopexy. a Prolene mesh (3x30 cm2) folded in U-shape. 1, sutured to the rectovaginal septum; 2, Base of the U is fixed to the promontory with 4 tacks by means of the Protack; 3, Sutured to the rectovaginal septum. b Prolene mesh positioned and fixed on the promontory (a) and rectovaginal septum (b) left, the peritoneum over the rectovaginal vault was opened. A small tunnel was made behind the mesorectum, starting proximally from the right side, running distally to the left side where communication with the opened peritoneum was created. During the complete dissection phase, the autonomic innervation was spared. Rectopexy was performed with a slip of Prolene (Johnson & Johnson, Amersfoort, The Netherlands) mesh of 3-cm width and 30-cm length, folded in a U-shape (Fig. 1). Conventional non-resorbable Mersilene 2.0 (Johnson & Johnson, Amersfoort, The Netherlands) sutures were used. First, one end of the slip was tunnelled down behind the mesorectum to the left side of the rectovaginal septum and there sutured to the ventral side of the rectum and the dorsal side of the vagina. The base of the U was then fixed to the promontory with 4 tacks by means of the Protack device (Autosuture, Tyco Healthcare, United States) which was introduced through a fourth 5-mm suprapubic trocar. The other end of the slip was brought down along the right side of the rectum and fixed to the rectovaginal septum in the same way as its counterpart. The peritoneum was closed with a running Vicryl 3.0 suture (Johnson & Johnson, Amersfoort, The Netherlands). Postoperatively patients were immediately mobilized and orally fed.

Surgical procedure

Results Pneumoperitoneum was established by the open technique using a Hasson trocar in the lower border of the umbilicus. Two additional trocars were used in the right lower quadrant: a 10mm trocar on the right and a 5-mm trocar on the left. The procedure was identical to that described by Silvis et al. for the open approach [4]. The peritoneum at the right lateral margin of the mesorectum was incised from the level of the promontory down, leaving the lateral ligaments intact. Next, from right to

In the study period, a consecutive series of 14 patients with complete rectum prolapse were planned for LRVP. The patients consisted of 13 women and one man of median age 73 years (range, 24–92 years). Six patients had a history of at least one abdominal or vaginal operation concerning prolapse of the pelvic floor. Medical history of

E.G.G. Verdaasdonk et al.: Laparoscopic rectovaginopexy

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Table 1 Accompanying symptoms reported by 13a patients with rectal prolapse, before and after LRVP. Values are number of patients reporting a symptom Symptom Rectal bleeding Anorectal pain when sitting Urge for defecation Dyspareunia Groin pain Recurrent urinary tract infections Urinary incontinence Abdominal pain Total a

Before

After

5 5 3 2 1 1 1 13 34

0 0 2 2 1 0 1 4 12

One patient died on day 14 due to cerebrovascular problems

Table 2 Anatomical and clinical results after LRVP for rectal prolapse for 13 patientsa at a median follow-up of 7 months Patients, n Anatomy Restored Residual mucosal prolapse Complete recurrence Symptoms Incontinence (n=13) Improved Stable Worsened Constipation (n=3) Improved Stable Worsened

9 2 2

9 4 0 2 1 0

Early complications Perioperative atrial fibrillation Postoperative delirium

2 1

Late complications Hernia at trocar site Skin abscess

1 1

a

One patient died on day 14 due to cerebrovascular problems

Median operative time was 180 minutes (range, 120–210 minutes). Operative blood loss varied from 0 to 250 ml (median, 50 ml). Two procedures were converted to an open rectovaginopexy because of adhesions due to previous abdominal hysterectomy. Median length of hospital stay was 7 days (range, 3–14 days). In the immediate postoperative period, two patients were successfully medically treated for an irregular atrial rhythm. Another 86-year-old patient had a fatal cerebrovascular accident 14 days postoperatively; she was excluded from further analysis. Thirteen patients visited the outpatients’ clinic for a median follow-up of 7 months (range, 0.75–38 months). In 9 of 13 patients (69%), anatomy was restored (Table 2). Eleven patients (85%) experienced a major improvement of their clinical symptoms of either incontinence (9 of 13) or constipation (2 of 3). No patients reported new or increased constipation or dyspareunia. Figure 2 shows the Parks scores of the patients before and after LRVP. A complete prolapse recurred in two patients (15%). One of these patients had persevered in excessive straining at defecation due to an obsessive disorder. This patient underwent a secondary abdominal rectopexy after which the prolapse recurred a second time. This situation was accepted. The other patient underwent a successful abdominal correction, during which the promontorial fixation turned out to have slipped. Two other patients (15%) had a residual rectal mucosal prolapse. One of these patients experienced only mild symptoms and refused further treatment. In the other rubber band ligation was successfully performed. In one patient a cicatricial hernia was diagnosed at one of the trocar sites. One patient had a small wound abscess at the navel trocar site. Many accompanying symptoms experienced before the LRVP were absent or diminished at follow-up (Table 1). In one patient, incontinence for urine developed and she complained of more abdominal pain than before the operation. Before LRVP After LRVP

Number of patients

three patients revealed cardiac problems, two had known hypothyroidism, one patient suffered from diabetes, one from severe chronic obstructive pulmonary disease, two patients were demented and one had a serious psychiatric obsessive disorder in combination with a history of drug abuse. Eight patients used four or more different medicines prescribed by a physician. None of these medicines were known to induce defecation disorders. Twelve of 14 patients (86%) had grade 4 incontinence and two patients had grade 2 incontinence. Several minor symptoms were experienced before operation (Table 1). These were mild and did not contribute to the indication for LRVP.

12 11 10 9 8 7 6 5 4 3 2 1 0 1

2

3

4

Parks score Fig. 2 Parks scores before and after laparoscopic rectovaginopexy (LRVP), for 13 patients at a median follow-up of 7 months. Parks classification [12]: normal continence = 1; incontinence to mucus or flatus = 2; to liquid or stool = 3 and to solid stool = 4

E.G.G. Verdaasdonk et al.: Laparoscopic rectovaginopexy

Discussion Laparoscopic rectovaginopexy (LRVP) is a novel procedure that combines the benefits of the open RVP and the laparoscopic approach. LRVP has three main goals: effective correction of rectal prolapse and its symptoms, avoidance of iatrogenic constipation or other discomfort, and maintaining the advantages of minimally invasive surgery (i.e. low morbidity). A laparoscopic approach is meant to facilitate postoperative recovery and to reduce morbidity. With respect to postoperative recovery, we found that LRVP had a median stay shorter than that for the open procedure but longer than that of the laparoscopic rectopexy [10, 13]. One patient died within two weeks of the procedure and was excluded from further analysis. Thus, results from followup of 13 patients were considered. Postoperative complications occurred in only three patients; mild morbidity occurred in two. Current laparoscopic treatment of rectal prolapse includes suture rectopexy [14], stapled rectopexy [15, 16], posterior mesh rectopexy with artificial material [17, 18] and resection of the sigmoid colon with colorectal anastomosis [19] with or without rectopexy [20]. Laparoscopic techniques used for anterior rectocele are suture or mesh rectopexy [21, 22]. Regardless of the laparoscopic technique, recurrence rates after surgical correction of complete rectal prolapse vary from 0 to 13% [10, 19, 21, 23–25]. In our study, the operation resulted in recurrence of a full prolapse in 2 patients (15%). This percentage is somewhat higher than reported for other techniques. However, in 85% the clinical symptoms improved and in 69% correction of rectal prolapse was successfully accomplished. In the literature, improvement of clinical symptoms is reported in 64% to 95% of patients [19–21, 23–25]. Increase of constipation after mesh procedures has been reported by several authors [3, 6, 20]. Although symptoms of prolapse have been successfully treated, new complaints of constipation or dyspareunia are bound to occur. In this study, no patients reported new or increased constipation or dyspareunia. Despite two recurrences, clinical results are comparable and, with respect to operationinduced constipation, in most cases better than reported with other techniques. As in the open RVP technique, the LRVP aims at correction of the rectal prolapse without causing damage to rectal innervation. The superior hypogastric plexus, the hypogastric nerves and the inferior hypogastric plexus are not put at risk, because extensive posterior blunt dissection of the rectum is not necessary and the lateral ligaments are not divided. By using this technique in an open procedure, Silvis et al. [4] described a favorable outcome with regard to the risk of operation-induced constipation. The rectopexy as performed by Silvis and colleagues also closely resembles the

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anterior rectopexy and reinforcement of the rectovaginal septum as used by D’Hoore et al. [11], although the latter authors performed an even more extensive dissection of the septum and a wider fixation of the mesh to the anterior side of the rectum. Only one slip of the mesh is used. In another recently described technique of (open) colporectopexy, Collopy and Barham [18] combined the classic Wells rectopexy with a mesh fixation of the vaginal vault. The dissection of the rectovaginal septum and its stretching and the reinforcement by a Prolene mesh make this procedure also suitable for correction of an anterior rectocele. Comparing success rates and recurrences in different studies should be done with caution because other authors used different definitions. In general, there seems to be no clear correlation between the surgical method used and the improvement of clinical symptoms [8, 26, 27]. Our results correspond with the percentages in the literature using mesh techniques with respect to reduction of symptoms and restoration of anatomy. Also, no patient developed operation-induced constipation. Therefore, the goals of LRVP seem to have been met. Considering the overall medical history of the patients, the results may be considered acceptable. In conclusion, LRVP is a feasible procedure to treat complete rectal prolapse. Taking into account the age and comorbidity of the patients, the results of our series may be considered encouraging, but larger series are needed to define the exact value of LRVP.

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