Surg Endosc (2000) 14: 634–640 DOI: 10.1007/s004640000017

© Springer-Verlag New York Inc. 2000

Laparoscopic repair of rectal prolapse A prospective study evaluating surgical outcome and changes in symptoms and bowel function I. H. Kellokumpu, J. Vironen, T. Scheinin Fourth Department of Surgery, Surgical Hospital, University of Helsinki, Kasarmikatu 11-13, FIN- 00130 Helsinki, Finland Received: 30 April 1999/Accepted: 8 July 1999/Online publication: 22 May 2000

Abstract Background: There have been few large series that have focused on the feasibility of the laparoscopic approach for rectal prolapse. This single-institution study prospectively examines the surgical outcome and changes in symptoms and bowel function following the laparoscopic repair of rectal prolapse. Methods: In a selected group of 34 patients (total prolapse, 28; intussusception, six), 17 patients underwent laparoscopic-assisted resection rectopexy and 17 patients received a laparoscopic sutured rectopexy. Preoperative and postoperative evaluation at 3, 6, and 12 months included assessment of the severity of anal incontinence, constipation, changes in constipation-related symptoms, and colonic transit time. Results: Median operation time was 255 min (range, 180– 360) in the resection rectopexy group and 150 min (range, 90–295) in the rectopexy alone group. Median postoperative hospital stay was 5 days (range, 3–15) and median time off work was 14 days (range, 12–21) in both groups. There were no deaths. Postoperative morbidity was 24%. Incontinence improved significantly regardless of which method was used. The main determinant of constipation was excessive straining at defecation. Constipation was cured in 70% of the patients in the rectopexy group and 64% in the resection rectopexy group. Symptoms of difficult evacuation improved, but the changes were significant only after resection rectopexy. Two patients (7%) developed recurrent total prolapse during a median follow-up of 2 years (range 12–60 months). Conclusions: Laparoscopic-sutured rectopexy and laparoscopic-assisted resection rectopexy are feasible and carry an acceptable morbidity rate. They eliminate prolapse and cure incontinence in the great majority of patients. Constipation and symptoms of difficult evacuation are alleviated.

Key words: Rectal prolapse — Laparoscopy — Rectopexy — Sigmoidectomy — Bowel function

Rectal prolapse is a disabling condition that is often associated with fecal incontinence and constipation [3, 14, 21, 22]. Surgical treatment can cure the prolapse and improve bowel function. Conventional transabdominal rectopexy and rectopexy with sigmoid resection are currently the most common surgical procedures for rectal prolapse [3, 5, 13, 17, 19, 20, 23, 24, 25, 26, 27, 32, 37, 38, 40]. They eliminate prolapse and cure incontinence in the great majority of patients. Constipation and failure of rectal evacuation usually improve after resection rectopexy [11, 17, 19, 20, 23, 25, 32, 38] but may remain a source of morbid after rectopexy alone [5, 13, 23, 24, 25, 26, 27, 32, 37, 40]. Perineal procedures, which are usually preserved for elderly high-risk patients [21, 22], produce higher recurrence rates than transabdominal procedures [3, 11, 14, 21, 22], as well as inferior functional results. Since its introduction in 1992 [4], laparoscopic rectopexy with posterior mesh fixation has gained popularity because it is simple and easily accomplished [8, 9, 30]. By now, the feasibility of laparoscopic rectopexy with posterior mesh fixation and laparoscopic-assisted resection rectopexy is well established [2, 3, 8, 9, 29, 30]. Only a few large series, however, have included data on the functional results and changes in symptoms after surgery. Therefore, we designed a study to assess prospectively the clinical outcomes, including functional results and changes in symptoms, of laparoscopic sutured rectopexy and laparoscopic-assisted resection rectopexy. Patients and methods

Correspondence to: I. H. Kellokumpu, Department of Surgery, Central Hospital of Jyva¨skyla¨, Keskussairaalatie 19, 40620 Jyva¨skyla¨, Finland

Between February 1993 and December 1997, 34 patients (31 female and three male) aged 19–88 years (median, 57) underwent laparoscopic repair of rectal prolapse (total prolapse, 28; intussusception, six). During the same time, two patients underwent conventional transabdominal rectopexy be-

635 Table 1. Incontinence score system Frequency

Flatus

Liquid

Solid

Never Less than once a month More than once a month but less than once a week More than once a week

0 1

0 4

0 7

2 3

5 6

8 9

Maximum score 18; the score is determined by adding points from the grid, which takes into account the grade and frequency of incontinence [28]

cause the laparoscopic procedure was deemed to be contraindicated (severe cyphosis with restricted intraabdominal space, one; recurrent total prolapse, one). Another two patients underwent perineal rectosigmoidectomy (unfit for abdominal surgery due to coexisting medical conditions, one; incarcerated prolapse, one). Surgical data were recorded prospectively.

its lateral attachments with careful identification of the left ureter. The dissection was then continued into the pelvis with complete posterior mobilization of the mesorectum to the level of levator ani muscles, leaving the hypogastric nerves intact [10, 18, 34]. In order to avoid parasympathetic denervation and subsequent problems with constipation and rectal evacuation [35], the lateral ligaments (e.g., lateral mesorectal tissue) [18] were not divided. Anterior dissection was carried out ∼5 cm beyond the peritoneal reflection. In cases where sigmoid resection was considered necessary, mobilization was carried out to the splenic flexure [34]. The sigmoidal vessels were clipped and/or stapled and divided with an endoscopic stapler. The bowel was divided with an endoscopic stapler and exteriorized for the final resection through a mini-laparotomy at the level of the left lower trocar site. After closure of the wound and re-creation of the pneumoperitoneum, a double-stapled anastomosis was performed with a circular stapling instrument. Sutured rectopexy was performed by anchoring the mesorectum to the presacral fascia below the promontory using two or three 2-0 nonabsorbable (Prolene) stitches with external slipknots (Tayside). The anastomosis was checked with a rigid sigmoidoscope and air insufflation for hemostasis and integrity. Finally, the port sites were closed with absorbable sutures.

Clinical evaluation Postoperative treatment and follow-up A full clinical history was obtained from each patient. Confirmation of the prolapse pre- and postoperatively was assessed with the patient straining on a commode. Assessment of anal continence was based on a scale similar to that described by Browning and Parks [6] where grades III (incontinence to flatus and liquid stool) and IV (incontinence to flatus and both liquid and solid stool) represent true incontinence. We also used the incontinence score described by Miller et al. [28], which reflects both the severity and frequency of the complaint (Table 1). Patients were judged to be constipated if they had two or fewer bowel movements per week or strained for >25% of their defecation times [12]. Constipation-related symptoms were broadly divided into two categories and assessed according to a detailed questionnaire. Symptoms attributed to impaired bowel action included infrequent defecation, use of laxatives and/or enemas, presence of hard stools, and absence of a normal urge to defecate. Symptoms attributed to difficult evacuation included excessive straining at defecation, a feeling of blockage, incompleteness of evacuation, and the need for digital evacuation. To measure impaired bowel action and difficult evacuation, a total symptom score (range, 0–4) was calculated for each patient by adding up the scores for each symptom (absent ⳱ 0, present ⳱ 1). Colonoscopy or double-contrast barium enema combined with proctosigmoidoscopy was done before operation. Colon transit study before and after surgery was performed according to the technique described by Arhan et al; 93 h was set as the upper limit of normal transit time [1]. Rectal intussusception was diagnosed with a dynamic defecating proctogram using semisolid barium. Anal manometry was performed only selectively due to preexisting data on the recovery of anal sphincter function after prolapse repair [15, 16, 31, 33, 39]. All patients with rectal intussusception were assessed with concentric needle sphincter electromyography before surgery to exclude pelvic floor dysfunction (paradoxical puborectalis contraction).

Operating technique Conventional rectopexy with sigmoid resection is the standard method used to repair rectal prolapse at our institution [20, 31]. In the present series, patients with delayed colonic transit, redundancy of the sigmoid colon, and/or diverticulosis were candidates for laparoscopic-assisted resection rectopexy. Laparoscopic sutured rectopexy was indicated in other patients, including elderly patients with coexisting medical morbidity in whom a prolonged laparoscopic operation, with its adverse physiological effects, would have been potentially harmful [7]. Prophylatic anticoagulation and compressive elastic stockings were used in every patient. All patients had mechanical cleansing of the bowel and received prophylactic antibiotics for 24 h. Patients were placed in a modified lithotomy position and Trendelenburg tilt. Five 10–12-mm trocars were used in each case as for laparoscopic abdominoperineal resection [10]. A 10-mm 30° laparoscope was inserted through the supraumbilical port. In female patients, the uterus was fixed to the ventral abdominal wall using a temporary 2-0 Prolene suture (Ethicon Inc.). The procedure involved mobilization of the rectosigmoid area from

The nasogastric tube was left in place until next morning, when the intake of liquids was started. Solid intake was usually started on the 2nd or 3rd postoperative day. During the 1st postoperative month, nonstimulant laxatives were given to all patients, along with instructions to avoid excessive straining at defecation. Thereafter, the use of laxatives was determined according to degree of recovery of bowel function. Changes in anal incontinence and constipation, as well as changes in symptoms and signs of recurrent mucosal or full-thickness prolapse, were reassessed at the hospital at 3, 6, and 12 months after surgery. The anastomosis, as well as the healing of solitary rectal ulcers, was checked postoperatively by fiberosigmoidoscopy.

Statistical analysis The chi-square test, with Yates’ correction when appropriate, and Fisher’s exact test were used to compare proportions. Comparison of normally distributed data was done by Student’s t-test. Variables not normally distributed were compared using Wilcoxon’s paired signed rank sum test. Correlation was examined using Spearman’s correlation test. A p value of <0.05 was considered statistically significant.

Results Details of the patients’ clinical history are shown in Table 2. Constipation (82 vs 59%; chi-square test 2.2667, p ⳱ NS), diverticulosis (35 vs 12%; Fisher’s exact test, p ⳱ NS), the presence of redundant sigmoid colon (100 vs 35%; chisquare test ⳱ 16.2608, p < 0.005), and slow colonic transit (21 vs 8%; Fisher’s exact test, p ⳱ NS) were more frequent in the resection rectopexy group. Nine patients who had indications for resection rectopexy (diverticulosis, two; redundant sigmoid colon, six; slow transit, one) underwent sutured rectopexy alone because of old age and coexisting medical morbidity. Two patients who had rectal intussusception and pelvic floor dysfunction were treated by biofeedback therapy before surgery with unsatisfactory results. The rates of anal incontinence, constipation, and constipation-related symptoms were similar in patients with total prolapse and intussusception (data not shown). Surgical outcome Laparoscopic sutured rectopexy (17 patients) and laparoscopic-assisted resection rectopexy (17 patients) were suc-

636 Table 2. Demographic data of 34 patients submitted to laparoscopic sutured rectopexy and laparoscopicassisted resection rectopexy

Age (median) (yr) (range) Sex ratio (M:F) Total prolapse Median duration (yr) (range) Median length (cm) (range) Rectal intussusception Childbirth Perineal descent Solitary rectal ulcer Rectocele Previous pelvic/lower abdominal surgery (n) Hysterectomy Prolapsed lumbar intervertebral disc Laminectomy L3–L4 (spinal stenosis) Anal encirclementa Perineal rectosigmoidecomy, resection of the sigmoid colona Adhesiolysis (small bowel obstruction) Other gynecological operations (colposuspension, posterior colporraphy) ASA classification I II III a

Rectopexy alone (n ⳱ 17)

Resection rectopexy (n ⳱ 17)

64 (19–88) 2:15 16 3 (1–22) 5 (2–6) 1 7 6 4 2 8 5 1 1 1

55 (24–79) 1:16 12 2 (1–18) 5 (2–8) 5 12 6 1 5 6 2 1 1

p value NS NS NS NS NS NS NS NS NS

1 1 1

2

6 4 7

8 7 2

NS

Previous operations for rectal prolapse

cessfully completed in all 34 patients. The procedure was associated with laparoscopic cholecystectomy in one patient and with extensive adhesiolysis in five others. Median length of the resected colon was 34 cm (range, 20–45). Median operation time was 255 min (range, 180– 360) in the resection rectopexy group and 150 min (range, 90–295) in the rectopexy group; it was 35 and 32 min less, respectively, when the first 12 and last five operations were compared. Median time for the passage of flatus was 2 days (range, 1–4). Median postoperative hospital stay was 5 days in both the resection rectopexy group (range, 3–7 days) and the sutured rectopexy group (range, 3–15 days). Median time before return to work was 14 days (range, 12–21). There were no deaths. Eight patients (24%) had postoperative complications. Major complications (9%) included ileus lasting >1 week in one patient, a port site hernia necessitating surgical exploration and fascia closure, and an early breakdown of rectopexy sutures necessitating rerectopexy on the 1st postoperative day. There were no anastomotic leaks. Other minor complications are shown in Table 3.

Functional outcome Details of functional outcome at 12 months after surgery are shown in Table 4. Incontinence to liquid or solid stool was reported by 11 patients (65%) before surgery and two patients (12%) after surgery (␹2 ⳱ 9.1188, p < 0.01) in the rectopexy group and by 10 (59%) and two patients respectively (12%) (␹2 ⳱ 8.2424, p < 0.01) in the resection rectopexy group. Nine patients (82%) in the rectopexy group

Table 3. Postoperative complications

Complications Major (9%) Small bowel obstructiona Breakdown of sutured rectopexyb Port site herniab Minor (15%) Urinary tract infection Wound painb Diarrhea (Clostridium difficile) Pulmonary edema Presacral hematoma

Rectopexy alone (n ⳱ 17)

Resection rectopexy (n ⳱ 17)

1 1 1 1 1 1 1 1

a

Conservative treatment Reoperation (re-rectopexy, one; reexploration and wound closure, one; suture removal under local anesthesia, one)

b

and eight (80%) in the resection rectopexy group regained full continence or were incontinent only to flatus. Incontinence score decreased from a median of 7.5 preoperatively (range, 0–18) to 0.5 (range, 0–17) at 3 months (Wilcoxon signed rank test, p ⳱ 0.002); it was 0 (range, 0–17) at 6 months (Wilcoxon signed rank test, p ⳱ 0.002) and 0 (range, 0–17) at 12 months (Wilcoxon signed rank test, p ⳱ 0.002) after surgery. The reason for persistent incontinence was a recurrent full-thickness prolapse in a patient whose two previous attempts at prolapse repair had failed. A latent disruption of anal sphincters, together with pudendal nerve damage, was identified in another patient; it was subsequently treated by overlapping anterior sphincteroplasty. Two other elderly patients had idiopathic incontinence.

637 Table 4. Functional outcome at 12 months after laparoscopic sutured rectopexy (n ⳱ 17) and laparoscopic-assisted resection rectopexy (n ⳱ 17) Preoperative status and Postoperative outcome

Rectopexy alone (%)

Resection rectopexy (%)

Incontinent before operation (grades III–IV)a Unchanged Worse Continence restored Constipated before operationb Unchanged Worse Constipation disappeared Not constipated before operation Unchanged Became constipated

11 (65) 2 0 9 (82) 10 (59) 3 0 7 (70) 7 (41) 6 1

10 (59) 2 0 8 (80) 14 (82) 5 0 9 (64) 3 (18) 1 2

p value NS

NS

NS

a

True incontinence: incontinent to flatus and liquid stool (grade III) or incontinent to flatus, liquid, and solid stool (grade IV). [6] b Constipation: infrequent stools (ⱕ two per week) and/or excessive straining at defecation (>25% of total defecation time) [12]

In the rectopexy group, constipation was reported by 10 patients (59%) before and four (24%) after surgery (chisquare test ⳱ 5.1248, p < 0.05). In the resection rectopexy group, fourteen patients (82%) and seven patients (41%) were constipated (chi-square test ⳱ 6.1026, p < 0.05) (Table 4). Seven of the 10 constipated patients (70%) in the rectopexy group and nine of the 14 constipated patients (64%) in the resection rectopexy group were free of constipation at 12 months after surgery. Of the 10 patients who were unaffected preoperatively, one patient in the rectopexy group and two in the resection rectopexy group became constipated after surgery. Both preoperative (24 of 34 patients, or 71%) and postoperative (11 of 34 patients, or 32%) constipation correlated better to excessive straining at defecation (preoperative, 65%, rs ⳱ 0.874, p < 0.0001; postoperative, 35%, rs ⳱ 0.936, p < 0.0001) than to impaired frequency of defecation (preoperative, 12%, rs ⳱ 0.236, p ⳱ 0.2; postoperative, 3%, rs ⳱ 0.252, p ⳱ 0.2).

Colon transit Colon transit time increased from a median of 56 h (range, 11–192) before surgery to 72 h (range, 16–192) (Wilcoxon signed rank test, p ⳱ 0.09) at 3 months after surgery in the rectopexy group (13 patients). It increased from 48 h (range, 14–240) to 81 h (range, 6–240) (Wilcoxon signed rank test, p ⳱ 0.03) in the resection rectopexy group (14 patients). As defined [12], neither preoperative (rs ⳱ 0.271, p ⳱ 0.2) nor postoperative (rs ⳱ 0.112, p ⳱ 0.1) constipation correlated to slow transit. Before surgery, three patients with symptoms of difficult evacuation in the resection rectopexy group and one in the rectopexy group had slow transit. At 3 months after surgery, transit time normalized in only one patient in the resection rectopexy group. The other three patients with persistent slow transit continued to have symptoms of difficult evacuation. Of those who had normal transit before surgery, four patients in the resection rectopexy group and two in the rectopexy group developed slow transit, despite

some improvement of symptoms attributed to difficult evacuation. In patients with slow transit, the markers were retained in the right and left hemicolon before surgery and in the right and left hemicolon (six patients) or left hemicolon alone (three patients) after surgery. Symptomatic outcome Symptomatic outcome during the 1-year follow-up is shown in Table 5. In the rectopexy group, the median score reflecting the severity of symptoms attributed to impaired bowel action was 0 (range, 0–3) before surgery and 1 (range, 0–3) at 12 months after surgery (Wilcoxon signed rank test, p ⳱ 0.99). In the resection rectopexy group, it was 1 (range, 0–3) both before and after surgery (Wilcoxon signed rank test, p ⳱ 0.01). Symptoms improved in three of the seven affected patients (43%) in the sutured rectopexy group and nine of the 14 (64%) in the resection rectopexy group. Of the 13 patients who were unaffected preoperatively, three patients in the rectopexy group became worse after surgery. The median symptom score reflecting the severity of evacuation difficulties decreased from 2 (range, 0–4) to 0 at 12 months after surgery (range, 0–4) (Wilcoxon signed rank test, p ⳱ 0.08) in the rectopexy group. It decreased from 3 (range, 0–4) to 1 (range, 0–4) (Wilcoxon signed rank test, p ⳱ 0.003) in the resection rectopexy group. Eleven of the 14 affected patients in the rectopexy group (79%) and 12 of the 17 (71%) in the resection rectopexy group reported that their symptoms had improved or disappeared. None of the unaffected patients was made worse. Recurrent prolapse Apart from the immediate recurrence related to suture breakdown, two of the 28 patients with total prolapse (7%) developed recurrent full-thickness prolapse during a median follow-up of 24 months (range, 12–60). The first recurrence occurred 6 months after a technically difficult laparoscopic rectopexy in a patient with a prior, failed perineal rectosigmoidectomy and subsequent sigmoid re-resection that had been performed elsewhere. The situation was managed by conventional re-rectopexy. A second recurrence, which was treated by re-rectopexy and sigmoid resection, occurred 3 years after laparoscopic sutured rectopexy in an elderly patient who continued to strain excessively. Symptomless mucosal prolapse has been observed in an additional 5 patients (18%) when straining on a commode. A solitary rectal ulcer was observed in five patients before surgery and in one patient at 12 months after surgery. Discussion Our results show that laparoscopic sutured rectopexy and laparoscopic-assisted resection rectopexy effectively cure prolapse and can be performed safely even in elderly patients. The primary disadvantage is the long operating time needed to perform the procedure, at least during the learning curve phase. In previous series, the median operation time has varied from 1.5 to 3 h for laparoscopic rectopexy with

638 Table 5. Changes in constipation-related symptoms during the 1-year follow-up Rectopexy alone (n ⳱ 17)

Resection rectopexy (n ⳱ 17)

Preop

3 mo

6 mo

12 mo

Preop

3 mo

6 mo

12 mo

n (%)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

1 (6)

Use of laxatives

n (%)

5 (29)

8 (47)

8 (47)

9 (53)

10 (59)

11 (65)

11 (65)

Hard Stools

n (%) n (%)

6 (35) 1 (6)

4 (24) 0 (0)

5 (29) 0 (0)

4 (24) 0 (0)

4 (24) 0.05a 12 (71) <0.05a 8 (47) 2 (12)

3 (18) 0 (0)

5 (29) 1 (6)

7 (41) 1 (6)

n (%)

9 (53)

6 (35)

6 (35)

4 (24)

13 (76)

n (%)

5 (29)

4 (24)

4 (24)

4 (24)

Incompleteness several attempts

n (%)

12 (71)

8 (47)

8 (47)

7 (41)

Digitation

n (%)

9 (53)

4 (24)

5 (29)

5 (29)

12 (71) <0.05a 17 (100) 0.02a 9 (53)

6 (35) <0.05 4 (24) <0.03 8 (47) 0.0005 2 (12) <0.05

8 (47)

Feeling of blockage

5 (29) <0.03 2 (12) <0.005 8 (47) 0.0005 1 (6) <0.01

Impaired bowel action Infrequent movements (ⱕ2/wk)

No urge to defecate Evacuation difficulties Excessive straining

a

7 (41) 10 (59) 0.004 3 (18)

Comparison of preoperative frequencies: resection rectopexy vs rectopexy alone

posterior mesh fixation [8, 9, 30] and from 3 to 4 h for laparoscopic-assisted resection rectopexy [2, 29, 36]. These results are similar to our own; however, a reduction in operating time can be expected with increasing experience. The median postoperative hospital stay (5 days) in this and other laparoscopic series [2, 4, 8, 9, 11, 29, 30] compares well with the 7–11 days reported with conventional transabdominal surgery [11, 19, 38]. Complications are not infrequent with abdominal procedures to repair rectal prolapse. In a recent review [21], they occurred in ∼20% of patients; this finding is also in line with our results.

Functional outcome Full continence to liquid or solid stool was achieved in 82% of the patients in the sutured rectopexy group and 80% of the patients in the resection rectopexy group. This outcome compares well with those of previous series that reported improved continence in 44–93% of cases, regardless of surgical technique [5, 13, 19, 20, 22, 24, 26, 27, 32, 37, 38, 40]. Our patients achieved restoration of anal continence within 3–6 months after anatomical correction of prolapse, as shown by the improvement in the overall continence scores. According to other investigators [15, 16], the restoration of anal continence after prolapse repair is related to the resolution of the patient’s chronic rectoanal inhibition and recovery of internal sphincter electromyographic activity, together with an increase in anal resting pressure. Other contributing factors include an increase in maximal voluntary contraction pressure, reflecting recovery of the external anal sphincter [15, 31, 39], as well as improved anorectal sensation [13]. Constipation as defined here [12] presented mainly as

difficulty in fecal evacuation due to pelvic outlet obstruction by the intussuscepting bowel. Colonic inertia was identified preoperatively in 15% of the patients, which corresponds well with the 10–50% reported in other studies [13, 19]. Earlier randomized studies have reported that the rate of postoperative constipation is lower when resection rectopexy is performed [23, 25, 32]. In our series, 64% of the patients in the resection rectopexy group achieved relief at 12 months after surgery. This outcome is in line with previous studies that reported an improvement in constipation symptoms in ∼50% of patients who underwent sigmoidectomy and rectopexy [20, 36, 38]. Our finding that the symptoms resolved in 70% of the patients in the sutured rectopexy group contrasts with other studies that reported increased or unchanged constipation after rectopexy alone [5, 13, 26, 27, 33, 35, 40]. However, the definition of constipation and the operating techniques (e.g., division of the lateral ligaments) have varied in different studies, making comparison of the results difficult. Impaired rectal motility caused by division of the lateral mesorectal tissue with parasympathic denervation, functional obstruction caused by kinking of the redundant sigmoid colon above the fixed rectum, and fibrosis related to the use of mesh are all regarded as ethiological factors for postoperative constipation after rectopexy alone [13, 25, 26, 32, 33, 35, 40].

Colon transit If colonic transit is defective preoperatively, partial colonic resection is now recommended at the time of rectopexy, with the extent of resection dependent on the site and degree of stasis [10, 22]. Huber et al. have shown that colonic transit improves after conventional rectopexy with sigmoid

639

resection [19]. In accordance with earlier randomized studies [23, 25], we found a shift toward a slower colonic transit time after both rectopexy alone and resection rectopexy. Four patients with slow transit in this series apparently would have benefited from subtotal colectomy instead of sigmoidectomy. However, subtotal colectomy was avoided because it carries an increased risk for diarrhea and diminished continence [22]. The underlying cause of slow transit in the patients who developed it after surgery despite lack of any evidence of bowel or anastomotic stenosis is unknown. However, this condition may reflect persisting difficulties with evacuation, which are known to contribute to slow colonic transit time. [14, 22]. Symptomatic outcome It is generally agreed that after nonresectional repairs, constipation-related symptoms remain unchanged or even increase if the lateral ligaments are divided during the rectal mobilization [13, 26, 33, 35]. In our series, neither sutured rectopexy nor resection rectopexy significantly altered the symptoms that were attributed to impaired bowel action, as evidenced by the symptom scores and the incidence of each specific symptom during the 1-year follow-up period. Some patients were even made worse. Symptoms attributed to difficult rectal evacuation, however, were significantly ameliorated in the resection rectopexy group, as was also reported in a previous study comparing various form of rectopexy [13]. These symptoms were also alleviated after sutured rectopexy, but the changes were not significant. Of note, the use of laxatives to maintain regular bowel habits tended to increase in the rectopexy group and decrease in the resection rectopexy group. Recurrent prolapse Conventional resection rectopexy is associated with a recurrence rate of 0–9% [16, 19, 20, 21, 22, 38], whereas the recurrence rate for abdominal rectopexies is 0–12% [21, 22]. In our series, recurrent full-thickness prolapse was observed in two patients (7%) after a median follow-up of 2 years (range, 12–60). Mucosal prolapse after conventional surgery is usually seen in 7–10% of cases [5, 40]; by contrast a rate of 18% was observed among our patients when we particularly sought this parameter by identifying which patients strained on a commode. Conclusion This study has shown that laparoscopic sutured rectopexy and laparoscopic-assisted resection rectopexy are technically feasible and can be performed safely even in elderly patients. The main advantages of the laparoscopic approach seem to be a rapid return of bowel function, a shorter hospital stay, and a quicker return to work. According to our intermediate follow-up data, the laparoscopic approach is not associated with increased recurrence rates. The anatomical correction of prolapse cures incontinence in the great majority of patients. Constipation and symptoms of difficult evacuation are usually ameliorated, but they may remain a

source of morbidity in some patients. Randomized studies are needed to validate the need for colonic resection and to determine its optimal extent in patients who suffer from rectal prolapse, constipation, and slow transit. Acknowledgments. This study was supported by a grant from the Kurt and Doris Palander Foundation.

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