coloproctology O Urban & Vogel 1997

Jahrgang 19 (1997), 28-32, Nr. 1, Januar/Februar

R Boccasanta 1, R. Rosati 2, G. Micheletto 1, S. Bona 2, U. Fumagalli 2, B. Chella ~, A. Peracchia ~

Laparoscopic Surgery and Rectal Prolapse: Personal Experience Summary: Laparoscopy is gaining an important role in the treatment of benign colorectal disorders. The aim of this study is to evaluate clinical and functional results in 4 patients subjected to laparoscopic rectopexy according to Wells. From 1993 through 1995, 4 females (mean age 53.7 years, range 22 to 76 years) affected from complete rectal prolapse with faec~tl incontinence underwent this procedure. Six months after surgery, at the end of a rehabilitation program consisting of kinesitherapy, biofeedback and electrostimulation, all patients were re-evaluated by means of a clinical examination, anorectal manometry and defecography. Preliminary results seem satisfactory and may allow this approach to be used instead of the traditional open surgery. (Key Words: Rectal prolapse . Laparoscopy assisted colonic surgery . Abdominal rectopexy)

Laparoskopische Operation beim Rektumprolaps: Pers6nlicher Erfahrungsbericht Zusammenfassung. Die Laparoskopie gewinnt bei der Behandlung benigner kolorektaler Affektionen immer mehr an Bedeutung. Ziel unserer Untersuchung war die Bewertung der klinischen und funktionellen Ergebnisse bei vier Patientinnen, die sich einer laparoskopischen Rektopexie nach Wells unterziehen mul3ten. Zwischen 1993 und 1995 wurden vier Frauen (Durchschnittsalter 53,7 Jahre [22 bis 76 Jahre]) mit eineto kompletten Rektumprolaps mit f~ikaler Inkontinenz auf diese Weise operiert. Sechs Monate postoperativ, nach Beendigung eines Rehabilitationsprogrammes mit Kinesiotherapie, Biofeedback und Elektrostimulation, wurde bei allen Patientinnen eine klinische Untersuchung durchgefª Die ersten Ergebnisse sind zufriedenstellend und sprechen fª den Einsatz dieser Vorgehensweise anstelle der bisherigen traditionellen offenen Operationsmethode. (Schlª

Rektumprolaps 9 Laparoskopie-unterstiitzte Kolonchirurgie, Abdominale Rektopexie)

M

inimally invasive surgery has spread beyond cholecystectomy and has been applied to various other abdominal and thoracic procedures. Even if concenas have been raised regarding whether laparoscopy can offer equivalent oncologic results [14], it offers an effective option in the treatment of benign colonic disease and particularly of rectal prolapse.

Reported benefits of laparoscopic procedures ate reduced postoperative mortality and morbidity. The evaluation of the immunologic response to surgical trauma has demonstrated that the laparoscopic approach induces a lower grade of lymphopenia than laparotomy both in the early and late postoperative period [12], leading to a lower risk of infectious complications extremely dangerous in prosthesis application.

Department of General Surgery and Surgical Oncology (Head: A. Peracchia, MD), Ospedale Policlinico, University of Milan, Milano, [taly. ~"Department of Minimally Invasive Surgery, Istituto Clinico Humanitas. Via Manzoni 56, Rozzano (MI), ltaly.

Patients with rectal prolapse have a variety of anorectal symptoms; if associated with faecal incontinence, it represents a cause of disability and of high social

Submitted: 27.7. 1996

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P. Boccasanta, R. Rosati, G. Micheletto et al. coloproctology 19 (1997), 28-32 (Nr 1)

impact and implies surgical treatment, as the transabdominal rectopexy or the perineal mucosectomy or rectosiomoidectomy [ 18].

coccyx and the anorectal junction) at test and during maximum evacuation straining [2]. Anorectal manometry was evaluated preoperatively and postoperatively 6 and 12 months after rectopexy; resting and squeezing pressures (mm Hg), rectal capacity (ml), rectoanal inhibitory reflex, threshold volume (rol) and painful reflex to rectal stretching (ml) were measured using open-ended continuously perfused catheters (infusion rate 1 rol/ruin) and air-fitled balloon probes.

Sacral fixation of the prolapsing rectum is perhaps the most common abdominal surgical procedure for the treatment of prolapse; in our department, we perform the posterior rectopexy according to Wells technique [7, 24], without dividing the lateral rectal attachments; unfil 1993 15 patients underwent this procedure through laparotomy and had good functional results. On the basis of this experience, we began to perform the same procedure through laparoscopy [8]; as reported by other authors [6], our preliminary results ate encouraging and allow us to state that the laparoscopic approach is safe and effective, and could represent the treatment of choice for rectal prolapse.

A Medelec MG6 instrument with MCD 50 electrode wires (length 50 mm, caliber 0.45 mm) was used to obtain a complete electromyographic evaluation of the external sphincter; fine electrode wires were placed percutaneously in the posterolateral commissure 1 cm in deptb [16].

Patients and Methods

Operative Technique

Between January 1993 and April 1995, 4 women with complete full-thickness rectal prolapse underwent laparoscopic rectopexy. They ranged in age between 22 and 73 years (average 53.7 years).

Al1 patients underwent conventional preoperative bowel preparation with an hypertonic saline solution for 24 h prior to surgery and received routine antibiotic prophylaxis; in all patients nasogastric tube and urinary cathether were placed after anaesthesia induction.

Preoperative work-up included a detailed history using a specially designed questionnaire dealing with evacuation habits. According to Kellys classification 3 categories of incontinence were adopted: 1. anal soiling, 2. partial loss of liquid stool, 3. regular loss of solid stool.

All procedures were performed with the patient in the Lloyd-Davis position with a 30 ~ Trendelenburg. Pneumoperitoneum was created using a standard closed technique for insufflation through a Veress needle and mantained at 10 to 12 mm Hg.

A full clinical investigation, including inspection and digital examination of the anorectum, proctoscopy, sigmoidoscopy, colonic transit study, dynamic defecography, anorectal manometry and anal electromyography, was undertaken in all patients.

The angled scope was inserted through a 10 mm trocar into the umbilical scar and initial inspection was performed. Two other 10 mm trocars were inserted into the left and right iliac fossa a n d a further 12 mm pon was inserted suprapubically.

Colonic transit study with radio-opaque markers was realized according to Hinton and Lennard-Jones techniques [ 11].

To disclose the operative field, the uterus was suspended from the abdominal wall, through a transfixed stitch of an intrauterine device, and the small bowel was dislocated from the pelvis in the upper abdomen. Grasping and elevating the middle third of the rectum, the ureter was identified and the left pe¡ reflexion of the mesorectum was sectioned with coagulating scissors. Dissection was continued anteriorly in the rectovaginal septum and then to the posterior mesorectum, in the avascular plan between the fascial capsule and the fascia, in order to create a wide retrorectal window.

Defecography was performed according to Mahieus technique [13]; spot films were taken at rest, during straining without evacuation, followed by straining and forced evacuation. The pathologic descent of the pelvic floor was radiologically evaluated measuring the posterior rectal inclination (described by the horizonal plane passing through the coccyx and the plan passing through the

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P. Boccasanta, R. Rosati, G. Micheletto et al. coloprocto[ogy 19 (1997), 2 8 -3 2 (Nr. I )

Name

Faecal incontinence Stage

Urinan/incontinence Stage

Rectal bteeding

Rectal dyschezia

P. G., 73 yrs Z. A., 7 2 y r s

3 (1) 3 (1)

1 (1) 1 (1)

+ (-) + (-)

+ (+) + (-)

P. 8., 22 yrs L. T., 4 8 y r s

1 (0) 2 (1)

1 (0) 1 (1)

+ (-) + (-)

+ (-) + (-)

in parenthesis s y m p t o m s 6 months after surgen/.

Table l. Effect o f rectopexy on incontinence, rectal bleeding and rectal dyschezia.

Anal resting pressure (mm Hg) M a x i m u m squeezing pressure (mm Hg) Rectal capacity (mi) Threshold for recto-anal refiex inhibition (ml/air) Defecation urge eliciting pressure (ml/air) Pain to recta] distension (ml/air)

Pre-op

6 months

12 months

34 ( 2 5 - 53) 88 (60-116) 180 15 (10-15) 16 (14 - 18) 30 (21 - 39)

42 ( 3 0 - 54) 100 (70-130) 175 16 (11 - 21 ) 15 (10 - 20) 34 (22 - 36)

47 (31-63) 97 (82-112) 170 17 (12 - 22) 14 (10 - 18) 30 ( 2 5 - 35)

A rectangular polypropylene mesh (lO x 6 cm) was then inserted into the pe¡ space through the 12 mm port and fixed to the sacrococcygeal area with an Endo-Hernia stapler; the lateral free margins of the mesh were finally sutured to the rectal lateral wall with non-absorbable interrupted stitches, knotted with intraor extracorporeal technique.

Table 2. Pre- and postoperative manometric findings.

Manometric parameters measured before and after (6 and 12 months) surgery do not demonstrate significant pressure variations as described by other authors and reported in Table 2 [15]. On electromyography, all aged patients presented fibrillation of recmitment unit as in a peripheric denervation pattern with a good/moderate strength of voluntary contraction.

The procedure was completed with peritoneal reapproximation and port sites closure. No drainage was left. Four women underwent laparoscopic rectopexy; all of them suffered from complete rectal prolapse, fecal incontinence (third stage in 2 patients); 3 patients had urinary incontinence under straining and cystocele (first stage in 2 and second stage in t patient) (Table 1); 3 patients were multipara (mean 2.5 pregnancy/patient). Two patients underwent episiotomy because of macrosomic fetus and 3 patients underwent hysterectomy.

Results

Mean operative time was 150 min. There were no intraoperative complications; no conversion to open technique was necessary. Postoperative course was uneventful; all patients passed flatus on the second postoperative day and stool on the fourth postoperative day with mild laxative administration (lactulose). Mean hospital stay was 5 days.

All patients had normal colic transit; according to Costalat and Garrigues c¡ based on posterior rectal angle at defecography 3 patients showed a descended perineum at rest and the fourth had a descending perineum under straining [5, 10].

In order to re-educate patients in the use of their pelvic floor muscles, they underwent physiotherapy, external electric and biofeedback stimulation [25] for 6 months after surgery. At the end of the training the results on

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P. Boccasanta, R. Rosati, G. Micheletto et al. coloproCtology 19 11997). 28-32 (Nr. I)

faecal continence of the laparoscopic rectopexy were evaluated.

patients should undergo a less invasive approach, such as mucosectomy and perineoplasty [21].

As shown in Table I, faecal incontinence score decreased from 3 to 1 in 3 patients and from 2 to 1 in the remaining patient; in 1 patient anal soiling disappeared.

Voluntary contraction of external sphincter should be carefully evaluated on electromyography because it is a prognostic factor of surgical effect on continence; if voIuntary contraction is preserved continence will be restored as the mechanical defect will be repaired, despite acquired neurologic impairments.

As concerns the u¡ incontinence, only 1 patient had an inprovement due to pelvic re-education. In 3 patients hematochezia and dyschezia disappeared. No postoperative complications were recorded apart from an umbilical wound infection which healed with ambulatory conservative treatment.

Other surgical acts associated with rectopexy, such as cystopexy of Douglas-ectomy, can be efficaciously realized through laparoscopy [4, 22, 23]. Ir is thus possible to transfer every approved procedure from laparotomy to laparoscopy and, as in open surgery, to tailor the procedure to each patient needs, in order to correct all the complex alterations of the pelvic statics in the same operation [1, 3].

Median follow-up was 20 months (range 7 to 33 months), no recurrences have been recorded.

Discussion

We prefer the Wells technique with lateral rectal ligament preservation and 270 ~ rectum mobitization in order to obtain a safe rectal fixation without significant alteration of colonic transit [20]. Ligament division has not been proved to prevent recurrences and it also induces further nervous injury to ah impaired pelvic floor [19]. This hypothesis fs gtrongly supported by reported rectal volume and rectal sensation decrease following hysterectomy.

A wide variety of surgical techniques to correct rectal prolapse have been proposed; since people affected are usually aged and unfit, surgical procedure should be proposed on the basis of a complete evaluation of local and general conditions of the patient. Rectopexy represents a safe and effective procedure, whereas radical operations, such as rectosigmoid resection of combined abdominoperineal pelvic floor repair, should be reserved only for younger and low-risk patients [9, 18].

To strengthen functional results, we strongly recommend physiotherapy and external electric and biofeedback stimulation [25] for 6 months after surgery and every time we suspect an alteration of the automatic process of defecation during the follow-up.

Laparoscopic approach to benign colonic disease potentially has the same advantages as other commonly accepted laparoscopic procedures; from the technical point of view, ir is now feasible due to the introduction of a particular clip applier, devised for laparoscopic hernia repair.

Conclusions

Patients should be selected for surgical procedure with special care; regarding our preliminary expe¡ the main indication for rectopexy was complete rectal prolapse with faecal incontinence and normal bowel transit.

Only complete rectal prolapse, associated with incontinence and normal colon transit, should be treated surgically. Voluntary external rectal sphincter preservation is fundamental to restore continence in the presence of a mechanical obstacle to anal closure, even if an acquired neurological impairment exists.

Patients affected from rectal prolapse, associated with chronic constipation due to prolonged bowel transit or distal constipation due to rectal inertia, were excluded in order to avoid the worsening of the colo-recto-anal transit and the raising of chronic obstruction state.

The Wells technique with lateral rectal tigament preservation provides the same results on prolapse and faeces continence as the other rectopexy procedures afteran adequate pelvic floor rehabilitation.

Even if the internal rectal prolapse with rectal dyschezia is a stage of rectal prolapse, we believe that

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P. Boccasanta, R. Rosati, G. Micheletto et al. coloproctology 19 (I997), 28-32 tNr. 1)

12. Horgan, P. J., J. Fitzpatrick, N. F. Couse: Is laparoscopy less immunotraumatic than laparotomy? Min. [nv. Ther. 1 (1992). 241-242. 13. Mahieu, P., J. Pringot, P. Bodart: Defecography. Contribution to the diagnosis of defecation disorders. Gastrointest. Radiol. 75 (1978), 623-631. 14. Mark E. Stocker: Laparoscopic colon surgery for cancer: controversy, caution and common sense. Int. Surg. 79 (1994), 240-241. 15. Micbeletto, G., A. Orio, P. Boccasanta, R. Lauro, A. Restelli, D. Corti, A. Tajana: Anorectal manometry in constipation. Personal experience. Atti XXVI Wld Congr. of Intem. Col. Surg. 5 (1988), 657-659. 16. Mori, G., V. Micheletto, V. Manzullo, A. Tajana: Ruolo della manometria e della elettromiografia nello studio della patologia anale. Chir. Gastroent. 1, Suppl. 20 (1986). 17. Parks, A. G., M. Swash, H. U¡ Sphincter denervation in anorectal incontinence and rectal prolapse. Gut 18 (1977), 656-665. 18. Prasad, M. L., R. K. Pearl, H. Abca¡ C. P. Orsay, R. L. Nelson: Perineal proctectomy, posterior rectopexy, and postanal elevator repair for the treatment of rectal prolapse. Dis. Colon Rect. 29 (1986), 547-552. 19. Scaglia. M., S. Fasth, T. Hal[gren, S. Nordgren, T. Ores[and, L. Hulten: Abdominal rectopexy for rectal prolapse: influence of surgical technique on functionaI outcome. Dis. Colon Rect. 37 (1994), 805-813. 20. Speakman, C. T., M. V. Madden, R. J. Nicholls, M. A. Kamm: Lateral ligament division during rectopexy causes constipation but prevents recurrences: results of a prospective, randomized study. Brit. J. Surg. 78 (1991), 1431-1433. 21. Sullivan, E. S., G. H. Leaverton, C. E. Hardwick: Transrectal perineal repair: ah adjunct to improved function after anorectal surgery. Dis. Colon Rect. 11 (1968), 106-114. 22. Vandelli, 1., C. A. Bruno: Chirurgia ginecologica ed ostetrica. Ediz. Inter. CIC l (1983), 108. 23. Villet, T. E., P. Morice, A. Bech, D. Salet-Lizee, M. Zafiropou1o: Approche abdominal des rectocele et des elytroceles. Ann. Chir. 47 (1993), 626-630. 24. Wells, C.: New operation for rectal prolapse. J. roy. Soc. Med. 52 (1959), 692-603. 25. Wexner, S. D., J. D. Cheope, M. N. J. Jose, S. Heyman, D. C. Jagelman: Biofeedback for constipation. Dis. Colon Rect. 35 (1992), 145-150.

Cystopexy and Douglas-ectomy - if required - can be safely performed through laparoscopy in the same operative procedure according to the up-to-date simultaneous approach to multiple pelvi-rectal statics alterations. Our preliminary laparoscopy experience is encouraging enough to extend its indications to pelvic and rectal statics alteration, even ir a longer follow-up and a wider patient group ate required to assess long-term results. References 1. Boccasanta, P., G. Salamina, A. Segalin: Diagnosi e terapia del disturbi comp[essi della statica pelvirettale: esperienza francese presso la Clinique St. Roch di Montpellier. Not. Chir. 9 (1993), IO-14. 2. Boccasanta, P., A. Segalin, M. Montorsi, A. Peracchia: Posterior rectal inclination in the radiological diagnosis of the a[terations of the pe[vic ftoor anatomy. Coloproctology 17 (1995), 200.205. 3. Boccasanta, P.: La chirurgia del prolasso rettaIe oggi. Notiz. Ass. Med. Brianza (1996), 101-111. 4. Burch, J. C.: Urethrovaginal fixation to Cooper's ligament for correction of stress incontinence, cystocele and prolapse. Amer. J. Obstet. Gynec. 81 (1961), 281-290. 5. Costalat, G., J. M. Garrigues, F. Drawed, M. Veyrac, J. Vernhet: Rectopexie antero-posterieure pour troubles de la statique rectale: resultats cliniques et radiologique8. Interet de la rectographie numeris› A propos de trente cas. Ann. Chir. 43 (1989), 733-743. 6. Darzi, A.: Stapled laparoscopic rectopexy for rectal prolapse. Atti 3 ~ Intern. Meeting of Coloproct. (Ivrea) 1994, p. 114-116. 7. Delemarre, J. B., H. G. Goozen, R. H. Kruyt, R. Soebhag, A. Maas Geesternaus: The effect of posterior rectopexy for complete rectal prolapse. Dis. Colon Rect. 34 ( 1991 ), 311-316. 8. Duthie, G. S., D. C. Bartolo: Abdominal rectopexy for rectal prolapse. A comparison of techniques. Brit. J. Surg. 79 (1992), 107-I 13. 9. Frykman, H. M., S. M. Goldberg: The surgical treatment of rectal procidentia. Surg. Gynec. Obstet. 129 (1969), 1225-1230. 10. Garrigues, J. M., G. Costalat, P. Lopez, J. L, Lamargue: La rectographie numeris› Ann. Gastroent. Hepatol. 35 (1989), 1-7. 1 I. Hinton, J. M., J. E. Lennard-Jones. A. C. Young: A new method for studying gut transit time using radiopaque markers. Gut lO (1969), 842-847.

For the Authors: Paolo Boccasanta, MD, Department of General Surgery. and Surgical Oncology, Ospedale Policlinico I. R. C. C. S. - Padiglione Monteggia, Universit)' oŸ Milan, Via F. Sforza 35, 1-20122 Milano.

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