Surg Endosc (2006) 20: 960–963 DOI: 10.1007/s00464-005-0424-y Ó Springer Science+Business Media, Inc. 2006

Laparoscopic suture rectopexy in the treatment of persisting rectal prolapse in children A preliminary report A. Koivusalo, M. Pakarinen, R. Rintala Hospital for Children and Adolescents, University of Helsinki, Helsinki 000290, Finland Received: 15 June 2005/Accepted: 18 December 2005/Online publication: 11 May 2006

Abstract Background: The repair of choice for persistent rectal prolapse (PRP) in children is disputed. Laparoscopic suture rectopexy (LSRP) is effective in adults, but its usefulness in pediatric PRP is unknown. We compared LSRP with posterosagittal rectopexy (PSRP). Methods: Sixteen children, with a median age of 6.5 years (range, 0.8–16.8) and duration of symptoms of 2.8 years (range, 0.5–10.2), underwent surgery for PRP. Eight (1991–2000) had PSRP, and eight (2002–2005) had LSRP. Three patients with LSRP were healthy; the others had mental retardation and epilepsy (n = 1), cerebral palsy (n = 1), AspegerÕs syndrome (n = 1), meningomyelocele (n = 1), and bladder extrophy (n = 1). Preoperative cologram (n = 6), sigmoideoscopy (n = 3), and anorectal manometry (n = 2) were normal in patients with LSRP. In LSRP, the rectum was mobilized and sutured to the sacral periosteum. Results: Median operation time for LSRP was 80 min (range, 62–90) and for PSRP 40 min (range, 25–70) (p < 0.05); median hospital time was 6 days (range, 3–8) for LSRP and 6 days (range, 3–9) for PSRP (not significant). Six patients with LSRP had a median follow-up of 13 months (range, 4–24). None have had recurrences, and two patients (33%) require laxatives. Of the patients with PSRP, two (25%) had recurrence and underwent abdominal rectopexy with sigmoid resection. Conclusion: Medium-term results indicate that LSPR is effective in pediatric PRP. Constipation is the only postoperative problem in a significant proportion of patients. Key words: Rectal prolapse — Laparoscopy — Rectopexy

Correspondence to: A. Koivusalo

Rectal prolapse (RP) in children without underlying conditions is usually a self-limiting problem and requires no surgical treatment. For children with persistent rectal prolapse (PRP), a variety of surgical procedures have been described, including sacral rectopexy through posterosagittal incision [2], transabdominal sacral rectopexy with or without sigmoid resection [2, 7], rectal submucosal sclerosant injections [6], Thiersch cerclage [1], and EkehornÕs rectosacropexy [11]. In adults, laparoscopic rectopexy has gained wide popularity because of its minor invasiveness and good cosmesis [8, 10]. Equally good results have been achieved by laparoscopic and open procedures [8, 10]. We present a series of eight patients with PRP who underwent laparoscopic rectopexy. A comparison between these eight and a historical series of eight patients with another surgical procedure for RP was performed.

Materials and methods From January 1991 to May 2005, 80 patients were referred to our institution because of RP. In 64 patients, RP as cured within 6–12 months with conservative laxative or expectant therapy. Sixteen of the 80 patients (20%) (10 males and six females) had PRP for a median follow-up of 2.8 years (range, 0.5–10.5) and underwent surgical therapy at the median age of 6.5 years (range, 0.8–16.8). According to the medical reports, all 16 patients had a full-thickness RP. Eight patients (six males and two females) underwent primary posterosagittal rectopexy between 1991 and 2000. Two of these patients (25%) had relapsing RP. One of these two patients underwent redo posterosagittal rectopexy, which also failed. Both eventually underwent abdominal rectopexy with sigmoid resection. From February 2002 to May 2005, eight patients underwent laparoscopic suture rectopexy (LSRP). Clinical data from the 16 patients operated on for RP are presented in Table 1. Three of the patients who underwent LSRP were completely healthy. Of the other five, one had a minor ventricular septal defect, one had cerebral palsy, one patient had lumbar meningomyelocele with ventriculoperitoneal shunt, one patient had undergone neonatal closure of bladder extrophy, one patient had AspergerÕs syndrome and gastroesophageal reflux, and one patient was mentally retarded and epileptic. The last two patients mentioned had occasional medication

961 Table 1. Clinical details of patients undergoing PSRP and LSRP

Period No. of patients Male:female Age, median (yr) (range) Duration of symptoms, median (yr) (range) Other diseases

Preoperatively Constipated RP at defecation Pain at defecation Bleeding at defecation Preoperative cologram

PSRP

LSRP

1991–2000 8 6:2 5.1 (0.8–15.6) 2.0 (0.2–7.1) Healthy (n = 2) Epilepsy (n = 2) Autism (n = 1) WilliamsÕ syndrome (n = 1) Anteperineal anus, tethered spinal cord (n = 1) Solitary rectal ulcer (n = 1) 3 8 8 7

10/2002–5/2005 8 5:3 7.7 (3.1–16.2) 2.8 (0.5–10.1) Healthy (n = 3) Mental retardation with epilepsy (n = 1) AspergerÕs syndrome (n = 1) Cerebral palsy (n = 1) Meningomyelocele (n = 1) Bladder extrophy (n = 1) 2 8 6 5

Rectal dilatation (n = 2) Normal (n = 3) Not done (n = 3)

Normal (n = 6) Not done (n = 2)

for constipation. Preoperative investigations included digital rectal examination in all eight patients, colonoscopy in three patients with bleeding, and cologram in six patients. Two patients underwent anorectal manometry. None of the examinations showed any abnormalities (Table 1). Of the eight patients who underwent posterosagittal rectopexy, seven had idiopathic or primary RP, whereas in one patient RP was secondary to anorectal malformation. Of the eight patients who underwent LSRP, six had idiopathic or primary RP, whereas RP in two may be classified secondary to meningomyelocele (n = 1) and bladder extrophy (n = 1). Prior to the rectopexy, the colon was emptied by enemas. All procedures were performed under general anesthesia. For antibiotic prophylaxis, a single dose of kefuroxime 30 mg/kg and metronidazole 7.5 mg/kg i.v. was given. The laparoscopic operation was performed by inserting a 10-mm umbilical port for a video camera and two 5-mm ports in the left and one in the right side of lower abdominal quadrants. The patient was placed in the Trendelenburg position, and the rectum was grasped and pulled taut with a Babcock forceps. The peritoneum on both sides of the rectum was opened from the promontorium up to the lateral ligaments, and the rectum was mobilized sufficiently until the surface of the sacrum was clearly felt with an instrument. Lateral ligaments of the rectum were not divided. With the rectum pulled taut, 2–0 Ti-Cron stitches were inserted through the periosteum of the promontorium and the lateral wall on both sides of the rectum. Another pair of stitches were inserted lower, between the lateral ligaments and sacral periosteum. In two patients, instead of hand-sewn promontorial periosteal sutures, Mi-Tek suture anchors with attached Ti-Cron needle thread were used. The anchors were pushed into the bone with an insertion instrument through a separate 5-mm incision. After the rectopexy, the port incisions were closed in layers. The patients were allowed to eat and drink at will. Postoperatively, lactulose was prescribed for 1 month to soften the stools. The patients were discharged after the onset of spontaneous bowel movements. We compared operative time, hospital time, complications, and postoperative results. Statistical analysis was performed using the StatView computer program (StatView 512 software; Brain Power, Calabasas, CA, USA). FischerÕs exact test was used to compare nominal frequencies, whereas numerical means were compared by using analysis of variance and the Mann–Whitney U-test. p < 0.05 was considered significant.

Results LSRP was completed laparoscopically in all eight patients. The patient with meningomyelocele underwent simultaneous appendicostomy for antegrade

colonic lavage. Median operation time was 80 min (range, 62–100). No intraoperative complications occurred. The use of Mi-Tek suture anchors did not make the operation faster, and a separate small incision for insertion was required. On the first postoperative day, all patients had normal enteral feeds. From the second postoperative day, all patients had only oral paracetamol or ketoprofen for pain medication. Median hospital stay was 6 days (range, 3–8). After the discharge, one patient, a 6-year old girl with epilepsy, developed difficulty in passing stools. At colonoscopy, no cause for obstruction was found. After change of the laxative to sodium picosulfate, she resumed bowel movement. Increased medication for epilepsy at the time of the rectopexy may have contributed to the development of constipation. Six of the eight patients had a median follow-up of 13 months (range, 4–23). None of the six patients reported recurrent rectal prolapses. At the first outpatient visit, 2 months postoperatively, two of the six patients needed laxatives. Comparison of operative time, hospitalization time, and follow-up details of PSRP and LSRP are presented in Table 2. Discussion From January 1991 to May 2005, 20% of all patients who were referred to our institution for RP underwent surgical treatment. This figure is slightly higher than the 14% of surgically treated RP patients reported by Sander et al. [11]. In healthy children with RP without serious symptoms, our policy has been to wait at least until they are 5 years of age before commencing surgical treatment. In neurologically impaired children and in children whose symptoms are causing significant discomfort, earlier surgery is advocated. In children, a multitude of procedures have been advocated for RP. A cure rate of at least 90% has been reported for posterosagittal rectopexy [2], Delorme operation [5], EkehornÕs rectosacropexy [6], and sub-

962 Table 2. Comparison of results after laparoscopic and posterosagittal rectopexies

No. of patients Duration of operation, median (min) (range) Duration of hospitalization, median (d) (range) Postoperative complications Follow-up, median (mo) (range) Constipation requiring laxatives after surgery RP relapse

PSRP

LSRP

8 40 (25–70) 6 (3–9) None 129 (50–165) 1 2 (25%)

8 80 (62–100) 6 (3–8) Difficulties passing stools (n = 1) 13 (4–23) 2 0

p value

<0.05 NS <0.05 NS NS

NS, not significant

mucosal injections of phenol oil, alcohol, or Deflux [7]. In a 46-patient series, Ashcraft et al. [2] reported a success rate of 89% for the posterosagittal operation, and RP was associated with congenital anomalies such as sacral agenesia, trisomy 9, Williams syndrome, and HirschsprungÕs disease. Ashcraft et al. speculated that posterosagittal fixation may have been inadequate in certain patients in whom RP was more likely rectosigmoid intussusception with a high lead point. Two of our earlier patients with RP relapse after posterosagittal rectopexy had no congenital anomalies but were neurologically impaired. In adults, a higher relapse rate for surgery for RP has been reported following perineal or transanal procedures than after transabdominal procedures [4, 9]. Although the results for adults are not comparable with those for children, they suggest that, in some patients, control of RP requires more extensive rectal fixation than can be achieved through the transanal or posterosagittal route. All of our 16 patients who underwent surgery had circumferential full-thickness RP and, accordingly, we considered rectopexy to be the procedure of choice independent of whether RP was primary or secondary. We see mucosal RP mainly in patients who have undergone surgery for anorectal malformations. For mucosal RP, local excision and plasty without rectopexy are used. We hypothesized that laparoscopic rectopexy may be a good alternative for abdominal and posterosagittal rectopexy because it is less invasive. There are two case reports of laparoscopic rectopexy in pediatric patients. Bonnard et al. [3] treated a 12-year-old boy with solitary rectal ulcer syndrome by laparoscopic rectopexy with a mesh, and Saxena et al. [12] used LSRP to treat a 22month-old girl with recurring rectum prolapse. After 18 and 24 months, both patients were free of symptoms. In the current series, the duration of surgery for LSRP was significantly longer than for earlier posterosagittal rectopexies. However, the operation time for LSRP was not disproportionately long, and further experience with the procedure will probably result in a shorter operative time. The length of postoperative hospitalization was similar for LSRP and posterosagittal rectopexy. After laparoscopic rectopexy, we noted that during the first postoperative months constipation worsened in two patients, one of whom had epilepsy and the other AspergerÕs syndrome. How much this was related to the surgical procedure or the patientsÕ underlying conditions

is unclear. In pediatric patients, there are very few reports on long-term functional problems after surgery for RP. In adults, Brown et al. [4] reported a slight increase in the frequency of constipation after abdominal fixation rectopexy, whereas there was less constipation after rectopexy with sigmoid resection and perineal procedures. It has been speculated that loss of compliance of rectum after rectopexy or a redundant sigmoid loop may be associated with constipation [1, 4]. Kairaluoma et al. [8] noted that laparoscopic rectopexy either with or without sigmoid resection controlled RP equally well. Both operations alleviated constipation in some patients, but after both procedures some previously nonconstipated patients developed constipation. In the current LSRP technique, the lateral rectal ligaments were not divided. Reports concerning the advantages of preservation of the rectal lateral ligaments are conflicting. It appears that patients have less constipation and incontinence if the ligaments can be preserved [9]. Currently, both of our patients with postoperative constipation can be managed with laxatives. It remains to be seen whether constipation is a significant postoperative disadvantage after pediatric LSRP. Based on the current series of eight patients, laparoscopic rectopexy is feasible for PRP in children. Our series is too small to provide definite support for LSRP. The overall number of children for whom surgery for RP is indicated is small, and thus it is difficult to obtain sufficiently large series for statistical power. Further studies and longer follow-up are required to determine whether laparoscopic rectopexy is the procedure of choice for these patients.

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