Langenbeck’s Arch Surg (2002) 387:130–137 DOI 10.1007/s00423-002-0305-y

J. Rose C. Schneider H. Scheidbach C. Yildirim H. P. Bruch J. Konradt E. Bärlehner F. Köckerling

Received: 28 August 2001 Accepted: 6 June 2002 Published online: 18 July 2002 © Springer-Verlag 2002

J. Rose · C. Schneider · H. Scheidbach C. Yildirim · H.P. Bruch · J. Konradt E. Bärlehner · F. Köckerling (✉) Department of Surgery and Center for Minimally Invasive Surgery, Hanover Hospital, Roesebeckstrasse 15 (Siloah), 30449 Hanover, Germany Tel.: +49-511-9272331 Fax: +49-511-9272591

O R I G I N A L A RT I C L E

Laparoscopic treatment of rectal prolapse: experience gained in a prospective multicenter study

Abstract Background: We report the findings of a prospective multicenter observational study carried out by the Study Group for Laparoscopic Colorectal Surgery on patients undergoing laparoscopic or laparoscopic-assisted surgery for rectal prolapse. The study investigated the safety of various laparoscopic techniques in terms of perioperative and postoperative general and technique-specific complications and compared the results with those reported for open surgery in this area. Methods: Of the 150 patients undergoing laparoscopic or laparoscopicassisted colorectal surgery for rectal prolapse 124 received rectopexy combined with resection and 26 rectopexy alone. In 85 patients a mesh was employed during rectopexy. The conversion rate was 5.3%. Results: Perioperative complications (21 surgical and 35 general perioperative) were recorded in 37 patients (24.7%). The reoperation rate was

Introduction Rectal prolapse is defined as a protrusion of the wall of the rectum into the lumen and anal canal (intussusception) or through the latter to the outside (procidentia recti). Typically inspection reveals a circular “folded” structure reminiscent in appearance of a beehive. Prolapsed hemorrhoids and mucosal prolapse must be considered in the differential diagnostic work-up. Many of the patients are constipated and incontinent. The condition most often affects women of advanced age, who experi-

5.3% (bleeding 2, anastomotic leak 2, ileus 4). No procedure-specific perioperative complications were observed. In particular, reduced surgical trauma led to fewer severe postoperative complications such as cardiopulmonary problems (3.3%). Conclusions: The techniques of conventional prolapse surgery can readily be translated to the laparoscopic modality, since oncological criteria do not have to be considered. The usually elderly patients in this group benefit to a particular degree from the known advantages associated with reduced surgical trauma. Perioperative morbidity is determined largely by the surgeon’s experience. We therefore believe that rectal prolapse is a suitable indication for the minimally invasive modality in the hands of trained surgeons. Keywords Rectal prolapse · Laparoscopic colorectal surgery · Multicenter study

ence prolapse six times more frequently than men [30, 35]. Prolapse of the rectum is associated with an inordinate impairment of the patient’s quality of life. This lead to a strong desire on the part of the patient for a treatment that will enable him or her to resume normal social activities, and explains the considerable demands made on the surgeon treating this condition. The indications for minimally invasive surgery do not differ from those of conventional surgery. Merely the relative contraindications that apply to laparoscopy in general, must be observed, for example, prior extensive ab-

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dominal surgery or the presence of appreciable cardiopulmonary risk factors. The fact that prolapse repair procedures were an early indication in the field of minimally invasive surgery reflects the relative simplicity of translating the open surgical techniques to the laparoscopic modality, in particular since the problem of achieving a reliable anastomosis did not apply to rectopexy. In the meantime studies have shown that no increased insufficiency risk attaches to anastomoses performed laparoscopically or laparoscopic assisted [26, 27, 29]. The aim of the present study was to take stock of the current place of laparoscopic surgery in the treatment of rectal prolapse. We whether, in terms of perioperative morbidity, the laparoscopic technique can be considered an alternative to conventional surgery. We therefore present the perioperative results observed in the patients of the Laparoscopic Colorectal Surgery Study Group using various laparoscopic techniques and compare them with data reported for conventional surgery.

Methods and materials Patients This study from which the present data are drawn began in August 1995 at centers in Germany, Austria, and Switzerland. All patients undergoing laparoscopic or laparoscopic-assisted colorectal procedures at any of the participating hospitals were admitted to the study. By September 2000 there were 44 participating centers which had treated a total of 2471 patients, of whom 150 underwent rectal prolapse repair in 24 centers (19 men, 131 women, ratio 1:7; age range 52–91 years). Women had a mean age 64.5±11.3 years, mean height 163.4±6.6 cm, mean weight 61.5±10.4 kg, body mass index 23.0±3.7; the corresponding figures for men were 45.4±13.4 years, 168.6±10.5 cm, 69±13.1 kg, and 24.1±3.5. The incidences of the various symptoms associated with rectal prolapse are shown in Table 1. No exclusion criteria were applied, nor were any terms of reference stipulated with regard to the technique to be applied. The range of laparoscopic procedures performed for rectal prolapse extended from 1 (11 hospitals) to 47 (1 hospital). Twenty-one centers have so far performed fewer than 10, and only three centers more than 10 such operations. Patient demographics, indications for surgery, surgical procedure and postoperative course were anonymized on standardized protocols by the participating center immediately after collection, before being passed on to the study center. The data obtained in this way were entered and evaluated in an SPSS data base. The patients were compared with regard to perioperative and postopera-

Table 1 Symptoms (n=150)

Constipation Sensation of prolapse Anal discomfort Incontinence Rectal bleeding Recurrent diarrhea

n

%

124 121 50 46 21 5

82.7 80.7 33.3 30.7 14.0 3.3

Table 2 Surgical procedures (n=150) Operation

Resection (n=124, 83%)

Rectopexy (n=26, 17%)

With rectopexy No mesh Mesh Without rectopexy Stoma

97 81 16 27 2

26 4 22 0 0

tive complications, reestablishment of postoperative bowel movements, and postoperative hospital stay, separately for each surgical procedure. Operations No stipulations were made with regard to operative strategy or technique, and each participating hospital was thus free to adopt an individual approach. As shown in Table 2, 124 patients underwent rectosigmoidectomy, of whom 97 patients also underwent a rectopexy procedure; 26 patients received rectopexy alone. Depending on the individual situation encountered at surgery, 38 of the 123 rectopexies were carried out using a mesh fixed dorsally (Wells procedure; n=37) or ventrally (Ripstein procedure, n=1) while in 85 cases suture rectopexy was performed. In the case of rectopexy with resection suturing (81/97, 83.5%) was given preference over mesh rectopexy (16/97, 16.5%). Whenever rectopexy was performed alone, the mesh technique was preferentially employed (22/26, 84.6%). In this subgroup only 4 suture rectopexies were performed (4/22, 15.4%). In 13 patients surgery was extended to include Sudeck anal repair (n=4), posterior vaginoplasty (n=1), sphincter reefing (n=5), Thiersch operation (n=1), or Park’s hemorrhoidectomy (n=2). A stoma has to be constructed in two patients after a Hartmann’s procedure. Overall, 122 anastomoses were constructed during 124 resections (2 cases with a descendostomy), 86 (70.5%) of which using the double-stapling technique, and 36 (29.5%) being handsewn extracorporeally via a minilaparotomy. Overall the mean duration of the operation was 188±78 min. For resection alone the mean duration of the operation was 212±92 min, for resection plus rectopexy 190±78 min, and for rectopexy alone 158±47 min.

Results Intraoperative complications Intraoperative complications were observed in nine patients (6%): four bleeds, three bowel injuries, and two other complications. Complications occurred in six patients (6/124, 4.8%) undergoing prolapse repair in combination with resection. In the case of rectopexy alone complications were seen in three patients (3/26, 11.5%). Injuries to the bowel occurred only in the group undergoing resection with no rectopexy. As presented in Tables 3 and 4, bleeding was distributed equally among all the individual techniques. Seven of the nine intraoperative complications were amenable to laparoscopic management. Only two patients with a bowel injury had to be laparotomied.

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Table 3 Complications; more than one complication per patient possible (n=56)

Surgical Bleeding Intraoperative Postoperative Bowel injury Anastomotic insufficiency Necessitating reoperation Peritonitis Wound healing disorders Ileus necessitating reoperation General Bowel motility disturbances >3 days Urinary tract infection Cardiopulmonary Others

n

%

21 6 4 2 3 3 2 1 4 4 35 6 11 5 13

14.0 4.0 2.7 1.3 2.0 2.0 1.3 0.7 2.7 2.7 23.3 4.0 7.3 3.3 8.6

Postoperative course During the postoperative course a total of 47 complications occurred in 37 patients (24.7%; Table 3). The most commonly observed problems were general complications such as urinary tract infection (11, 7.3%), motility disorders of the bowel lasting for more than 3 days (6, 4.0%), and cardiopulmonary problems (5, 3.3%). The leading surgical postoperative complications were ileus

Table 4 Patients developing intraoperative and postoperative complications

Surgical procedure

Resection alone Resection +rectopexy Mesh Suture Rectopexy alone Mesh Suture Total

n

27 97 16 81 26 22 4 150

requiring reoperation (4, 2.7%) and wound healing disorders (4, 2.7%), followed by anastomotic insufficiency (3, 2.0%) and afterbleeding requiring reoperation (2, 1.3%). Most of the patients developing a postoperative complication had had prolapse surgery combined with resection (34/124, 27.4%). In the group undergoing rectopexy alone postoperative complications occurred in three patients (3/26, 11.5%; Table 4). In eight patients (5.3%) a postoperative complication made reoperation necessary. Five of these patients had undergone resection with or without rectopexy, and included anastomotic insufficiency in two, transfusion-requiring bleeding in two, and adhesion ileus requiring revision in one. All three reoperations following rectopexy alone were made necessary by an ileus (Table 5). The first postoperative bowel movement was observed after a mean of 3.8±1.6 days. Following rectopexy alone the first bowel movement was seen after a mean of 2.8±1.2 days; following resection alone after 3.8±1.7 days, and following rectopexy with resection after 4.1±1.6 days. Postoperative motility disorders of the bowel and ileus requiring reoperation were equally distributed among the various surgical procedures. The mean postoperative hospital stay was 12.7± 5.7 days. The earliest discharge was seen after rectopexy alone (mean 10±5.3 days), mean hospital stays after resection alone and rectopexy with resection were 12.7±4.0 days, and 13.3±6.0 days, respectively.

Intraoperative complications

Postoperative complications

n

%

n

%

5 1 0 1 3 3

18.5 1.1 – 1.1 11.5 13.6 – 6.0

9 25 4 21 3 3 0 37

33.3 25.8 25.0 25.9 11.5 11.5 – 24.7

9

Table 5 Reoperations Patient no.

Age (years)

Sex

Reason

Prior operations

Perioperative complications

Discharge day

1 2 3 4 5

78 41 89 66 60

F M F F F

Resection + suture rectopexy Resection + suture rectopexy Rectopexy (mesh) + Thiersch ring Resection + pelvoplasty Resection

58

F

Resection + suture rectopexy

None None None None Bleeding from presacral plexus None

45 23 28 25 13

6 7 8

82 75

F F

Anastomotic insufficiency Anastomotic insufficiency Strangulation adhesion ileus Adhesion ileus Afterbleeding (7 red cell units transfused) Afterbleeding (2 red cell units transfused) Ileus Ileus

Rectopexy (mesh) Resection + suture rectopexy

None None

25 18

7

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The only death was that of an 85-year-old woman (American Society of Anesthesiologists classification III; age, cardiac insufficiency, obesity) undergoing resection of the sigmoid with no rectopexy, who died of cardiogenic shock on the 7th postoperative day (30-day mortality 0.7%). Conversion The overall conversion rate was 5.3% (n=8). In two patients perioperative complications (bowel perforation) required conversion, while in the other six patients conversion was due to anatomical or technical problems, including poor vision caused by extensive adhesions (n=4), cardiac decompensation in the Trendelenburg position (n=1), and a defective light source (n=1).

Discussion Transabdominal procedures predominate in the surgical treatment of rectal prolapse because of their superior functional results, in particular the improvement in continence. Simultaneously, rectosigmoid resection can considerably improve the symptoms of constipation, from which a large number of prolapse patients suffer. In addition, the recurrence rate associated with transabdominal procedures is lower than that seen with the perineal procedures [25, 30, 38, 43]. Today the latter are indicated only in elderly patients with a considerable surgical risk, although modern anesthetic techniques make it possible to be more liberal when establishing the indication. In the meantime the laparoscopic technique has been standardized and now represents a much less traumatic surgical option for the patient that can also be applied to the treatment of rectal prolapse. The usually elderly patients with rectal prolapse gain particular benefit from the advantages of this minimally invasive approach. The reduced surgical trauma, in association with less postoperative pain, means that the patient can be rapidly mobilized, thus contributing considerably to a lowering of postoperative morbidity. Patient recovery is quicker and is associated with fewer problems. On the basis of the data of our large group of patients and standardized documentation we are now in a position to present valid results. Our patient data reflect the demographic data reported in the literature, which show that rectal prolapse is predominantly a disease of elderly women [30, 35]. In our series women outnumbered men by a factor of seven and were also considerably older than the men (average age approx. 65 vs. 45 years). With regard to symptoms a large majority of patients suffered from constipation (82.7%). One-third each complained of anal discomfort (33.3%) and incontinence (30.7%). Further symptoms reported were rectal bleeding (14%) and recurrent diar-

rhea (3.3%). Patient interviews revealed that the sensation of prolapse in combination with fecal incontinence and constipation was considered the most troubling symptoms. The resulting restriction in social activities, together with increasing social isolation caused by the patient’s uncertainty outside the home, was the main reason for their undergoing surgery. The surgical strategy and technique is largely analogous to those in conventional transabdominal procedures [4, 9, 11, 21, 22, 24]. Were employed either resection alone, rectopexy alone, or a combination of the two,. Most patients underwent resection in combination with rectopexy in the form of a Frykman-Goldberg procedure (97/150, 64.7%). For the most part the aim was to improve or normalize bowel movements by repairing the prolapse. Other authors also consider the combination of rectosigmoidectomy and rectopexy to be the approach most likely to eliminate the cause of the prolapse [10, 35]. At the same time, this approach also effectively deals with constipation. Athanasiadis et al. [2] compared two groups operated on for rectal prolapse associated with constipation: 84% of the patients in the resection group were cured of, or experienced appreciable improvement in, their constipation, as compared with 8% in the rectopexy group. Other studies have confirmed these results, reporting improvements in constipation in 41–83% following rectopexy with partial resection of the colon, compared with 11–28% following rectopexy alone [19, 38, 43]. When resection alone resulted in the removal of a sufficient amount of redundant colon, a number of participating centers did not perform additional rectopexy. In the group undergoing rectopexy alone (25.3%), mesh fixation (84.6%, 22/26) was appreciably more common than suture fixation (15.4%, 4/26). In operations combining resection and rectopexy suture fixation (83.5%, 81/97) predominated. In this combination the use of mesh was far less common (16.5%, 16/97). Mesh rectopexy was carried out mainly as a dorsal (Wells) procedure (97.4%, 37/38); only in one case was a ventral (Ripstein) procedure (2.6%, 1/38) employed. Other groups have also largely forgone the use of foreign material for rectopexy with colonic resection on account of the danger of infection and resulting severe complications [18, 37]. That effective rectopexy is possible with suture fixation alone has been shown in a number of studies [9, 13, 33]. The technique of laparoscopic rectopexy with and without resection of the colon corresponds largely to that employed in open surgery and, in the hands of an experienced laparoscopic surgeon, can be applied with safety [10, 24, 43]. The results of the present study show that the laparoscopic approach to prolapse repair carries no higher risk in terms of morbidity and mortality. For conventional colorectal surgery studies involving more than 1000 patients report morbidity rates of up to 31% and mortality of up to 5.5% [12, 40]. Large laparoscopic colorectal

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Table 6 Morbidity and mortality in laparoscopic and open prolapse surgery

Reference

Year

n

Operation

Morbidity (%)

Mortality (%)

Laparoscopic Darzi et al. [11] Poen et al. [34] Herold and Bruch [18] Stevenson et al. [36] Heah et al. [17] Present study

1995 1996 1997 1998 1999 2000

29 12 66 30 25 150 27 26 97

Rectopexy Rectopexy Rectopexy All patients Rectopexy All patients Resection Rectopexy Resection + rectopexy

10.3 16.7 9.1 13.0 16.0 24.7 33.3 11.5 25.8

0.0 0.0 0.0 3.0 0.0 0.7 3.7 0.0 0.0

Open Tjandra et al. [38] Winde et al. [43] Novell et al. [33] Köckerling et al. [25] Husa et al. [21] Huber et al. [20] Leppert et al. [30]

1993 1993 1994 1996 1988 1995 1996

142 45 63 58 45 39 57

Rectopexy Rectopexy Rectopexy Rectopexy Resection + rectopexy Resection + rectopexy Resection + rectopexy

16.0 25.0 14.0 25.9 13.0 7.0 10.0

1.0 0.0 0.0 0.0 2.0 0.0 2.0

studies show similar results, with morbidity rates also up to 31%, and mortality of up to 4.5% [1, 5, 27, 42]. Overall morbidity in our series was 24.7%. It must, however, be noted that a large proportion of the complications were minor, namely urinary tract infection and constipation lasting more than 3 days. It is to be expected that the morbidity and mortality rates associated with prolapse surgery would be higher than those of a cross-section of colorectal interventions since prolapse patients are typically elderly and consequently multimorbid. Since most of the data in our study were contributed by centers with experience of fewer than ten operations, the data of course also include the early part of the learning curve. A comparison of the results achieved by hospitals with a large case load with those achieved by hospitals with little experience (fewer than 20 laparoscopic interventions for rectal prolapse) with laparoscopic rectal prolapse surgery, dramatically reflects the impact of the surgeon. Here we have two hospitals with a total of 86 interventions, on the one hand, and the remaining 22 hospitals with a combined total of 64 interventions, on the other. With regard to intraoperative complications we see a significant difference favoring the hospitals with the greatest experience (3.3% vs. 9.3%). Also in terms of postoperative complications these hospitals achieved better results, although the difference (15.1% vs. 25%) was not significant (P=0.181, Fisher’s exact test). Also, better results have been reported by groups with considerable experience of laparoscopic procedures in treating rectal prolapse. Bruch et al. [6] report an overall morbidity rate of 9.7% in a total of 72 patients undergoing the Frykman-Goldberg procedure. Reports in the literature present morbidity rates for the laparoscopic procedure in rectal prolapse of 9.1–16.7% [11, 17, 18, 23, 34]. A comparison with data obtained with open transab-

dominal prolapse surgery shows morbidity rates of 15–25% for rectopexy, and 7–19% for the resective procedure. Perioperative mortality rates for conventional prolapse surgery are reported to be up to 1% for rectopexy and up to 6% for resective procedures [20, 21, 25, 30, 33, 38, 43]. Our own study observed one death, which translated as a 30-day mortality rate of 0.7%; the cause of this death was not a surgical complication but cardiogenic shock. Similar mortality rates with a range of 0–3% are reported in studies by other working groups [18, 22, 36]. An overview of the morbidity and mortality rates of laparoscopic and conventional transabdominal procedures in rectal prolapse reported in the literature is presented in Table 6. In 37 patients there was a total of 56 intraoperative and postoperative complications (24.7%). Nine patients (6%) in our series experienced intraoperative complications, the most common being bleeding, which was observed in 2.7%. Other authors have also reported bleeding to be the most common complication associated with the laparoscopic modality [18]. Every reported case of bleeding, whether intraoperative or postoperative, has proven amenable to laparoscopic management. At 5.3%, our conversion rate was similar to that already reported in the literature for laparoscopic colorectal surgery, with rates ranging between 2% and 17% [15, 27, 31]. The most common reasons for conversion were anatomical and technical problems. In 37 patients a total of 47 postoperative complications occurred, giving a rate of 24.7%. The highest risk of developing a postoperative complication was seen in patients undergoing resection alone (9/27, 33.3%). This complication rate of resection alone would appear unacceptably high. Since, however, high complication rates were observed mainly in hospitals with a small case load, they must be considered to be further evidence that in laparoscopic rectal

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prolapse surgery a high level of experience with the technique is required to obtain an acceptable outcome. The most common surgical complications were ileus requiring reoperation (2.7%) and wound healing disorders (2.7%). The latter comprised minor infections or hematomas at the port sites, which, however, responded to local treatment. Deep wound infections with dehiscence, or burst abdomen are no longer seen in laparoscopic surgery. Most of the anastomoses performed in the rectum were carried out with the double-stapling technique. Overall three anastomotic leaks were observed (2.5%), a strikingly low number for anastomoses in the upper and middle rectum. The leaks were seen in two of 86 stapled anastomoses (2.3%) and in one of 36 hand-sutured anastomoses (2.8%). In conventional colorectal surgery insufficiency rates of 2–12% are regularly reported for anastomoses in these regions [14, 16]. The fact that laparoscopic or laparoscopic-assisted colorectal anastomoses are not associated with a higher risk of anastomotic insufficiency has previously been demonstrated in an earlier study that we carried out involving a large number of patients [27]. Also the rate of reoperations made necessary by a complication (5.3%) is compatible with data reported for laparoscopic prolapse surgery in the literature, ranging from 2.7% to 9.3% [6, 17, 18, 23, 36]. The indications for reoperation are identical in laparoscopic and conventional surgery, that is, such postoperative complications as bleeding, ileus, and anastomotic insufficiency. The majority of groups practicing laparoscopic surgery claim an overall advantage of this modality over open surgery for the postoperative course of patients undergoing prolapse surgery [3, 44]. For example, in a retrospective analysis of prolapse patients operated on at the University of Erlangen, Germany, over a period of 14 years, Köckerling et al. [25] determined an appreciable advantage for laparoscopic patients with regard to postoperative complications, freedom from pain, restoration of spontaneous micturition, and bowel movements. In prolapse surgery patients Bocasanta et al. [4] also observed reestablishment of bowel movements, on average on the third postoperative day after laparoscopy as compared with the fifth day after open surgery. Furthermore, the hospital stay of 7 days in the laparoscopic group was appreciably lower than the 9 days seen in the open surgery group. In our own patients bowel movements were reestablished on average after 3.8±1.6 days, the difference between the individual laparoscopic techniques being 1.3 days, which does not appear to have any particular significance. As was to be expected, the delay in the reestablishment of bowel movements is somewhat longer in resected patients than in those undergoing rectopexy only. The only noteworthy observation was the larger number of patients with more prolonged motility disorders in the group undergoing rectopexy with resection. With regard to the development of surgery-requiring ileus, however, this was of no importance since a uniform distribu-

tion was observed over all surgical techniques. The average hospital stay was 12.7±5.7 days. As was to be expected, patients undergoing colorectal anastomosis had a longer hospital stay (3.3 days). The possibility that this reflects an overly cautious approach in Germany is supported by figures from the United States, where patients are usually discharged after 5–7 days, especially since reliable anastomotic strength is already achieved after 4 days [23]. A further advantage of the laparoscopic modality, we believe, is the smaller number of general complications. In our series general complications occurred in only 25 patients, that is, 16.7%. Figures reported for conventional colorectal surgery reach as high as 31% [39]. In particular, pneumonia, which is especially feared among elderly patients, appears to be considerably less common, probably due in part to earlier mobilization. The thrombosis rate, as also the number of pulmonary emboli, appears to be reduced. In our opinion, this is a major advantage of the laparoscopic modality over open surgery with otherwise equally good functional results. This applies especially to the usually elderly rectal prolapse patients. Nor is the appreciably greater patient comfort in this group, due to the considerable reduction in surgical trauma, to be neglected.

Conclusion The present study describes the current status of laparoscopic surgery in the treatment of rectal prolapse. The results clearly show that rectal prolapse is a good indication for the laparoscopic modality. At the same time, however, they also make clear that only the trained laparoscopic surgeon with appropriate experience in the treatment of rectal prolapse is capable of combining the known advantages of minimally invasive surgery (low perioperative morbidity, more rapid convalescence) and the good functional results of transabdominal repair of rectal prolapse. On the basis of the data presented here, it must be noted that at the present time the use of the laparoscopic modality to treat rectal prolapse should remain the domain of surgical centers with the necessary experience and high case loads. Randomized trials are needed to draw definitive conclusions. Acknowledgements Participating centers and surgeons in the Laparoscopic Colorectal Surgery Study Group are: E. Bärlehner, B. Heukrodt, Berlin; J. Konradt, Berlin; G. Szinicz, Bregenz; I. Baca, V. Götzen, Bremen; H.A. Richter, Bremen; I. Gastinger, Cottbus; K. Ludwig, M. Freitag, Dresden; T. Reck, W. Hohenberger, Erlangen; C. Hottenrott, D. Menzel, Frankfurt a.M.; H. Faust, Gelsenkirchen; L. Goedecke, Goslar; C. Zornig, Hamburg; E. Gross, Hamburg; K. Rückert, Hamburg; F. Köckerling, C. Schneider, H. Scheidbach, C. Yildirim, Hanover; A. Kuthe, Hanover; E. Eypasch, Cologne; T. Hager, Kronach; H.P. Bruch, A. Herold, Lübeck; G. Meyer, W. Bittmann, Munich; J. Nägeli, St. Gallen; W. Lenze, Witten; W. Tigges, Zweibrücken. This research was supported by Ethicon Endosurgery, Norderstedt, Germany, and by Takeda Pharma, Aachen, Germany.

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References 1. Agachan F, Joo JS, Sher M, Weiss EG, Nogueras JJ, Wexner SD (1997) Laparoscopic colorectal surgery – do we get faster? Surg Endosc 11:331–335 2. Athanasiadis S, Heiligers J, Kuprian A, Heumüller L (1995) Surgery of rectal prolapse by rectopexy and colectomy. Chirurg 66:27–33 3. Baker R, Senagore AJ, Luchtefeld MA (1995) Laparoscopic assisted vs. open resection. Rectopexy offers excellent results. Dis Colon Rectum 38:199–201 4. Bocasanta 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. Surg Laparosc Endosc 8:460–465 5. Bokey EL, Moore JWE, Keating JP, Zelas P, Chapuis PH, Newland RC (1997) Laparoscopic resection of the colon and rectum for cancer. Br J Surg 84:822–825 6. Bruch HP, Herold A, Schiedeck T, Schwandner O (1999) Laparoscopic surgery for rectal prolapse and outlet obstruction. Dis Colon Rectum 42:1189–1194 7. Carter AE (1983) Rectosacral suture fixation for complete rectal prolapse in the elderly, the frail and the demented. Br J Surg 70:522–523 8. Cormann ML (1988) Rectal prolapse – surgical techniques. Surg Clin North Am 68:12555 9. Cuesta MA, Borgstein PJ, de Jong D, Meijer S (1993) Laparoscopic rectopexy. Surg Laparosc Endosc 3:456–458 10. Cuschieri A, Shimi SM, Vander Velpen G, Wood RAB (1994) Laparoscopic prosthesis fixation rectopexy for complete rectal prolapse. Br J Surg 81:138–139 11. Darzi A, Henry MM, Guillou PJ, Shorvon P, Monson JRT (1995) Stapled laparoscopic rectopexy for rectal prolapse. Surg Endosc 9:301–303 12. Detry RJ, Kartheuser A, Delriviere L, Saba J, Kestens PJ (1995) Use of the circular stapler in 1000 consecutive colorectal anastomoses: Experience of one surgical team. Surgery 117:140–145 13. Eijsbouts QAJ, Cuesta MA, de Brauw LM, Sietses C (1997) Elective laparoscopic-assisted sigmoid resection for diverticular disease. Surg Endosc 11:750–753

14. Feinberg SM, Parker F, Cohen Z, Jamieson CG, Myers ED, Railton RH, Langer B, Stern HS, McLeod RS (1986) The double stapling technique for low anterior resection of rectal carcinoma. Dis Colon Rectum 29:885–890 15. Gellman L, Salky B, Edye M (1996) Laparoscopic assisted colectomy. Surg Endosc 10:1041–1044 16. Griffen FD, Knight Sr CD, Whitaker JM, Knight Jr CD (1990) The double stapling technique for low anterior resection – results, modifications and observations. Ann Surg 221:745–751 17. Heah SM, Hartley JE, Hurley J, Duthie GS, Monson JRT (2000) Laparoscopic suture rectopexy without resection is effective treatment for full-thickness rectal prolapse. Dis Colon Rectum 43:638–644 18. Herold A, Bruch HP (1997) Laparoscopic rectopexy. Zentralbl Chir 122:578–585 19. Himpens J, Cadiere J, Bruyns J, Vertuyen M (1997) Laparoscopic rectopexy according to Wells. Surg Endosc 13:139–141 20. Huber FT, Stein H, Siewert JR (1995) Functional results after treatment of rectal prolapse with rectopexy and sigmoid resection. World J Surg 19:138–143 21. Husa A, Sainio P, von Smitten K (1988) Abdominal rectopexy and sigmoid resection (Frykman-Goldberg operation) for rectal prolapse. Acta Chir Scand 154:221–224 22. Kessler H, Hermanek Jr P, Wiebelt H (1993) Operative mortality in carcinoma of the rectum. Int J Colorectal Dis 8:158–166 23. Kessler H, Jerby BL, Milsom JW (1999) Successful treatment of rectal prolapse by laparoscopic suture rectopexy. Surg Endosc 13:858–861 24. Köckerling F, Gastinger I, Gall CW, Schneider B, Krause W, Gall FP (1992) Laparoscopic rectopexy. Minim Invasive Chir 1:68–72 25. Köckerling F, Schneider C, Hohenberger W (1996) Prolapse of the rectum – choice of procedure and the possibilities of minimally invasive surgery. Chirurg 67:471–482 26. Köckerling F, Schneider C, Reymond MA and Laparoscopic Colorectal Surgery Study Group – LCSSG (1998) Early results of a prospective multicenter study on 500 consecutive cases of laparoscopic colorectal surgery. Surg Endosc 12:37–41 27. Köckerling F, Rose J, Schneider C, Scheidbach H, Scheuerlein H and the Laparoscopic Colorectal Surgery Study Group (1999) Laparoscopic colorectal anastomosis: risk of postoperative leakage. Results of a multicenter study. Surg Endosc 13:639–644

28. Köckerling F, Scheidbach H, Schneider C, Bärlehner E, Köhler L, Bruch HP, Konradt J, Wittekind C, Hohenberger W (2000) Laparoscopic abdominoperineal resection: early results of a prospective study involving 116 patients. Dis Colon Rectum 43:1503–1511 29. Lacy AM, Garcia-Valdecasas JC, Delgado S, Grande L, Fuster J, Tabet J, Ramo C, Pique JM, Cifuentes A, Visa J (1997) Postoperative complications of laparoscopic-assisted colectomy. Surg Endosc 11:119–122 30. Leppert R, Fuchs KH, Kraemer M, Thiede A (1996) Surgical therapy of rectal prolapse. Zentralbl Chir 121:698–703 31. Monson JRT, Darzi A, Declan Carey P, Guillou PJ (1992) Prospective evaluation of laparoscopic-assisted colectomy in an unselected group of patients. Lancet 340:831–833 32. Milsom JW, Böhm B, Hammerhofer KA, Fazio V, Steiger E, Elson P (1998) A prospective, randomized trial comparing laparoscopic versus conventional techniques in colorectal cancer surgery: a preliminary report. J Am Coll Surg 187:46–55 33. Novell JR, Osborne MJ, Winslet MC, Lewis AAM (1994) Prospective randomized trial of Ivalon sponge versus sutured rectopexy for full-thickness rectal prolapse. Br J Surg 81:904–906 34. Poen AC, de Brauw M, Felt-Bersma RJF, de Jong D, Cuesta MA (1996) Laparoscopic rectopexy for complete rectal prolapse. Clinical outcome and anorectal function tests. Surg Endosc 10:904–908 35. Stelzner F (1994) On the cause and the therapy of rectal prolapse. Chirurg 65:533–545 36. Stevenson ARL, Stitz RW, Lumley JW (1998) Laparoscopic-assisted resection-rectopexy for rectal prolapse. Early and medium follow-up. Dis Colon Rectum 41:46–54 37. Thompson JP, Ross AH (1989) Management of infection after prosthetic abdominal rectopexy (Wells procedure). Br J Surg 76:610–612 38. Tjandra JJ, Fazio VW, Church JM, Milsom JW, Oakley JR, Lavery IC (1993) Rippstein procedure is an effective treatment for rectal prolapse without constipation. Dis Colon Rectum 36:501–507

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39. Wehrli H, Koch R, Akovbiantz A (1988) Erfahrung mit 169 maschinellen kolorektalen Anastomosen (1981–1984). Helv Chir Acta 55:649–654 40. West of Scotland and Highland Anastomosis Study Group (1991) Suturing or stapling in gastrointestinal surgery: a prospective randomized study. Br J Surg 78:337–341

41. Wexner SD, Cohen SM, Johansen OB, Nogueras JJ, Jagelman DG (1993) Laparoscopic colorectal surgery: a prospective assessment and current perspective. Br J Surg 80:1602–1605 42. Wexner SD, Reissman P, Pfeifer J, Bernstein M, Geron N (1996) Laparoscopic colorectal surgery – analysis of 140 cases. Surg Endosc 10:133–136

43. Winde G, Reers B, Holzgreve A, Fischer R, Bohlmann A, Bünte H (1993) Klinische und funktionelle Ergebnisse der abdominalen Rektopexie unter Verwendung verschiedener Fixierungsgrundlagen. Langenbecks Arch Chir 378:86–91 44. Xynos E, Chryson E, Tsiasoursis J, Cpanomerthakis E, Vanilakis JS (1999) Rectum rectopexy for rectal prolapse. Surg Endosc 13:862–864