Surg Endosc (1999) 13: 862–864

© Springer-Verlag New York Inc. 1999

Resection rectopexy for rectal prolapse The laparoscopic approach E. Xynos, E. Chrysos, J. Tsiaoussis, E. Epanomeritakis, J.-S. Vassilakis Department of General Surgery, University Hospital of Heraklion Medical School, University of Crete, GR-711 10 Greece Received: 16 February 1998/Accepted: 2 September 1998

Abstract Background: Resection rectopexy through open laparotomy is an established procedure for the treatment of rectal prolapse. Methods: Resection rectopexy was successfully performed in 10 multiparous women by the laparoscopic approach (LAP), and the results were compared to those of eight women with laparotomy resection rectopexy (OPEN). Preoperative and postoperative assessment included anorectal manometry, defecography, and measurement of large-bowel transit. Results: The duration of the operation was longer in the LAP than in the OPEN group (p < 0.01). Morbidity was lower (p < 0.01) and hospital stay was shorter (p < 0.001) after the LAP than in the OPEN group. Prolapse was cured in all cases. Postoperatively, anal resting and squeeze pressures and rectal compliance increased significantly in both groups of patients (p ⳱ 0.007, p ⳱ 0.003, and p < 0.001, respectively). In all patients, the operation resulted in acceleration of large-bowel transit (p < 0.001) and in more obtuse anorectal angles at rest (p ⳱ 0.007). In addition, sampling events were observed more commonly (p ⳱ 0.008) postoperatively. Preoperatively, incontinence was present in 13 patients (seven LAP and six OPEN) and persisted in four of them after rectopexy (two LAP and two OPEN). Conclusions: Resection rectopexy for rectal prolapse can be performed safely via the laparoscopic route. Recovery is uneventful and of shorter duration after the laparoscopic than after the open approach. Similarly satisfactory functional results are obtained with both procedures.

Several transabdominal and transanal procedures have been designed to treat rectal prolapse [3]. Abdominal procedures achieve a success rate of >90% in controlling prolapse [3], while coexisting incontinence is cured in approximately two-thirds of cases [6, 7, 9], depending on technique. Fixation of the rectum to the sacrum with the interposition of prosthetic material is one procedure that has been widely applied. However, this procedure is associated with severe constipation in rates as high as 50% [5, 6, 9, 11]. Recently, a few cases of rectopexy with or without the use of prosthetic material, via the laparoscopic approach, have been reported [2, 8]. Based on a few comparative studies, there is evidence that resection rectopexy without the use of prosthetic material offers better functional results than rectopexy alone [6, 9, 11]. Herein we report on our preliminary experience with laparoscopically assisted resection rectopexy. The results after the laparoscopic approach are also compared to a matched series of open resection rectopexy.

Key words: Rectal prolapse — Fecal incontinence — Rectopexy — Colon resection — Laparoscopy

Operative technique

Correspondence to: E. Xynos

Patients and methods Ten multiparous women (mean age, 69 ± 11 years; range, 49–81 years) with full-thickness rectal prolapse underwent resection rectopexy via the laparoscopic route (LAP). All patients were assessed preoperatively and 6–9 months postoperatively by clinical examination, anorectal manometry, estimation of large-bowel transit, defecography, and ultrasonography of the anorectum according to standard techniques and definitions [14, 15]. Their outcome was compared to that of a historical control group of eight female patients, matched for age (71 ± 13 years; range, 51–85 years) and parity, who underwent resection rectopexy through the open approach for overt rectal prolapse (OPEN). Another group of 16 healthy women, matched for age and parity, was also used as controls.

Under general anesthesia, the pneumoperitoneum was established, and four ports were placed at the lower abdomen as follows: one 10-mm port just below the umbilicus for the 0° or 30° laparoscope, one 12-mm port at the right iliac fossa, one 12-mm port at the midline just above the symphysis pubis, and a fourth one at the left iliac fossa. The latter three served as working ports. The left and sigmoid colon were mobilized from the splenic flexure

863 Table 1. Anorectal manometry variables in controls and patients before and after operation (antanal repair not included)a LAP patients Control Anal resting pressure (mmHg) Anal squeeze pressure (mmHg) Presence of slow wave (cases) Frequency of slow waves (c/min) Presence of sampling events (cases) Frequency of sampling events (c/h) Rectal compliance (ml/cm H2O) Maximum tolerable rectal volume (ml) a

63 ± 15 120 ± 38 13/16 7.2 ± 2.1 15/16 5.9 ± 1.4 12.1 ± 2.4 258 ± 36

Preop 26 ± 8 41 ± 17 0/10 — 2/10 6 7 ± 2.2 182 ± 43

OPEN patients

Postop

Preop

51 ± 22 70 ± 22 7/10 6.8 ± 2.7 8/10 6 ± 1.4 10.4 ± 2.2 232 ± 35

27 ± 6 36 ± 20 0/8 — 1/8 5 6.8 ± 1.8 167 ± 51

Postop 51 ± 19 80 ± 24 6/8 7 ± 2.8 7/8 5.8 ± 1.4 9.7 ± 2 240 ± 41

Values are presented as mean ± one standard deviation

down to the pelvis. The peritoneum was also incised at the median aspect of the left colon and sigmoid, from the level of the inferior mesenteric vessels down to the pelvis. Thereafter, the rectum was dissected at all aspects, down to the levator muscles. The mesorectum was detached from the presacral fascia, the lateral ligaments of the rectum were divided, and the anterior rectal wall was dissected for the vagina by dividing the rectovaginal septum. Then the rectum and mesorectum were divided using an Endo-GIA stapler (Auto Suture, USSC, Connecticut, USA) at ∼15 cm from the anal verge. The distance of division was assessed by placing transanally the shaft of a PCEEA stapler (Auto Suture, USSC, Connecticut, USA). The next step was to dissect and divide the superior mesenteric vessels between clips or by using an Endo-GIA stapler with a vascular unit (Auto Suture). At this stage, the length of the redundant left sigmoid-colon to be excised was assessed, and the exact point of proximal division of the colon was marked with clips. Following this, a 4-cm incision was made at the site of the left port, and the sigmoid stump was brought out of the abdominal cavity. The redundant segment of the bowel was resected, and the anvil of a 31-mm PCEEA plus stapler (Auto Suture, USSC, Connecticut, USA) was inserted into the proximal stump of the descending colon through a purse string. After the proximal stump was placed into the abdomen and the left lateral incision was closed, the pneumoperitoneum was reestablished. The colorectal anastomosis was fashioned by inserting the shaft of the stapler transanally. Then the rectal stump was fixed high onto the presacral fascia with two to three nonabsorbable sutures or Endo-Hernia clips (Auto Suture, USSC, Connecticut, USA) at each side. A suction drain was placed into the pelvis, above which the peritoneum was closed with Endo-Hernia clips. For the open approach, the same principles of dissection and mobilization of the rectum, length of resection of the redundant rectosigmoid, and fashioning of the anastomosis were followed.

Statistical analysis Comparisons of various parameters were made by applying the Student’s t-test or the Mann-Whitney U-test for paired and unpaired values, as appropriate. P values of <0.05 were considered to be statistically significant.

Results Seven of the LAP group and six of the OPEN group reported overt prolapse of the rectum through the anus during defecation. These 13 patients also reported major (LAP: five; OPEN: five) or minor (LAP: two; OPEN: one) fecal incontinence. In addition, six patients (LAP: four; OPEN: two) complained of blood discharge. At proctoscopy, these six patients had a solitary rectal ulcer. Anal sphincter function as shown by anorectal manometry (table) and anorectal anatomy as detected by defecography and anal ultrasonography in all patients were significantly impaired, as compared to controls. The operation lasted significantly longer in the LAP (130 ± 32 min) than in the OPEN group (80 ± 25 min; p <

0.01). Estimated blood losses were similar for the two groups. Immediate postoperative morbidity was significantly higher in the OPEN group (pulmonary atelectasis: four, wound infection: three) than in the LAP group (pulmonary atelectasis: one; p < 0.01). Bowel function and oral diet were resumed significantly sooner in the LAP (2.4 ± 0.8 days) than in the OPEN group (4.1 ± 0.9 days; p < 0.001). Postoperative hospital stay was significantly shorter in the LAP (4.7 ± 1.1 days) than in the OPEN group (8.3 ± 1.9 days; p < 0.001). Follow-up assessment was performed at 6 and 12 months postoperatively. Symptoms attributed to obstructive defecation were absent. Incontinence was present in four patients (LAP: two; OPEN: two, one with a defect of the external anal sphincter), but it was corrected successfully after antanal sphincter repair. Although anorectal function, as tested by manometry, improved postoperatively in all patients, it did not reach the normal state. There were no significant differences in manometric values between the two groups of patients either before or after the operation (Table 1). Postoperative defecography confirmed the correction of prolapse and rectocele in all cases. Perineal descent was no longer evident, and large-bowel transit was accelerated to rates even faster than in normals (p < 0.001 versus preoperative state; p ⳱ 0.02 versus controls). Discussion Recently, laparoscopic abdominal rectopexy with the use of prosthetic material has been proposed as a feasible and rather easy procedure for the treatment of rectal prolapse, without recurrences [2, 4, 8]. However, like the open approach [5, 6, 9, 11, 12], this procedure is associated with severe constipation. Cushieri et al. [4] reported this complication in two of five cases treated laparoscopically with prosthetic rectopexy; but in a more recent study, constipation after prosthesis rectopexy was reported in only two of 12 patients [10]. It has been suggested that kinking of the redundant sigmoid colon over the fixed rectum causes mechanical obstruction, which manifests as constipation [6, 9]. Alternatively, it has been speculated that constipation is the consequence of impaired motility of the rectum, which acts as a functionally obstructing segment. This might be the result of fibrosis, caused by the presence of foreign material [9]. It

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has been also hypothesized that the division of the lateral ligaments of the rectum and the disruption of its nervous supply contribute to the impairment of the rectal motility [12]. Resection of the redundant colon, colorectal anastomosis, and suture fixation of the rectum onto the presacral fascia for the treatment of rectal prolapse is associated with minimal recurrence rates, comparable to those after rectopexy with prosthetic material, while defecatory problems such as constipation or fecal impaction are absent [3, 6, 9, 11]. These results may be due to the resection of the redundant sigmoid loop, which otherwise kinks over the fixed rectum and obstructs the lumen. In addition, the danger of fibrosis around the rectum is avoided because no prosthetic material is used. It might be argued that full mobilization of the rectum by dividing the lateral ligaments can impair rectal motility, thus contributing to postoperative constipation [10, 12]. We do not share this view; constipation was not a problem either in our small series or in the earlier reports [6, 7, 9, 11]. In addition, as shown by the group reported by Speakman et al., preservation of the lateral ligaments is associated with a higher recurrence rate of prolapse [13]. Laparoscopically assisted resection rectopexy is a feasible procedure. Full mobilization of the rectum down to the pelvic floor necessitates division of the lateral ligaments of the rectum. Transection of the rectum and ligation of the inferior mesenteric vessels can be easily achieved with stapling devices. The extracorporeal stage of the procedure involves resection of the redundant colon and preparation of the proximal stump for the anastomosis. The colorectal anastomosis with the circular stapler is performed intracorporeally and under direct vision. Although it takes longer than the open approach, the duration of the operation is not very long, lasting for <150 min on average in our hands. Postoperative pain is minimal, and mild analgesics are given during the first 24 postoperative hours. Full mobilization of the patient is achieved within a few hours postoperatively, and oral feeding is resumed by the 2nd to 3rd postoperative day—significantly sooner than after the open procedure. Wound complications are absent, and hospital stay is shorter than with the open procedure, which, in addition, is associated with an increased incidence of pulmonary complications. In a retrospective comparative study, Baker et al. [1] found that laparoscopically assisted resection rectopexy is associated with

much prompter recovery than the open approach. However, they did not present any details on surgical techniques and postoperative functional results. Of course, prospective comparative studies are still needed to document the aforementioned advantages of the laparoscopic approach over the open procedure. References 1. Baker R, Senagore AJ, Luchtefeld MA (1995) Laparoscopic-assisted vs. open resection: rectopexy offers excellent results. Dis Colon Rectum 38: 199–201 2. Berman IR (1992) Sutureless laparoscopic rectopexy for procidentia: technique and implications. Dis Colon Rectum 35: 689–693 3. Corman ML (1989) Rectal prolapse. In: Corman ML (ed) Colon and rectal surgery. 2nd ed. Philadelphia, JB Lippincott, pp 209–247 4. Cuschieri A, Shimi SM, Vander Velpen G, Banting S, Wood RAB (1994) Laparoscopic prosthesis fixation rectopexy for complete rectal prolapse. Br J Surg 81: 138–139 5. Deen KI, Grant E, Billingham C, Keighley MRB (1994) Abdominal resection rectopexy with pelvic floor repair versus perineal rectosigmoidectomy and pelvic floor repair for full-thickness rectal prolapse. Br J Surg 81: 302–304 6. Duthie GS, Bartolo DCC (1992) Abdominal rectopexy for rectal prolapse: a comparison of techniques. Br J Surg 79: 107–113 7. Faouk R, Duthie GS, Bartolo DCC, Mac Gregor AB (1992) Restoration of continence following rectopexy for rectal prolapse and recovery of the internal and sphincter electromyogram. Br J Surg 79: 439–440 8. Kwox SPY, Carey DP, Lau WY, Li AKC (1994) Laparoscopic rectopexy. Dis Colon Rectum 37: 947–948 9. McKee RF, Lauder JC, Poon FW, Aitchison MA, Finlay IG (1992) A prospective randomized study of abdominal rectopexy with and without sigmoidectomy in rectal prolapse. Surg Gynecol Obstet 174: 145– 148 10. 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 11. Sayfan J, Pinho M, Alexander Williams J, Keighley MRB (1990) Sutured posterior rectopexy with sigmoidectomy compared with Marlex mesh for rectal prolapse. Br J Surg 77: 143–145 12. Scaglia M, Fasth S, Hallgren T, Nordgren S, Oresland T, Hulten L (1994) Abdominal rectopexy for rectal prolapse: influence of surgical technique on functional outcome. Dis Colon Rectum 37: 805–813 13. Speakman CT, Madden MV, Nicholls RJ, Kamm MA (1991) Lateral ligament division during rectopexy causes constipation but prevents recurrence: results of a prospective randomized study. Br J Surg 78: 1431–1433 14. Vassilakis JS, Pechlivanides G, Zoras OJ, Vrachasotakis N, Chrysos E, Tzovaras G, Xynos E (1995) Anorectal function after anterior resection of the rectum. Int J Colorectal Dis 10: 101–106 15. Xynos E, Tzortzinis A, Chrysos E, Tzovaras G, Vassilakis JS (1993) Anal manometry in patients with fissure-in-ano before and after internal sphincterotomy. Int J Colorectal Dis 8: 125–128