Conclusions: Resection rectopexy for rectal prolapse can be performed safely via the laparoscopic route. Recovery is uneventful and of shorter duration after the ...
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
