Evidence - Resection rectopexy, laparoscopic

The precise pathogenesis and etiology of rectal prolapse is still under discussion: Is it a sliding hernia, an intussusception or a combination of both mechanisms? This clinical entity is characterized by the following functional anatomical pathologies which are present in varying degrees:

• Atypically low Douglas pouch (3, 13, 19)
• Levator ani muscle diastasis
• Functional weakness of the external and internal anal sphincter (3, 13)
• Weak pelvic floor musculature
• Pudendal neuropathy (13, 19)
• Mobile mesorectum with insufficient posterior and lateral fixation of the rectum (13, 19, 29)
• Elongated redundant sigma (13,19,29).

Ultimately, it is unclear which of the changes favor rectal prolapse and which are sequelae, and this is almost impossible to clarify in diagnostic work-up.

The treatment aims to remedy the prolapse and restore defecation and continence. The following treatment options are available (13, 19, 29):

• Fixation of the rectum to the sacrum
• Resection or plication of the redundant bowel.

A distinction is made between intraabdominal and local procedures.

2.1 Rectopexy

The rectum is fixated to the presacral fascia, thereby eliminating its inadequate attachment to the sacrum. The stretched rectum relieves the load on the pelvic floor, thereby supposedly promoting regeneration of the pelvic floor muscles. Rectopexy knows the following variants:

2.1.1 Suture rectopexy

Sudeck (24) was the first to perform this procedure, where the rectum is mobilized down to the pelvic floor and fixated to the promontory with interrupted sutures. The presacral fibrosis induced by the mobilization of the rectum supposedly further stabilizes the anatomical situation. The reported recurrence rate ranges up to 10% and data on postoperative dysfunction vary considerably (16).

2.1.2 Rectopexy with foreign material

Foreign material should result in a more extensive presacral fixation of the mobilized and stretched rectum. Anterior sling rectopexy according to Ripstein (22), lateral fixation according to Orr-Loygue and posterior mesh rectopexy according to Wells (26) differ in their position of the material. Another variant is anterior rectopexy, where the rectum is mobilized only in the rectouterine pouch and attached to the promontory with a mesh fixed anteriorly to the rectum (6). This technique is based on the concept that mobilization of the rectum results in postoperatively impaired evacuation (18, 23).

The above procedures have recurrence rates of up to 12%, and after the Wells procedure almost all patients note a tendency of constipation. The type of foreign material does not affect the recurrence rate (5, 20, 28); Marlex excels in terms of the lowest infection rates (12, 14). However, the use of foreign material has its own risks: Fistulas, stenoses and erosions (10). Studies suggest that problems with continence and constipation are more likely to be resolved with simple suture rectopexy rather than with foreign material (8).

2.1.3 Resection rectopexy (Frykman-Goldberg)

The procedure described by Frykman (9) combines rectopexy and sigmoidectomy and aims to achieve the following:

• Removal of the redundant sigmoid, which either exerts caudal pressure or can become angulated against the rectum, thereby having an obstructive effect.
• More stable fixation of the stretched rectum
• Fixation of the rectum by fibrous scarring around the descendorectostomy
• Improvement of preexisting constipation

The combined procedure has a low risk of recurrence and the improvement in continence is comparable to that of rectopexy without resection; the significantly lower risk of postoperative constipation apparently results from the resection (15).

Surgical aspects of abdominal procedures
The approach - open or laparoscopic - does not impact on recurrence rate and functional results (4, 12). The benefits of minimally invasive surgery (MIS) include reduced postoperative pain, faster convalescence and shorter hospital stays.

While incomplete division of the lateral stalks during rectal mobilization appears to increase the recurrence rate; the functional results are more favorable (16, 18, 23).

The original benefit of local procedures was that they avoided laparotomy; in view of the MIS techniques available today this aspect has lost its significance. While wrapping the anus with subcutaneous foreign material or muscle has become obsolete due to considerable complication and recurrence rates, the following local measures may be considered in patients with contraindications for invasive procedures (21):

3.1 Rehn-Delorme procedure

In the procedure described by Rehn (7) and modified by Delorme, the mucosa is separated transanally from the sphincter and muscularis propria and the denuded muscularis layer is plicated longitudinally around the prolapsed rectum; this shortens the muscularis tube. After resection of the redundant mucosa, it is reapproximated. The procedure can be performed under analgesic sedation but is not suitable in pronounced prolapse. Studies demonstrate improved continence, but also a rather high recurrence rate.

3.2 Perineal proctosigmoidectomy (Altemeier)

In the Altemeier procedure (1), transanal resection of the rectum and parts of the sigmoid with subsequent restoration of continuity is carried out at the level of the dentate line, similar to construction of a colon pouch (30). It is possible to combine this procedure with levatorplasty (27). While the recurrence rate is lower compared to the Rehn-Delorme technique, the functional results regarding incontinence and spotting are less favorable.

Selection of procedure

Due to the present inconsistent data, no evidence-based recommendations can be given regarding the choice of procedure in the treatment of rectal prolapse (2). There is no clearly superior operation in the management of rectal prolapse; rather, each surgical procedure has its own risks and benefits:

• Intraabdominal procedures are characterized by a lower recurrence rate
• The efficacy of simple suture rectopexy is comparable to that of rectopexy techniques with foreign material
• The use of foreign material has its own risks
• Resection rectopexy seem to offer benefits in preexisting constipation, particularly in patients with elongated sigmoid
• The laparoscopic approach has no drawbacks; benefits include less postoperative pain and faster convalescence
• While local techniques benefit from less surgical stress, the functional results are worse

Therefore, when settling on a procedure the decisive factors are patient resilience, size of the prolapse and medical history for functional defecation disorders.

Abdominal access not possible (multimorbid high-risk patient)
> Minor prolapse: Rehn-Delorme
> Major prolapse: Altemeier
> In preexisting incontinence: Additional levatorplasty

Abdominal access is possible: Rectopexy, preferably laparoscopically
> Suture rectopexy
> Mesh rectopexy
> In preexisting incontinence: No resection
> In preexisting constipation with redundant sigmoid: Resection

The Nordic Rectal Prolapse Study - a Multicentre, International Cohort Study

BIC4VMR: Breakthrough Improvement Collaborative for Ventral Mesh Rectopexy

Obstructed Defecation Caused by Rectal Prolapse and Rectocele: Laparoscopic Ventral Rectopexy Alone Versus Laparoscopic Ventral Rectopexy Combined With Stapled Trans-anal Rectal Resection

A Prospective Study Evaluating the Clinical Outcome of a Modified d'Hoore Technique for Laparoscopic Ventral Mesh Rectopexy

Multicenter Ventral Mesh Rectopexy Registry Collaborative

Early Safety and Efficiency of Interdisciplinary Laparoscopic Resection Rectopexy Combined With Sacrocolpopexy for Women With Obstructive Defecation Syndrome and Pelvic Organ Prolapse