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Evidence - Resection rectopexy, laparoscopic

general and visceral surgery
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Anatomy Perioperative management Technique Complications Evidence Total Video

  1. Literature summary

    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. Intraabdominal procedures (laparotomy, laparoscopy)

    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).

  3. Local techniques (perineal, transanal)

    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

  4. Ongoing trials on this topic

  5. References on this topic

    1. Altemeier WA, Giuseffi J, Hoxworth P (1952) Treatment of extensive prolapse of the rectum in aged or debilitated patients. AMA Arch Surg 65: 72–80

    2. Bachoo P, Brazzelli M, Grant A (2001) Surgery for complete rectal prolapse in adults (Cochrane Review). Cochran Libary, Issue 2

    3. Broden B, Snellman B (1968) Procidentia of the rectum studied with cineradiography. A contribution to the discussion of causative mechanism. Dis Colon Rectum 11: 330–347

    4. Bruch HP, Herold A, Schiedeck T, Schwandner O (1999) Laparoscopic surgery for rectal prolapse and outlet obstruction. Dis Colon Rectum 42: 1189–1194; discussion 1194–1195

    5. Corman ML (1988) Rectal prolapse. Surgical techniques. Surg Clin North Am 68: 1255–1265

    6. D’Hoore A, Cadoni R, Penninckx F (2004) Long-term outcome of laparoscopic ventral rectopexy for total rectal prolapse. Br J Surg 91: 1500–1505

    7. Delomre R (1900) Surle traitment des prolapses du rectum totaux pour lèxcision de la muscueuse rectale ou rectocolique. Bull Mem Soc Chir Paris 266: 499–518

    8. Duthie GS, Bartolo DC (1992) Abdominal rectopexy for rectal prolapse: a comparison of techniques. Br J Surg 79: 107–113

    9. Frykman HM (1955) Abdominal proctopexy and primary sigmoid resection for rectal procidentia. Am J Surg 90: 780–789

    10. Holmstrom B, Broden G, Dolk A (1986) Results of the Ripstein operation in the treatment of rectal prolapse and internal rectal procidentia. Dis Colon Rectum 29: 845–848

    11. Jarrett ME, Matzel KE, Stosser M et al. (2005) Sacral nerve stimulation for fecal incontinence following surgery for rectal prolapse repair: a multicenter study. Dis Colon Rectum 48: 1243–1248

    12. Kariv Y, Delaney CP, Casillas S et al. (2006) Long-term outcome after laparoscopic and open surgery for rectal prolapse: a case-control study. Surg Endosc 20: 35–42

    13. Kuijpers HC (1992) Treatment of complete rectal prolapse: to narrow, to wrap, to suspend, to fix, to encircle, to plicate or to resect? World J Surg 16: 826–830

    14. Kuijpers JH, Morree H de (1988) Toward a selection of the most appropriate procedure in the treatment of complete rectal prolapse. Dis Colon Rectum 31: 355–357

    15. Luukkonen P, Mikkonen U, Jarvinen H (1992) Abdominal rectopexy with sigmoidectomy vs. rectopexy alone for rectal prolapse: a prospective, randomized study. Int J Colorectal Dis 7: 219–222

    16. Madiba TE, Baig MK, Wexner SD (2005) Surgical management of rectal prolapse. Arch Surg 140: 63–73

    17. Marchal F, Bresler L, Ayav A et al. (2005) Long-term results of Delorme’s procedure and Orr-Loygue rectopexy to treat complete rectal prolapse. Dis Colon Rectum 48: 1785–1790

    18. Mollen RM, Kuijpers JH, Hoek F van (2000) Effects of rectal mobilization and lateral ligaments division on colonic and anorectal function. Dis Colon Rectum 43: 1283–1287

    19. Nicholls RJ (1994) Rectal prolapse and the solitary ulcer syndrome. Ann Ital Chir 65: 157–162

    20. Novell JR, Osborne MJ, Winslet MC, Lewis AA (1994) Prospective randomized trial of Ivalon sponge versus sutured rectopexy for full-thickness rectal prolapse. Br J Surg 81: 904–906

    21. Oliver GC, Vachon D, Eisenstat TE et al. (1994) Delorme’s procedure for complete rectal prolapse in severely debilitated patients. An analysis of 41 cases. Dis Colon Rectum 37: 461–467

    22. Ripstein CB (1952) Treatment of massive rectal prolapse. Am J Surg 83: 68–71

    23. 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

    24. Sudeck P (1922) Rektumprolapsoperation durch Auslösung des Rektum aus der Excavatio sacralis. Zentralbl Chir 20: 698–699

    25. Watts AM, Thompson MR (2000) Evaluation of Delorme’s procedure as a treatment for full-thickness rectal prolapse. Br J Surg 87: 218–222

    26. Wells C (1959) New operation for rectal prolapse. Proc R Soc Med 52: 602–603

    27. Williams JG, Rothenberger DA, Madoff RD, Goldberg SM (1992) Treatment of rectal prolapse in the elderly by perineal rectosigmoidectomy. Dis Colon Rectum 35: 830–834

    28. Winde G, Reers B, Nottberg H et al. (1993) Clinical and functional results of abdominal rectopexy with absorbable mesh-graft for treatment of complete rectal prolapse. Eur J Surg 159: 301–305

    29. Yakut M, Kaymakcioglu N, Simsek A et al. (1998) Surgical treatment of rectal prolapse. A retrospective analysis of 94 cases. Int Surg 83: 53–55

    30. Yoshioka K, Ogunbiyi OA, Keighley MR (1998) Pouch perineal rectosigmoidectomy gives better functional results than conventional rectosigmoidectomy in elderly patients with rectal prolapse. Br J Surg 85: 1525–1526

  6. Reviews

    Albayati S, Chen P, Morgan MJ, Toh JWT. Robotic vs. laparoscopic ventral mesh rectopexy for external rectal prolapse and rectal intussusception: a systematic review. Tech Coloproctol. 2019 Jun;23(6):529-535.

    Fagan G, Bathgate A, Dalzell A, Collinson R, Lin A. Outcomes for men undergoing rectal prolapse surgery - a systematic review. Colorectal Dis. 2023 Jun;25(6):1116-1127.

    Fan K, Cao AM, Barto W, De Lacavalerie P. Perineal stapled prolapse resection for external rectal prolapse: a systematic review and meta-analysis. Colorectal Dis.  2020 Dec;22(12):1850-1861.

    Flynn J, Larach JT, Kong JCH, Warrier SK, Heriot A. Robotic versus laparoscopic ventral mesh rectopexy: a systematic review and meta-analysis. Int J Colorectal Dis. 2021 Aug;36(8):1621-1631.

    Lobb HS, Kearsey CC, Ahmed S, Rajaganeshan R. Suture rectopexy versus ventral mesh rectopexy for complete full-thickness rectal prolapse and intussusception: systematic review and meta-analysis. BJS Open. 2021 Jan 8;5(1).

    Manatakis DK, Gouvas N, Pechlivanides G, Xynos E. Ventral Prosthesis Rectopexy for obstructed defaecation syndrome: a systematic review and meta-analysis. Updates Surg. 2022 Feb;74(1):11-21.

    Pellino G, Fuschillo G, Simillis C, Selvaggi L, Signoriello G, Vinci D, Kontovounisios C, Selvaggi F, Sciaudone G. Abdominal versus perineal approach for external rectal prolapse: systematic review with meta-analysis. BJS Open. 2022 Mar 8;6(2).

    van der Schans EM, Boom MA, El Moumni M, Verheijen PM, Broeders IAMJ, Consten ECJ. Mesh-related complications and recurrence after ventral mesh rectopexy with  synthetic versus biologic mesh: a systematic review and meta-analysis. Tech Coloproctol. 2022 Feb;26(2):85-98.

  7. Guidelines

  8. literature search

    Literature search on the pages of pubmed.