Abdominal rectopexy for rectal prolapse. Influence of surgical technique on functional outcome

Current diagnostic tools and treatment modalities for rectal prolapse

Rectal prolapse is a circumferential, full-thickness protrusion of the rectum through the anus. It is a rare condition, and only affects 0.5% of the general population. Multiple treatment modalities have been described, which have changed significantly over time. Particularly in the last decade, laparoscopic and robotic surgical approaches with different mobilization techniques, combined with medical therapies, have been widely implemented. Because patients have presented with a wide range of complaints (ranging from abdominal discomfort to incomplete bowel evacuation, mucus discharge, constipation, diarrhea, and fecal incontinence), understanding the extent of complaints and ruling out differential diagnoses are essential for choosing a tailored surgical procedure. It is crucial to assess these additional symptoms and their severities using preoperative scoring systems. Additionally, radiological and physiological evaluations may explain some vague symptoms and reveal concomitant pelvic disorders. However, there is no consensus on or standardization of the optimal extent of dissection, type of procedure, and materials used for rectal fixation; this makes providing maximum benefits to patients with minimal complications difficult. Even recent publications and systematic reviews have not recommended the most appropriate treatment options. This review explains the appropriate diagnostic tools for different conditions and summarizes the current treatment approaches based on existing literature and expert opinions.

A novel method for treating complete rectal prolapse with laparoscopic sigmoidopexy to the abdominal wall: A case report

Introduction

Presentation of case

Discussion

Conclusion

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This is the first reported case of abdominal wall fixation for rectal prolapse.

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Laparoscopic fixation of the abdominal wall with minimal dissection was performed.

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Repair is possible without the use of artificial material.

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The procedure requires only five sutures to fix.

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This method may be a useful option for patients who can undergo general anaesthesia.

Laparoscopic Suture versus Mesh Rectopexy for the Treatment of Persistent Complete Rectal Prolapse in Children: A Comparative Randomized Study

Purpose

To compare laparoscopic mesh rectopexy with laparoscopic suture rectopexy. Patients and Methods. The prospective study was conducted at Pediatric Surgery Department, Al-Azhar University Hospitals, Cairo, Egypt between Feb 2010 and Jan 2015. Seventy-eight children with persistent complete rectal prolapse were subjected to laparoscopic rectopexy. Fourteen parents refused to participate. All patients received initial conservative treatment for more than one year. The remaining 64 patients were randomized divided into two equal groups. Group A; 32 patients underwent laparoscopic mesh rectopexy and group B, 32 underwent laparoscopic suture rectopexy. The operative time, recurrence rate, post-operative constipation, and effect on fecal incontinence, were reported and evaluated for each group.

Results

Sixty-four cases presented with persistent complete rectal prolapse were the material of this study. They were 40 males and 24 females. Mean age at operation was 8 (5–12) years. All cases were completed laparoscopically. Mean operative time in laparoscopic suture rectopexy was shorter than laparoscopic mesh rectopexy group. No early post-operative complications were encountered. No cases of recurrence with mesh rectopexy group while in suture rectopexy group it was 4 cases (14.2%). Post-operative constipation occurred in one case (3.57%) in suture rectopexy group and occurred in one case (3.3%) in mesh rectopexy group. Fecal incontinence improved in 26/28 cases (92.8%) in suture rectopexy while in mesh rectopexy it was improved in 30/30 cases (100%) of cases.

Conclusion

Both laparoscopic mesh and suture rectopexy are feasible and reliable methods for the treatment of complete rectal prolapse in children. However, no recurrence, low incidence of constipation and high improvement of incontinence at follow up more than 36 months with mesh rectopexy accordingly, we considered mesh rectopexy to be the procedure of choice in treatment of complete rectal prolapse.

Simplified Laparoscopic Suture Rectopexy for Idiopathic Rectal Prolapse In Children: Technique and Results

BACKGROUND

Laparoscopic suture rectopexy is safe and effective treatment option for pediatric rectal prolapse. We performed this study to compare the outcome of modified laparoscopic suture rectopexy (MLSR) versus Classical Laparoscopic suture rectopexy (CLSR).

MATERIAL AND METHODS

The study was conducted between June 2015 to May 2019 including all the patients with persistent rectal prolapse who underwent surgery managed by either MLSR (Group A) or CLSR (Group B). The groups were compared for constipation, operative time, blood loss, length of stay, postoperative complications.

RESULTS

19 patients from MLSR and 22 patients from CLSR were evaluated. The mean operative time in MLSR group was 41.5 ± 6.2 min which was significantly lesser than CLSR group with a mean operative time of 78.6 ± 14.2 (p = 0.001). The blood loss was also less in MLSR group compared to CLSR group (p = 0.013). At three months of follow up, the constipation was less in MLSR group compared to CLSR group (p = 0.041).

CONCLUSION

The modification makes the procedure technically easy, minimizes the chances of complications and retaining all the advantages of suture rectopexy.

LEVEL OF EVIDENCE

Level II.

Long-term outcomes of robotic ventral mesh rectopexy for external rectal prolapse

INTRODUCTION

Nowadays in Europe, laparoscopic ventral mesh rectopexy is the gold standard treatment of external rectal prolapse (ERP). The benefits of robot ventral mesh rectopexy (RVMR) are not clearly defined. The primary objective of the study was to evaluate the long-term results of RVMR. The secondary objective was to determine predictive factors of recurrence.

DESIGN

Monocentric, retrospective study. Data, both pre-operative and peri-operative, were collected, and follow-up data were assessed prospectively by a telephone questionnaire. The study was performed in a tertiary referral center.

METHODS

Between August 2007 and August 2017, we evaluate all consecutive patients who underwent RVMR for ERP by three different surgeons. The primary outcome was the recurrence rate perceived by patients. Secondary outcome were functional results based on Knowles-Eccersley-Scott-Symptom score for constipation and Wexner score for incontinence, compared before and after surgery.

RESULTS

During the study period 96 patients (86 women) underwent RVMR. The mean age was 62.3 years (range 16-90). Twelve patients had a history of ERP repair. Sixty-nine patients were analyzed for long-term outcomes with a mean follow-up of 37 months (range 2.3-92 months). Recurrence rate was 12.5%. After surgery, constipation was significantly reduced: 44 patients were constipated before surgery versus 23 after surgery. Six patients described de novo constipation (6.25%). Fecal incontinence was significantly reduced: 59 patients were incontinent before surgery versus 14 after surgery. No predictive factor for recurrence was identified after multivariate analysis. No mesh related complications were related.

CONCLUSIONS

In conclusion, RVMR presents good long-term functional result and a recurrence rate similar to LVMR as published in the literature. The rate of mesh related complications seems lower.

Surgical options for full-thickness rectal prolapse: current status and institutional choice

Full-thickness rectal prolapse (FTRP) is generally believed to result from a sliding hernia through a pelvic fascial defect, or from rectal intussusception. The currently accepted cause is a pelvic floor disorder. Surgery is the only definitive treatment, although the ideal therapeutic option for FTRP has not been determined. Auffret reported the first FTRP surgery using a perineal approach in 1882, and rectopexy using conventional laparotomy was first described by Sudeck in 1922. Laparoscopy was first used by Bermann in 1992, and laparoscopic surgery is now used worldwide; robotic surgery was first described by Munz in 2004. Postoperative morbidity, mortality, and recurrence rates with FTRP surgery are an active research area and in this article we review previously documented surgeries and discuss the best approach for FTRP. We also introduce our institution's laparoscopic surgical technique for FTRP (laparoscopic rectopexy with posterior wrap and peritoneal closure). Therapeutic decisions must be individualized to each patient, while the surgeon's experience must also be considered.

The Role of Biofeedback Therapy in Functional Proctologic Disorders

Background and Aims:

The question which patients with functional proctologic disorders truly benefit from the biofeedback has not been equivocally resolved. The aim of this study was to assess our results of biofeedback therapy in patients with anal incontinence or constipation.

Material and Methods:

Fifty-two consecutive patients who were treated with biofeedback therapy between January 1998 and March 2002 were studied. Data was collected from our proctologic database.

Results:

Of the twenty-two patients with anal incontinence who underwent biofeedback therapy during the study period, twenty patients had incontinence affecting quality of life. Twelve patients (60 percent) benefited from biofeedback as judged by improvement of incontinence symptoms affecting quality of life; all four patients with partial sphincter defects, three out of four patients after secondary repair, three out of five patients with persistent incontinence after rectal prolapse surgery and two out of seven patients having idiopathic incontinence. Of the thirty patients who underwent biofeedback therapy for constipation, twenty-five had intractable symptoms of constipation. Constipation resolved in sixteen patients (64 percent); in thirteen out of nineteen (68 percent) of those with pelvic floor dysfunction (PFD) and in three out of six (50 percent) having combined PFD and slow transit constipation. In patients with PFD constipation was resolved in ten out of thirteen patients (77 percent) with anismus but in only three out of six (50 percent) having other causes.

Conclusions:

Biofeedback therapy improves incontinence after sphincter repairs and in patients with partial external sphincter defects, but does not improve idiopathic incontinence. Biofeedback is also effective in patients with constipation, especially when anismus is the only cause for symptoms of constipation and difficult evacuation.

Ventral colporectopexy for overt rectal prolapse and obstructed defaecation syndrome: a systematic review

AIM

Laparoscopic ventral rectopexy (VR) with the use of prosthesis has been advocated for both overt rectal prolapse (ORP) and obstructed defaecation syndrome (ODS). The present study reviews the short-term and functional results of laparoscopic VR.

METHOD

A search was performed of MEDLINE, EMBASE, Ovid and Cochrane databases on all studies reporting on VR for ORP, ODS and other anatomical abnormalities of the pelvic floor from 2004 until February 2013. No language restrictions were made. All studies on VR were reviewed systematically. The main outcomes were intra-operative complications, conversion, procedure duration, short-term mortality and morbidity, length of stay, recurrence of ORP, recurrence of anatomical disorder, faecal incontinence and constipation, quality of life (QoL) score and patient satisfaction. Quality assessment and data extraction were performed independently by three observers.

RESULTS

Twenty-three studies including 1460 patients were eligible for analysis. The conversion rate ranged from 0 to 14.3%. No mortality was reported. The immediate postoperative morbidity rate was 8.6%. Length of stay ranged from 1 to 7 days. A significant improvement in constipation and incontinence symptoms was observed in the postoperative period for both ORP and ODS (chi-square test, P < 0.0001).

CONCLUSION

Laparoscopic VR is a safe and effective procedure for ORP and ODS. Longer follow-up is required, and studies comparing VR with standard rectopexy and stapled transanal rectal resection are not yet available.

Ligaments of the Rectum: Anatomical and Surgical Considerations

The ligaments of the rectum have been the subject of controversy for decades. Not only have their contents and components been a source of contention, but also the very existence of these ligaments has been called into question. This article explores the anatomical features of these ligaments with implications for surgical treatment of rectal prolapse, rectal cancer, and resection of the rectum and mesorectum. A theory about the evolution of the lateral rectal ligaments and the mesorectum in humans and higher mammals is also presented.

A single centre comparative study of laparoscopic mesh rectopexy versus suture rectopexy

AIM:

The aim of our study is to compare the results of laparoscopic mesh vs. suture rectopexy.

MATERIALS AND METHODS:

In this retrospective study, 70 patients including both male and female of age ranging between 20 years and 65 years (mean 42.5 yrs) were subjected to laparoscopic rectopexy during the period between March 2007 and June 2012, of which 38 patients underwent laparoscopic mesh rectopexy and 32 patients laparoscopic suture rectopexy. These patients were followed up for a mean period of 12 months assessing first bowel movement, hospital stay, duration of surgery, faecal incontinence, constipation, recurrence and morbidity.

RESULTS:

Duration of surgery was 100.8 ± 12.4 minutes in laparoscopic suture rectopexy and 120 ± 10.8 min in laparoscopic mesh rectopexy. Postoperatively, the mean time for the first bowel movement was 38 hrs and 40 hrs, respectively, for suture and mesh rectopexy. Mean hospital stay was five (range: 4-7) days. There was no significant postoperative complication except for one port site infection in mesh rectopexy group. Patients who had varying degree of incontinence preoperatively showed improvement after surgery. Eleven out of 18 (61.1%) patients who underwent laparoscopic suture rectopexy as compared to nine of 19 (47.3%) patients who underwent laparoscopic mesh rectopexy improved as regards constipation after surgery.

CONCLUSION:

There were no significant difference in both groups who underwent surgery except for patients undergoing suture rectopexy had better symptomatic improvement of continence and constipation. Also, cost of mesh used in laparoscopic mesh rectopexy is absent in lap suture rectopexy group. To conclude that laparoscopic suture rectopexy is a safe and feasible procedure and have comparable results as regards operative time, morbidity, bowel function, cost and recurrence or even slightly better results than mesh rectopexy.

Rectal prolapse and intussusception

Rectal prolapse continues to be problematic for both patients and surgeons alike, in part because of increased recurrence rates despite several well-described operations. Patients should be aware that although the prolapse will resolve with operative therapy, functional results may continue to be problematic. This article describes the recommended evaluation, role of adjunctive testing, and outcomes associated with both perineal and abdominal approaches.

Resection rectopexy--laparoscopic neuromapping reveals neurogenic pathways to the lower segment of the rectum: preliminary results

PURPOSE

Nerve sparing in functional pelvic floor surgery is strongly recommended as intraoperative damage to the autonomic nerves may predispose to persistent or worsened anorectal and urogenital function. The aim of this study was to investigate the intraoperative neural topography above the pelvic floor in patients undergoing laparoscopic resection rectopexy in combination with electrophysiologic neuromapping.

METHODS

Ten consecutive female patients underwent laparoscopic resection rectopexy for rectal prolapse. Intraoperative identification of pelvic autonomic nerves was carried out with a novel intraoperative neuromonitoring system based on electric stimulation under simultaneous electromyography of the internal anal sphincter and manometry of the bladder. Neuromonitoring results were compared to patients' preoperative anorectal and urogenital function and their functional results at the 3-month follow-up.

RESULTS

Laparoscopy in combination with electrophysiologic neuromapping revealed neurogenic pathways to the lower segment of the rectum during surgical mobilization. In all procedures, intraoperative neuromonitoring finally confirmed functional nerve integrity to the internal anal sphincter and the bladder. Patients with preoperatively diagnosed fecal incontinence were continent at the 3-month follow-up. The Wexner score improved in median from preoperative 4 (range 1-18) to 1 (range 0-3) at follow-up (p = 0.012). Cleveland Clinical Constipation Score improved in median from 10 (range 5-17) to 3 (range 1-7; p = 0.005). In none of the investigated patients a new onset of urinary dysfunction did occur. No change in sexual function was observed.

CONCLUSIONS

Laparoscopy in combination with electrophysiologic neuromapping during nerve-sparing resection rectopexy identified and preserved neurogenic pathways heading to the lower segment of the rectum above the level of the pelvic floor.

Laparoscopic low ventral rectocolpopexy (LLVR) for rectal and rectogenital prolapse: surgical technique and functional results

BACKGROUND

Laparoscopic ventral rectopexy limits the risk of autonomic nerve damage, and the colpopexy allows correction of a concomitant prolapse of the middle compartment. The aim of this study is to describe a modified laparoscopic ventral rectocolpopexy procedure with a low approach to the sacral hollow (laparoscopic low ventral rectocolpopexy: LLVR). We propose this technique to manage combined rectogenital prolapse.

METHODS

Between November 2006 and June 2009, all patients with symptomatic rectal prolapse associated with genital prolapse and/or enterocele underwent LLVR. Demographics, results of imaging studies, mortality, morbidity, and functional outcome were retrospectively analyzed.

RESULTS

Thirty patients underwent LLVR: two patients suffered from a full-thickness rectal prolapse while 28 had symptomatic recto-anal intussusception. The mean operating time was 94 ± 39 minutes. Conversion to laparotomy was never needed. Hospital stay ranged between 2 and 14 days (mean of 5 ± 2.5 days). No mortality was recorded and only two complications occurred (6.6%): one trocar site incisional hernia and one vaginal suture erosion in a patient who had concomitant hysterectomy. After a mean follow-up of 13.9 months, constipation was completely resolved or improved in 92.8% patients. Significant reduction in the mean Altomare obstructed defecation score (14.7-5.6; p < 0.05) was recorded. Preoperative incontinence improved after the procedure in all patients affected. No new cases of postoperative constipation or fecal incontinence were registered. Only one case of recurrence in a patient with recto-anal intussusception was recorded (3.4%), after 19 months.

CONCLUSIONS

Laparoscopic low ventral rectocolpopexy is safe and associated with very low morbidity. In the medium term, it provides good result for prolapse and associated symptoms.

Laparoscopic anterior rectopexy to the promontory for full-thickness rectal prolapse in 175 consecutive patients: short- and long-term follow-up

BACKGROUND

There are multiple procedures to treat full-thickness rectal prolapse. No consensus exists as to the best surgical option. All procedures have a significant recurrence rate.

OBJECTIVE

The aim of this study was to report short- and long-term technical results following laparoscopic removal of the Douglas pouch peritoneum and anterior rectopexy in patients with total rectal prolapse.

DESIGN

This study is a prospective evaluation of consecutive patients.

SETTINGS

This investigation was conducted at a single academic colorectal unit.

PATIENTS

Between May 1996 and June 2009, 175 consecutive patients (17 males) with a mean age of 58 years (range, 16-94) were operated on.

INTERVENTION

The Douglas pouch peritoneum was excised, 2 synthetic meshes were fixated to the anterior part of the lower rectum with five 4-mm staples and to the promontory with 3 spiked chromium staples, and the peritoneum was closed over the meshes to isolate them from the abdominal cavity.

MAIN OUTCOME MEASURES

Patients were reviewed at months 1, 6, 12, and then annually. Mortality, morbidity, and recurrence were analyzed. Median follow-up was 74 months (range, 24-181). Recurrence rate was calculated according to the Kaplan-Meier method.

RESULTS

: There was no mortality. Morbidity (5.1%) consisted in temporary brachial plexus palsy in 2 cases, urinary infection in 3 cases, ureteral lesion in 1 patient having had a previous bone graft on the promontory for spondylolisthesis (JJ catheter), and perforation of the small bowel because of adhesions (laparoscopic suture) in 1 case. One patient presented with a rectal erosion at month 9 (transanal removal of the mesh). Two patients presented with a recurrence of the rectal prolapse at months 6 and 24 (recurrence rate of 3% at 5 years) that was treated with anal artificial sphincter in one and redo operation in the other.

CONCLUSION

Laparoscopic removal of the Douglas pouch peritoneum and rectopexy to the promontory is a safe and efficient procedure to treat full-thickness rectal prolapse.

Laparoscopic Suture Rectopexy: An Effective Treatment for Complete Rectal Prolapse

BACKGROUND

The study was undertaken to validate the efficacy of laparoscopic suture rectopexy as the treatment modality of choice for complete prolapse of rectum.

METHODS

Data was prospectively collected and analyzed on 36 patients who underwent laparoscopic suture rectopexy for full thickness rectal prolapse between May 2006 to May 2008. There were 10 male and 26 female patients in this study with a mean age of 43.5 years. The pre and postoperative course of each patient was followed up with attention paid to ano-rectal manometery pressures, first bowel movement, hospital stay, duration of surgery, faecal incontinence, constipation, recurrence and morbidity. Mean follow up period was 12 months (range 1-24 months).

RESULT

One patient had conversion from laparoscopic to open surgery. while another had recurrence of prolapse in the follow up period. Mean duration of surgery was 115 (range 100-150) minutes. Postoperatively, the mean time for the first bowel movement was 40 (range 24-64) hours. Mean hospital stay was five (range 4-7) days. There was no significant postoperative complication except for one port site infection and one pelvic collection. Of the 20 patients who had varying degree of incontinence preoperatively, 16 (80%) showed improvement after surgery. Constipation was present in 15 (41%) patients preoperatively. Nine of these 15 patients (60%) improved as regards constipation after surgery.

CONCLUSION

Laparoscopic suture rectopexy is both safe and effective operation for the management of complete prolapse rectum. The procedure carries minimal morbidity and helps improve the problems of incontinence and constipation.

Functional disorders of defecation: evaluation and treatment

Functional disorders of defecation are common and often overlap with slow-transit constipation. They are comprised of functional obstructive conditions such as dyssynergic defecation, as well as structural obstructive conditions such as rectal prolapse, excessive perineal descent, and rectocele. Evaluation includes detailed history and rectal and pelvic exam together with physiologic tests such as anorectal manometry, balloon expulsion test, defecography, and MRI. Treatment involves several medical, behavioral, and surgical approaches. Recently, randomized controlled trials have shown that biofeedback therapy is an effective treatment for dyssynergic defecation. Stapled transanal rectal resection appears to be a promising technique for treating defecation disorders associated with rectocele, excessive perineal descent, and mucosal intussusception, but controlled trials are lacking.

Rectal prolapse: review according to the personal experience

The aim of treatment of rectal prolapse is to control the prolapse, restore continence, and prevent constipation or impaired evacuation. Faced with a multitude of options, the choice of an optimal treatment is difficult. It is best tailored to patient and surgeon. Numerous procedures have been described and are generally categorized into perineal or abdominal approaches. In general, an abdominal procedure has associated with lower recurrence and better functional outcome than perineal procedures. The widespread success of laparoscopic surgery has led to the development of laparoscopic procedures in the treatment of complete rectal prolapse. In Korea, there has been a trend toward offering perineal procedures because of the high incidence of rectal prolapse in young males and its being a lesser procedure. Delorme-Thiersch procedure has appeal as a lesser procedure for patients of any age or risk category, especially for elderly low-risk patients, patients with constipation or evacuation difficulties, young males, and patients with symptomatic hemorrhoids or mucosal prolapse. Laparoscopic suture rectopexy is recommended for either low-risk female patients or patients who are concerned with postoperative aggravation of their incontinence.

Surgical treatment of rectal prolapse

Rectal prolapse is defined as a protrusion of the rectum beyond the anus. Although rectal prolapse was recognized as early as 1500 BC, the optimal surgical procedure is still debated. The varied operative procedures available for treating rectal prolapsed can be confusing. The aim of treatment is to control the prolapse, restore continence, and prevent constipation or impaired evacuation. In elderly and high-risk patients, perineal approaches, such as Delorme's operation and Altemeier's operation, have been preferred, although the incidence of recurrence and the rate of persistent incontinence seem to be high when compared with transabdominal procedures. Abdominal operations involve dissection and fixation of the rectum and may include a rectosigmoid resection. From the late twentieth century, the laparoscopic procedure has been applied to the treatment of rectal prolapse. Current laparoscopic surgical techniques include suture rectopexy, stapled rectopexy, posterior mesh rectopexy with artificial material, and resection of the sigmoid colon with colorectal anastomosis with or without rectopexy. The choice of surgery depends on the status of the patient and the surgeon's preference.

Laparoscopic ventral rectopexy for external rectal prolapse improves constipation and avoids de novo constipation

OBJECTIVE

Abdominal rectopexy is ideal for otherwise healthy patients with rectal prolapse because of low recurrence, yet after posterior rectopexy, half of the patients complain of severe constipation. Resection mitigates this dysfunction but risks a pelvic anastomosis. The novel nerve-sparing ventral rectopexy appears to avoid postero-lateral rectal dissection denervation and thus postoperative constipation. We aimed to evaluate our functional results with laparoscopic ventral rectopexy.

METHOD

Consecutive rectal prolapse patients undergoing laparoscopic ventral rectopexy were prospectively assessed (Wexner Constipation and Faecal Incontinence Severity Index scores) pre-, 3 months postoperatively, and late (> 12 months).

RESULTS

Sixty-five consecutive patients with external rectal prolapse (median age 72 years, 34% > 80 years, median follow up 19 months) underwent laparoscopic ventral rectopexy. There was one recurrence (2%) and one conversion. Morbidity (17%) and mortality (0%) were low. Median operating time was 140 min and median length of stay 2 days. At 3 months, constipation was improved in 72% and mildly induced in 2% (median pre-and postoperative Wexner scores 9 vs 4, P < 0.0001). Continence was improved in 83% and mild incontinence was induced or worsened in 5% (median pre- and postoperative incontinence score 40 vs 4, P < 0.0001). Significant improvement in both constipation and incontinence (P < 0.0001) remained at median 24 months late follow-up.

CONCLUSION

Ventral rectopexy has a recurrent prolapse rate of < 5%, similar to that of posterior rectopexy. Its correction of preoperative constipation and avoidance of de novo constipation appear superior to historical functional results of posterior rectopexy. A laparoscopic approach allows low morbidity and short hospital stay, even in those patients over 80 years of age in whom a perineal approach is usually preferred for safety.

Laparoscopic ventral rectopexy for internal rectal prolapse: short-term functional results

OBJECTIVE

Over the last 15 years, posterior rectopexy, which causes rectal autonomic denervation, was discredited for internal rectal prolapse because of poor results. The condition became medical, managed largely by biofeedback. We aimed to audit the short-term functional results of autonomic nerve-sparing laparoscopic ventral rectopexy (LVR) for internal rectal prolapse.

METHOD

Prospectively collected data on LVR for internal rectal prolapse were analysed. End-points were changes in bowel function (Wexner Constipation Score and Fecal Incontinence Severity Index) at 3 and 12 months. Analysis was performed using Mann-Whitney U-test for unpaired data and Wilcoxon signed rank test for paired data (two-sided p-test). Functional outcomes were compared with those achieved previously for external rectal prolapse (ERP).

RESULTS

Seventy-five patients underwent LVR (median age 58, range 25-88 years, median follow up was 12 months). Mortality (0%), major (0%) and minor morbidity (4%) were acceptably low. Median length of stay was 2 days. Preoperative constipation (median Wexner score 12) and faecal incontinence (median FISI score 28) improved significantly at 3 months (Wexner 4, FISI 8, both P < 0.0001) and 12 months (Wexner 5, FISI 8, both P < 0.0001). No patient had worse function. Functional outcomes were similar to those for ERP.

CONCLUSION

Laparoscopic ventral rectopexy for internal rectal prolapse improves symptoms of obstructed defaecation and faecal incontinence in the short-term. This establishes proof of concept for a nerve-sparing surgical treatment for internal rectal prolapse.

Complications and reinterventions after surgery for obstructed defecation

PURPOSE

Functional results following surgery for obstructed defecation (OD) have been widely investigated, but there are few reports aimed to analyze postoperative complications and re-interventions. This study investigates the adverse events requiring retreatment for obstructed defecation.

METHODS

We retrospectively analyzed the records of 203 patients operated on by a single surgeon, 20 transabdominally and 183 transperineally (159 manual and 24 stapled). Postoperative complications requiring retreatment and outcome of reinterventions were analyzed.

RESULTS

Adverse events requiring retreatment occurred in 14.3% more frequently after abdominal than after perineal procedures (20% vs. 13.7%), but the sample size of the two arms is different. Rectal bleeding and strictures were the most common adverse events (6.9%). Major complications, i.e., ischemic colitis requiring hemicolectomy and pelvic sepsis requiring colostomy also occurred (1%). The overall reintervention rate was 7.5%, (5% after abdominal and 7.6% after perineal surgery). Overall, 59% of the reoperated patients were still constipated at a median follow up of 2 years.

CONCLUSIONS

Complications requiring retreatment are not uncommon after surgery for OD and reinterventions are often unsuccessful. A careful preoperative evaluation and selection of patients should be undertaken in order to minimize adverse events.

A new technique for suture rectopexy without resection for rectal prolapse

BACKGROUND

We surmised that if rectopexy was performed without dissection of the lateral rectal stalks in patients with full-thickness rectal prolapse and normal preoperative transit, sigmoid resection may not be required. This study evaluated a new approach to abdominal suture rectopexy for rectal prolapse.

METHODS

A total of 81 patients (57 male, 24 female; median age 37 years, range 5-82 years) with rectal prolapse were assessed by clinical examination, anal manometry (maximum resting pressure, MRP, and squeeze pressure, MSP) and radioopaque marker transit studies. Of the 81 patients, 70 with normal preoperative transit underwent suture fixation alone, without resection, performed under spinal anaesthesia, through a 7-cm transverse left lower quadrant incision gaining access to the presacral space via a left pararectal "window", preserving the lateral stalks.

RESULTS

Average surgical time was 50 min, mortality was zero, and morbidity was 9% (three patients with wound infection, four with urinary retention). Anal incontinence improved in 43 of 53 patients (81%, p=0.001). MRP and MSP had improved at 3 months after surgery: MRP from a mean of 27.6+/-1.4 mmHg (range 2-30 mmHg) before surgery to 32.5+/-2.21 mmHg (2-60 mmHg) after surgery (p=0.008); MSP from 69.25+/-6.4 mmHg (8-153 mmHg) before surgery to 79+/-4.77 mmHg (35-157 mmHg) after surgery (p=0.001).. Transit was unchanged in 18 of 20 patients (90%) who were evaluated before and after surgery; none was constipated after surgery. At 56 months, prolapse had recurred in five patients (7%).

CONCLUSION

Abdominal suture rectopexy with a left pararectal approach without sigmoid resection in those with normal preoperative transit resulted in an improvement in anal incontinence and satisfactory long-term control of prolapse. The operation did not alter transit and did not result in significant constipation.

Long-term follow-up of simultaneous abdominoperineal repair of enterorectocele and internal mucosal prolapse

BACKGROUND

Enterorectocele with recto-rectal intussusception and internal mucosal prolapse (ER-RI-MP) may require surgery for obstructed defecation, but symptoms tend to recur if only one lesion is corrected. This prospective study was designed to investigate the results of an abdominoperineal procedure aimed at treating all these lesions in one stage.

METHODS

Thirteen women with constipation (median age, 58 years) and ER-RI-MP underwent Douglas pouch suture, mesh obliteration of the pelvic inlet with or without rectopexy, and omentoplasty plus rectocele and prolapse obliteration. Constipation was scored on a scale from 0 to 20. Proctoscopy, enterocolpodefecography, manometry, anal-vaginal-perineal ultrasound, and psychological evaluation were performed before and after surgery.

RESULTS

Bleeding requiring transfusion, pelvic hygroma, and ureteric stricture requiring adhesiolysis occurred in three patients. Constipation score significantly decreased from a mean (+/- standard error of the mean) of 16 +/- 0.6 before to 7 +/- 0.9 after surgery (P < 0.0001). Seven patients were considered cured, five improved, and one remained unchanged at a median follow-up of 42 months. Anorectal physiology and imaging returned to normal in seven patients. Four patients had successful rehabilitation and psychotherapy for anismus, rectal hyposensation, and depression.

CONCLUSIONS

Simultaneous abdominoperineal ER-RI-MP repair integrated with conservative treatment of associated dysfunctions achieved a satisfactory long-term outcome. The results need to be confirmed in larger series.

Prospective study of colonic irrigation for the treatment of defaecation disorders

BACKGROUND

Retrograde colonic irrigation is a possible treatment for defaecation disorders when conservative treatment or surgery has failed. The aim of this prospective study was to investigate its effectiveness.

METHODS

Patients were divided into three groups: those with faecal incontinence (A), constipation (B) or both (C). The Biotrol Irrimatic pump or the irrigation bag was used for colonic irrigation. Patients completed a questionnaire at baseline and after 3, 6 and 12 months, as well as a Short Form 36 health survey and an American Society of Colon and Rectal Surgery quality of life questionnaire at baseline and after 6 months.

RESULTS

The study included 39 patients (26 women; mean age 58.0 years). In group A, 11 of 18 patients were pseudocontinent for faeces at 3 months (P < 0.001). Parks' incontinence scores decreased for all patients in this group at 3 months (P < 0.001), 6 months (P = 0.036) and 1 year (P = 0.005). In group B, three of ten patients reported a major improvement. The mean score for the feeling of incomplete evacuation decreased at 3 months (P = 0.007), 6 months (P = 0.013) and 1 year (P = 0.036). In group C, six of ten patients became pseudocontinent for faeces (P = 0.009) and three reported improvement in constipation. The overall quality of life scores improved (P = 0.012).

CONCLUSION

Retrograde colonic irrigation is an undervalued but effective alternative treatment for intractable defaecation disorders.

Rectal prolapse, rectal intussusception, rectocele, solitary rectal ulcer syndrome, and enterocele

Rectal prolapse is best diagnosed by physical examination and by having the patient strain as if to defecate; a laparoscopic rectopexy is the preferred treatment approach. Intussusception is more an epiphenomena than a defecatory disorder and should be managed conservatively. Solitary rectal ulcer syndrome is a consequence of chronic straining and therapy should be aimed at restoring a normal bowel habit with behavioral approaches including biofeedback therapy. Rectocele correction may be considered if it can be definitively established that it is a cause of defecation disorder and only after conservative measures have failed. An enterocele should only be operated when pain and heaviness are predominant symptoms and it is refractory to conservative therapy.

Laparoscopic ventral recto(colpo)pexy for rectal prolapse: surgical technique and outcome for 109 patients

The authors propose a new laparoscopic technique for correction of rectal prolapse. The unique feature of this technique is that it avoids any posterolateral dissection of the rectum. The mesh is sutured to the anterior aspect of the rectum to inhibit intussusception. The technique was applied in 109 consecutive patients to correct total rectal prolapse. Conversion was needed for four patients. No postoperative mortality or major morbidity occurred. Minor morbidity was noted for 7% of the patients, and a recurrence rate of 3.66% was observed. Because this technique limited the dissection and the subsequent risk of autonomic nerve damage, a cure comparable with that resulting from classical mesh rectopexy can be anticipated.

Robot-assisted vs. conventional laparoscopic rectopexy for rectal prolapse: a comparative study on costs and time

PURPOSE

Laparoscopic rectopexy has become one of the most advocated treatments for full-thickness rectal prolapse, offering good functional results compared with open surgery and resulting in less postoperative pain and faster convalescence. However, laparoscopic rectopexy can be technically demanding. Once having mastered dexterity, with robotic assistance, laparoscopic rectopexy can be performed faster. Moreover, it shortens the learning curve in simple laparoscopic tasks. This may lead to faster and safer laparoscopic surgery. Robot-assisted rectopexy has been proven safe and feasible; however, until now, no study has been performed comparing costs and time consumption in conventional laparoscopic rectopexy vs. robot-assisted rectopexy.

METHODS

Our first 14 cases of robot-assisted laparoscopic rectopexy were reviewed and compared with 19 patients who underwent conventional laparoscopic rectopexy in the same period.

RESULTS

Robot-assisted laparoscopic rectopexy did not show more complications. However, the average operating time was 39 minutes longer, and costs were euro 557.29 (or: dollars 745.09) higher.

CONCLUSION

Robot-assisted laparoscopic rectopexy is a safe and feasible procedure but results in increased time and higher costs than conventional laparoscopy.

Clinical and functional outcome of laparoscopic posterior rectopexy (Wells) for full-thickness rectal prolapse. A prospective study

BACKGROUND

Laparoscopic rectopexy offers the advantages of the open transabdominal approach while decreasing the surgical comorbidity. The aim of this prospective study was to assess the clinical and functional outcome of laparoscopic Wells procedure for full-thickness rectal prolapse.

METHODS

Between 1999 and 2005, 77 patients underwent laparoscopic modified Wells procedure for full-thickness rectal prolapse. The patients were evaluated postoperatively for resolution of their prolapse and functional outcome, as well as for their satisfaction level regarding the procedure.

RESULTS

Laparoscopy was successful in all but one case. There were no major intra- or postoperative complications and the mean hospital stay was 4.9 days. Approximately half of the patients had some degree of fecal incontinence preoperatively. At long-term follow up, 89 percent experienced alleviation of symptoms. Constipation was improved in 36% of cases. Eighteen percent of the patients suffered a new onset of constipation. Recurrent prolapse was observed in one patient. Ninety percent of the patients were satisfied at long-term follow-up.

CONCLUSION

The laparoscopic Wells procedure for rectal prolapse had good functional results, a low recurrence rate and proved to be a feasible and safe procedure. Postoperative constipation remains a problem, which should be solved.

Rectal prolapse

INTRODUCTION

Rectal prolapse, or procidentia, is defined as a protrusion of the rectum beyond the anus. It commonly occurs at the extremes of age. Rectal prolapse frequently coexists with other pelvic floor disorders, and patients have symptoms associated with combined rectal and genital prolapse. Few patients, a lack of randomized trials and difficulties in the interpretation of studies of anorectal physiology have made the understanding of this disorder difficult.

METHODS OF TREATMENT

Surgical management is aimed at restoring physiology by correcting the prolapse and improving continence and constipation, whereas in patients with concurrent genital and rectal prolapse, an interdisciplinary surgical approach is required. Operation should be reserved for those patients in whom medical treatment has failed, and it may be expected to relieve symptoms. Numerous surgical procedures have been suggested to treat rectal prolapse. They are generally classified as abdominal or perineal according to the route of access. However, the controversy as to which operation is appropriate cannot be answered definitively, as the extent of a standardized diagnostic assessment and the types of surgical procedures have not been identified in published series.

LITERATURE REVIEW

This review encompasses rectal prolapse, including aetiology, symptoms and treatment. The English-language literature about rectal prolapse was identified using Medline, and additional cited works not detected in the initial search were obtained. Articles reporting on prospective and retrospective comparisons and case reports were included.

Laparoscopic rectal surgery: rectal cancer, pelvic pouch surgery, and rectal prolapse

With the increasing popularity of minimally invasive approaches to surgery, laparoscopic techniques are being applied increasingly to more complex procedures. Surgeons who are interested in gaining skill and confidence with the techniques of rectal mobilization and resection initially should consider attempting procedures for benign disease. Patients who have rectal prolapse, who often have wide, accommodating pelvic anatomy, are the logical choice with whom to begin the laparoscopic rectal experience. Laparoscopic restorative proctocolectomy is more technically challenging. Laparoscopic proctectomy for rectal cancer probably should remain in the hands of well-trained, high-volume, experienced surgeons who have built a dedicated team for treatment of these patients, and who track their outcomes prospectively.

Technical and functional results after laparoscopic rectopexy to the promontory for complete rectal prolapse. Prospective study in 54 consecutive patients

INTRODUCTION

Laparoscopic rectopexy for complete rectal prolapse offers short-term advantages compared with operations performed by laparotomy. The aim of this prospective study was to report technical and functional outcome after laparoscopic rectopexy to the promontory in consecutive patients operated on by a single surgeon.

PATIENTS AND METHODS

From May 1996 to July 2004, 54 consecutive patients (47 women), median age 53 years (range: 16-84 years), underwent laparoscopic rectopexy to the promontory for complete rectal prolapse. Preoperative evaluation included physical examination, dynamic videoproctography and, in patients with constipation, colonic transit time (with radiopaque markers). Postoperative evaluation included the same examinations and a simple global quality-of-life questionnaire.

RESULTS

Conversion to laparotomy was required for three patients during the learning curve. Median duration of operation was 157 minutes (range: 50-370). There was no mortality and morbidity was 5.5% (brachial plexus palsy in two patients and urinary tract infection in one). Median hospital stay was 3.5 days (range: 1-11). There were 4 recurrences (7.4%). Functional outcome at 12 months showed the presence of constipation in 20.3% of patients (persistence in eight and de novo in three) and the presence of outlet obstruction in 25.9% of patients (persistence in six and de novo in eight). Anal continence improved in 72.4% of the 29 patients who complained of this symptom. The global quality-of-life questionnaire showed a satisfactory result in 96% of patients.

CONCLUSION

Laparoscopic rectopexy to the promontory is a safe and efficient procedure to treat complete rectal prolapse; morbidity is low. Functional outcome is at least equivalent to that obtained with open procedures in terms of continence, constipation and outlet obstruction.

Surgery for rectal prolapse: Orr-Loygue ventral rectopexy with limited dissection prevents postoperative-induced constipation without increasing recurrence

PURPOSE

Abdominal rectopexy is the preferred surgical technique for the treatment of total rectal prolapse. In many reported series, its results are impaired by induced constipation. Lateral rectal ligaments preservation could prevent constipation but increase recurrence rates. We report anatomic and functional results of abdominal Orr-Loygue ventral rectopexy with dissection limited to anterior and posterior rectal wall.

METHODS

Consecutive patients with total rectal prolapse or intra-anal rectal prolapse associated to fecal incontinence or outlet obstruction were treated by abdominal rectopexy. Recurrences, correction of symptoms, and induced constipation were prospectively analyzed.

RESULTS

Seventy-three patients were treated between 1993 and 2004. Recurrence was observed in 3 of 73 patients (4.1 percent) after a mean follow-up period of 28.6 (range, 6-84) months. Overall patient satisfaction (correction of prolapse, incontinence, and/or outlet obstruction) after the procedure was classified in three categories: Cured: n = 45 (61.6 percent); Improved: n = 24 (32.9 percent); Failure: n = 4 (5.5 percent). Postoperative constipation appeared in 2 of 36 (5.5 percent) preoperatively nonconstipated patients and worsened in 2 of 37 (5.4 percent) preoperatively constipated patients.

CONCLUSIONS

Orr-Loygue abdominal ventral rectopexy with limited dissection and preservation of rectal lateral ligaments is a safe and effective procedure for the treatment of complete rectal prolapse, or internal prolapse associated with fecal incontinence or outlet obstruction. Preservation of lateral ligaments seems to prevent postoperative constipation without increasing the risk of prolapse recurrence.

Impact of functional results on quality of life after rectal cancer surgery

PURPOSE

Quality of life is an important outcome measure that has to be considered when deciding treatment strategy for rectal cancer. The aim of this study was to find out the impact of surgery-related adverse effects on quality of life.

METHODS

The RAND-36 questionnaire and questionnaires assessing urinary, sexual, and bowel dysfunction were administered to 94 patients with no sign of recurrence a minimum of one year after curative surgery. Results were compared with age-matched and gender-matched general population.

RESULTS

Eighty-two (87 percent) patients answered the questionnaires. Major bowel dysfunction was as common after high anterior resection as after low anterior resection. Urinary complaints occurred as often after anterior resection as after abdominoperineal resection, but sexual dysfunction was more common after abdominoperineal resection. Overall, the patients reported better general health perception but poorer social functioning than population controls. In particular, elderly patients reported a significantly better quality of life in many dimensions than their population controls. There was no significant difference in quality of life between treatment groups. Major bowel dysfunction after anterior resection impaired social functioning compared with that of patients without such symptoms. Urinary dysfunction impaired social functioning and impotence impaired physical and social functioning.

CONCLUSIONS

Quality of life after rectal cancer surgery is not worse than that of the general population. The major adverse impact of bowel and urogenital dysfunction is on social functioning. These adverse effects need to be discussed with the patient and preoperative function needs to be taken into account when choosing between treatment options. Permanent colostomy is not always the factor that disrupts a person's quality of life most.

Epidemiologic aspects of complete rectal prolapse

BACKGROUND AND AIMS

This study was undertaken to find out the incidence of rectal prolapse.

MATERIAL AND METHODS

Ninety-nine patients operated on for rectal prolapse at Jyväskylä Central Hospital were studied. Patients operated between 1988 and 1998 were studied retrospectively from hospital records using chart review and thirty-five patients operated on between 1999 and 2002 were studied prospectively using our proctologic database.

RESULTS

The annual incidence of diagnosed complete rectal prolapse in the district of Central Finland was mean 2.5 (range, 0.79-6.08) per 100 000 population. There were ten men (10 percent) and 89 women (90 percent). Median age of the patients was 69 (range, 21-91) years. Forty-eight percent of the patients had concomitant cardiovascular disease and 15 percent psychiatric illness. Anal incontinence affecting quality of life was seen in 64 percent and constipation in 72 percent of patients. Constipation tended to be more attributed to difficult evacuation (72 percent) than to impaired bowel action (18 percent).

CONCLUSION

The annual incidence of rectal prolapse is 2.5 per 100 000 population. Rectal prolapse is associated with anal incontinence and constipation in majority of patients.

Long-term outcome after laparoscopic and open surgery for rectal prolapse: a case-control study

BACKGROUND

Laparoscopic repair (LR) of rectal prolapse is potentially associated with earlier recovery and lower perioperative morbidity, as compared with open transabdominal repair (OR). Data on the long-term recurrence rate and functional outcome are limited.

METHODS

Perioperative data on rectal prolapse in relation to all LRs performed between December 1991 and April 2004 were prospectively collected. The LR patients were matched by age, gender, and procedure type with OR patients who underwent surgery during the same period. Patients with previous complex abdominal surgery or a body mass index exceeding 40 were excluded from the study. Data on recurrence rate, bowel habits, continence, and satisfaction scores were collected using a telephone survey.

RESULTS

A total of 111 patients (age, 56.8 +/- 18.1 years; female, 87%) underwent attempted LR. An operative complication deferred repair in two cases. Among the 111 patients, 42 had posterior mesh fixation, and 67 had sutured rectopexy (32 patients with sigmoid colectomy for constipation). Eight patients (7.2%) had conversion to laparotomy. Matching was established for 86 patients. The LR patients had a shorter hospital stay (mean, 3.9 vs 6.0 days; p < 0.0001). The 30-day reoperation and readmission rates were similar for the two groups. The rates for recurrence requiring surgery were 9.3% for LR and 4.7% for OR (p = 0.39) during a mean follow-up period of 59 months. An additional seven patients in each group reported possible recurrence by telephone. Postoperatively, 35% of the LR patients and 53% of the OR patients experienced constipation (p = 0.09). Constipation was improved in 74% of the LR patients and 54% of the OR patients, and worsened, respectively, in 3% and 17% (p = 0.037). The postoperative incontinence rates were 30% for LR and 33% for OR (p = 0.83). Continence was improved in 48% of the LR patients and 35% of the OR patients, and worsened, respectively, in 9% and 18% (p = 0.22). The mean satisfaction rates for surgery (on a scale of 0 to 10) were 7.3 for the LR patients and 8.1 for the OR patients (p = 0.17).

CONCLUSIONS

The hospital stay is shorter for LR than for OR. Both functional results and recurrent full-thickness rectal prolapse were similar for LR and OR during a mean follow-up period of 5 years.

Prospective study of the effect of rectopexy on colonic motility in patients with rectal prolapse

BACKGROUND

Patients with rectal prolapse have abnormal hindgut motility. This study examined the effect of rectal prolapse surgery on colonic motility.

METHODS

Twelve patients undergoing sutured rectopexy were studied before and 6 months after surgery by colonic manometry, colonic transit study and clinical assessment of bowel function. The results were compared with those from seven control subjects.

RESULTS

Before surgery colonic pressure was greater in patients than controls (P < 0.050). Controls responded to a meal stimulus by increasing colonic pressure; this increase was absent in patients. After rectopexy, colonic pressure reduced towards control values and patients' colonic pressure response to a meal returned. High-amplitude propagated contractions (HAPCs) were seen in all controls but in only three patients before and two patients after surgery. Three patients had prolonged colonic transit before and eight after rectopexy.

CONCLUSION

Patients with rectal prolapse have abnormal colonic motility associated with reduced HAPC activity. Rectopexy reduces colonic pressure but fails to restore HAPCs, reduce constipation or improve colonic transit. These observations help explain the pathophysiology of constipation associated with rectal prolapse.

External pelvic rectal suspension (the Express procedure) for full-thickness rectal prolapse: evolution of a new technique

OBJECTIVE

The Délorme's operation for rectal prolapse is a safe procedure but has a high recurrence rate. We aimed to develop an operation akin to it, but designed to reduce this deficit.

PATIENTS AND METHODS

Thirty-one consecutive patients with rectal prolapse were included in the study. Initially, a conventional Délorme's procedure was performed and sutures or strips of Gore-Tex were attached circumferentially to the apex of the prolapse, tunneled subcutaneously, and anchored to the external surface of the pelvis. Subsequently, the procedure was modified. Acellular porcine collagen strips were used and buried within the apex without plication of the denuded rectal musculature. Patients were formally assessed preoperatively and four months postoperatively by symptom and quality of life questionnaires and subsequently by regular clinical review.

RESULTS

In the Gore-Tex group (N = 11; males:females = 10:1; mean age, 61 years) three patients underwent suture repair and eight had strip fixation. All suture repairs developed sepsis and one patient had a recurrence. Seven of the strip fixations (88 percent) developed sepsis that resulted in implant extrusion. There was one full-thickness and one mucosal recurrence after a median follow-up of 25 months. In the collagen group (N = 20; males:females = 2:18; mean age, 63 years), sepsis occurred in four patients, requiring surgical intervention in one patient (5 percent) (cf Gore-Tex group, P = 0.002). There was one mucosal and three full-thickness (15 percent) recurrences after a median follow-up of 14 months (cf Gore-Tex group, P = not significant). Significant improvements in symptom and quality of life scores were recorded in both groups at four months.

CONCLUSION

A new, minimally invasive perineal procedure for rectal prolapse has been developed and initial data testify to its relative safety provided collagen is used. It remains to be seen whether long-term recurrence rates will be lower than those of conventional perineal procedures.

Long-term outcome of laparoscopic ventral rectopexy for total rectal prolapse

BACKGROUND

Postoperative constipation is a common problem with most mesh suspension techniques used to correct rectal prolapse. Autonomic denervation of the rectum subsequent to its complete mobilization has been suggested as a contributory factor. The aim of this study was to assess the long-term outcome of patients who underwent a novel, autonomic nerve-sparing, laparoscopic technique for rectal prolapse.

METHODS

Between 1995 and 1999, 42 patients had laparoscopic ventral rectopexy for total rectal prolapse. The long-term results after a median follow-up of 61 (range 29-98) months were analysed.

RESULTS

There were no major postoperative complications. Late recurrence occurred in two patients. In 28 of 31 patients with incontinence there was a significant improvement in continence. Symptoms of obstructed defaecation resolved in 16 of 19 patients. During follow-up, new onset of mild obstructed defaecation was noted in only two patients. Symptoms suggestive of slow-transit colonic obstipation were not induced.

CONCLUSION

Laparoscopic ventral rectopexy is an effective technique for the correction of rectal prolapse and appears to avoid severe postoperative constipation. The ventral position of the prosthesis may explain the beneficial effect on symptoms of obstructed defaecation.

Rectal prolapse: which surgical option is appropriate?

Numerous surgical procedures have been suggested to treat rectal prolapse. In elderly and high-risk patients, perineal approaches such as Delorme's procedure and perineal rectosigmoidectomy (Altemeier's procedure) have been preferred, although the incidence of recurrence and the rate of persistent incontinence seem to be high when compared with transabdominal procedures. Functional results of transabdominal procedures, including mesh or suture rectopexy and resection-rectopexy, are thought to be associated with low recurrence rates and improved continence. Transabdominal procedures, however, usually imply rectal mobilization and fixation, colonic resection, or both, and some concern is voiced that morbidity, in terms of infection or leakage, and mortality could be increased. If we focus on surgical outcome, our own experience of laparoscopic resection-rectopexy for rectal prolapse shows that the laparoscopic approach is safe and effective, and functional results with respect to recurrence are favorable. However, the controversy "which operation is appropriate?" cannot be answered definitely, as a clear definition of rectal prolapse, the extent of a standardized diagnostic assessment, and the type of surgical procedure have not been identified in published series. Randomized trials are needed to improve the evidence with which the optimal surgical treatment of rectal prolapse can be defined.

Surgical intervention for adult patients with rectal prolapse

This review describes the pathogenesis, diagnosis, preoperative testing, and surgical decision making involved in the management of full-thickness rectal protrusion in adults. Historic and current procedures are described in detail. No one procedure is favored over others, and selection depends on the individual characteristics of the patient.