Laparoscopic rectopexy

Laparoscopically-assisted resection rectopexy for rectal prolapse: ten years' experience

PURPOSE

This study has been undertaken to audit a single-center experience with laparoscopically-assisted resection rectopexy for full-thickness rectal prolapse. The clinical outcomes and long-term results were evaluated.

METHODS

The data were prospectively collected for the duration of the operation, time to passage of flatus postoperatively, hospital stay, morbidity, and mortality. For follow-up, patients received a questionnaire or were contacted. The data were divided into quartiles over the study period, and the differences in operating time and length of hospital stay were tested using the Kruskal-Wallis test.

RESULTS

Between March 1992 and October 2003, a total of 117 patients underwent laparoscopic resection rectopexy for rectal prolapse. The median operating time during the first quartile (representing the early experience) was 180 minutes compared with 110 minutes for the fourth quartile (Kruskal-Wallis test for operating time = 35.523, 3 df, P < 0.0001). Overall morbidity was 9 percent (ten patients), with one death (<1 percent). One patient had a ureteric injury requiring conversion. One minor anastomotic leak occurred, necessitating laparoscopic evacuation of a pelvic abscess. Altogether, 77 patients were available for follow-up. The median follow-up was 62 months. Eighty percent of the patients reported alleviation of their symptoms after the operation. Sixty-nine percent of the constipated patients experienced an improvement in bowel frequency. No patient had new or worsening symptoms of constipation after surgery. Two (2.5 percent) patients had full-thickness rectal prolapse recurrence. Mucosal prolapse recurred in 14 (18 percent) patients. Anastomotic dilation was performed for stricture in five (4 percent) patients.

CONCLUSIONS

Laparoscopically-assisted resection rectopexy for rectal prolapse provides a favorable functional outcome and low recurrence rate. Shorter operating time is achieved with experience. The minimally invasive technique benefits should be considered when offering rectal prolapse patients a transabdominal approach for repair, and emphasis should now be on advanced training in the laparoscopic approach.

Randomized clinical trial of laparoscopic versus open abdominal rectopexy for rectal prolapse

BACKGROUND

The objectives of this study were to compare both subjective clinical outcomes and the objective stress response of laparoscopic and open abdominal rectopexy in patients with full-thickness rectal prolapse. Abdominal rectopexy for patients with rectal prolapse is well suited for a laparoscopic approach as no resection or anastomosis is necessary.

METHODS

Forty patients with a full-thickness rectal prolapse were randomized before operation to a laparoscopic group and an open group. They agreed to conform to a clinical pathway (CP) of liquid diet (CP1) and full mobility (CP2) on day 1, solid diet (CP3) on day 2 and discharge (CP4) before day 5. Their compliance was monitored by an assessor blinded to the operative group, who also rated pain and mobility. Patient-controlled morphine use was documented. Neuroendocrine and immune stress response and respiratory function were measured.

RESULTS

Some 75 per cent of all clinical pathway objectives of early recovery were achieved in the laparoscopic group compared with 37 per cent in the open group (P < 0.01). Significant differences in favour of laparoscopy were noted with regard to narcotic requirements, and pain and mobility scores. Differences in objective measures of stress response favouring laparoscopy were found for urinary catecholamines, interleukin 6, serum cortisol and C-reactive protein. No differences were noted in respiratory function but significant respiratory morbidity was greater in the open group (P < 0.05). None of the measured outcomes, subjective or objective, favoured the open group apart from operating time, which was significantly shorter (153 versus 102 min; P < 0.01).

CONCLUSION

This study has demonstrated significant subjective and objective differences in favour of a laparoscopic technique for abdominal rectopexy. The advantages were all short term but no evidence of any adverse effect on longer-term outcomes was observed.

Laparoscopic surgery for rectal prolapse and outlet obstruction

PURPOSE

The aim of this study was to assess the outcome of both laparoscopic suture rectopexy and resection-rectopexy in the treatment of complete and incomplete rectal prolapse, outlet obstruction, or both.

METHODS

Data from surgery were collected prospectively. Semiannual follow-up was performed by assessment of recurrence, continence, and constipation using patients' history, physical examination, continence score, and anorectal manometry. Statistical analysis was performed by chi-squared test and Student's t-test (P < 0.05 was accepted as statistically significant).

RESULTS

Between September 1992 and February 1997, 72 patients (68 females) with a mean age of 62 (range, 23-88) years were treated laparoscopically. Indications for surgery were rectal prolapse in 21 patients, rectal prolapse combined with outlet obstruction in 36 patients, and outlet obstruction alone in 15 patients. Standard procedure was a laparoscopic suture rectopexy. A sigmoid resection was added in 40 patients. Mean duration of surgery was 227 (range, 125-360) minutes for rectopexy and 258 (range, 150-380) minutes for resection-rectopexy. Conversion was necessary in 1.4 percent (n = 1). Overall complication rate was 9.7 percent (n = 7) and mortality rate was 0 percent. Mean postoperative hospitalization was 15 (range, 6-47) days. All patients with a minimal follow-up of two years (n = 53) could be enrolled in a prospective follow-up study (mean follow-up, 30 months). No recurrence of rectal prolapse had to be recognized. Sixty-four percent of patients with incontinence before surgery were continent or had improved continence. In patients experiencing constipation preoperatively, constipation was improved or completely removed in 76 percent. No additional symptoms of constipation occurred after surgery.

CONCLUSION

Laparoscopic procedures in the treatment of pelvic floor disorders, e.g., rectal prolapse or outlet obstruction, lead to acceptable functional results. However, follow-up has to be extended and long-term results of recurrence, continence, and constipation have to be evaluated.

Laparoscopic-assisted resection-rectopexy for rectal prolapse: early and medium follow-up

PURPOSE

Objectives of this study were to describe the technique of laparoscopic-assisted resection rectopexy and audit the clinical outcomes, including review of functional results.

METHODS

Data were prospectively collected for duration of operation, time to passage of flatus and feces postoperatively, hospital stay, morbidity, and mortality. Follow-up was performed by an independent assessor using a standardized questionnaire. Patients were also assessed by clinical review or telephone interview.

RESULTS

During a four-year period, 34 patients underwent laparoscopic repair for rectal prolapse, of which 30 patients underwent laparoscopic-assisted resection rectopexy. Median duration of the operations was 185 minutes, median time for passage of flatus was two days postoperatively, and median length of hospital stay was five days. Morbidity was 13 percent and mortality rate was 3 percent. Comparison between the first ten patients who underwent laparoscopic-assisted resection rectopexy and the last ten revealed a significant reduction in both median duration of operating time (224 vs. 163 minutes; P < 0.005) and length of stay (6 vs. 4 days; P < 0.015). Follow-up study conducted at a median time of 18 months revealed that most patients (92 percent) felt that the operation had improved their symptoms, that incontinence was improved in 14 of 20 patients with impaired continence (70 percent), and that constipation was improved in 64 percent. Symptoms of incomplete emptying and the need to strain at stool were both improved in 62 and 59 percent of patients, respectively. No full-thickness recurrences have occurred, but two patients have had mucosal prolapse detected (7 percent) and treated.

CONCLUSION

Laparoscopic-assisted resection rectopexy is feasible and safe, with acceptable recurrence rates and functional results compared with the open procedure in the surgical literature. There is rapid return of intestinal function associated with an early discharge from hospital.

Functional problems in adult rectal prolapse and controversies in surgical treatment

BACKGROUND

Rectal prolapse is a condition that has fascinated surgeons for a long time. To date, no single ideal surgical treatment has been identified. The aetiology of rectal prolapse remains highly controversial, but it is recognized that associated functional problems, such as incontinence and constipation, are common. The pathophysiology, and controversies surrounding continence and constipation, remain topics of debate.

METHOD

All relevant papers derived from Medline and manual searching on rectal prolapse and associated functional problems were reviewed.

RESULTS AND CONCLUSION

The surgical management of rectal prolapse has evolved from historical encirclement procedures to current minimally invasive ones. Successful management must include adequate attention to the associated functional problems in order to eradicate the basic abnormality.

Laparoscopic rectopexy using mesh fixation with a spiked chromium staple

Abdominal rectopexy for patients with rectal prolapse is well suited for performance laparoscopically because no resection or anastomosis is necessary, with potential benefits being a decrease in postoperative pain, better cosmesis, and an earlier return to normal activity.

PURPOSE

Objectives of this study were to determine the feasibility of laparoscopic abdominal rectopexy using a solitary spiked chromium staple to fix the mesh to the sacrum and to compare initial results with consecutive previous abdominal rectopexies (historical control study).

METHODS

Duration of operation (anesthetic plus surgery), the day a solid diet was first tolerated, day of discharge, and patient morphine requirements in the first 48 hours were documented prospectively for the laparoscopic group and retrospectively from medical records for an open abdominal rectopexy group.

RESULTS

Laparoscopic rectopexy group had lower morphine requirements when using patient-controlled analgesia (mean, 38.2 vs. 100.6 mg; P < 0.02), an earlier tolerance of solid diet (mean, 2.7 vs. 5.8 days; P < 0.001), and an earlier discharge from the hospital (mean, 6.3 vs. 11.0 days; P < 0.01). Operating time was longer for the laparoscopic group (mean, 198 vs. 130 minutes; P < 0.001).

CONCLUSIONS

Laparoscopic rectopexy is feasible, may have benefits in reducing postoperative pain, and may aid earlier return to normal diet and activity. Given the inherent bias of a historical control study, a randomized controlled study has commenced to confirm these results.