Laparoscopic rectopexy for rectal prolapse to reduce surgical-site infections and length of stay

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.

Outcome of a Modified Laparoscopic Suture Rectopexy for Rectal Prolapse with the Use of a Single or Double Suture: A Case Series of 15 Patients

BACKGROUND Surgery is considered to be a mainstay of therapy for full-thickness rectal prolapse (FTRP). Surgical procedures for FTRP have been described, but optimal treatment is still controversial. The aim of this report is to evaluate the safety and feasibility of a simplified laparoscopic suture rectopexy (LSR) in a case series of 15 patients who presented with FTRP and who had postoperative follow-up for six months. CASE REPORT Fifteen patients who underwent a modified LSR at our surgical unit from September 2010 were retrospectively evaluated. The mean age of the patients was 72.5±10.9 years. All 15 patients underwent general anesthesia, with rectal mobilization performed according to the plane of the total mesorectal excision. By lifting the mobilized and dissected rectum cranially to the promontorium, the optimal point for subsequent suture fixation of the rectum was marked. The seromuscular layer of the anterior right wall was then sutured to the presacral fascia using only one or two interrupted nonabsorbable polypropylene sutures. The mean operative time was 176.2±35.2 minutes, with minimal blood loss. No moderate or severe postoperative complications were observed, and there was no postoperative mortality. One patient (6.7%) developed recurrence of rectal prolapse one month following surgery. CONCLUSIONS The advantages of this LSR procedure for the management of patients with FTRP are its simplicity, safety, efficacy, and practicality and the potential for its use in patients who can tolerate general anesthesia.

[Robot assisted Frykman-Goldberg procedure. Case report]

BACKGROUND

Rectal prolapse is defined as the protrusion of the rectal wall through the anal canal; with a prevalence of less than 0.5%. The most frequent symptoms include pain, incomplete defecation sensation with blood and mucus, fecal incontinence and/or constipation. The surgical approach can be perineal or abdominal with the tendency for minimal invasion. Robot-assisted procedures are a novel option that offer technique advantages over open or laparoscopic approaches.

CASE REPORT

67 year-old female, who presented with rectal prolapse, posterior to an episode of constipation, that required manual reduction, associated with transanal hemorrhage during defecation and occasional fecal incontinence. A RMI defecography was performed that reported complete rectal and uterine prolapse, and cystocele. A robotic assisted Frykman-Goldberg procedure wass performed.

DISCUSSION

There are more than 100 surgical procedures for rectal prolapse treatment. We report the first robot assisted procedure in Mexico. Robotic assisted surgery has the same safety rate as laparoscopic surgery, with the advantages of better instrument mobility, no human hand tremor, better vision, and access to complicated and narrow areas.

CONCLUSION

Robotic surgery as the surgical treatment is a feasible, safe and effective option, there is no difference in recurrence and function compared with laparoscopy. It facilitates the technique, improves nerve preservation and bleeding. Further clinical, prospective and randomized studies to compare the different minimal invasive approaches, their functional and long term results for this pathology are needed.

Abdominal Approaches to Rectal Prolapse

Rectal prolapse is a debilitating condition with a complex etiology. Symptoms are most commonly prolapse of the rectum and pain with bowel movements or straining, with worsening fecal incontinence over time due to progressive stretching of the anal sphincters. Physical findings are fairly consistent from patient to patient-most notably diastasis of the levator ani muscles, deep pouch of Douglas, redundant sigmoid colon, a mobile mesorectum, and occasionally a solitary rectal ulcer. Evaluation includes a physical exam or imaging demonstrating the prolapse, and evaluating for other causes of pelvic floor dysfunction. Multiple surgical repairs are available, but treatment must be individualized based on patient symptoms and the presence or absence of constipation or other pelvic floor disorders. Mesh repairs have shown promising results, but carry the added risks of mesh erosion, infection, and mesh migration. The optimal repair has not been clearly demonstrated at this time.

Laparoscopic surgery for rectal prolapse and pelvic floor disorders

Pelvic floor disorders are different dysfunctions of gynaecological, urinary or anorectal organs, which can present as incontinence, outlet-obstruction and organ prolapse or as a combination of these symptoms. Pelvic floor disorders affect a substantial amount of people, predominantly women. Transabdominal procedures play a major role in the treatment of these disorders. With the development of new techniques established open procedures are now increasingly performed laparoscopically. Operation techniques consist of various rectopexies with suture, staples or meshes eventually combined with sigmoid resection. The different approaches need to be measured by their operative and functional outcome and their recurrence rates. Although these operations are performed frequently a comparison and evaluation of the different methods is difficult, as most of the used outcome measures in the available studies have not been standardised and data from randomised studies comparing these outcome measures directly are lacking. Therefore evidence based guidelines do not exist. Currently the laparoscopic approach with ventral mesh rectopexy or resection rectopexy is the two most commonly used techniques. Observational and retrospective studies show good functional results, a low rate of complications and a low recurrence rate. As high quality evidence is missing, an individualized approach is recommend for every patient considering age, individual health status and the underlying morphological and functional disorders.

Modified laparoscopic anterior resection of the rectum for rectal prolapse in elderly patients

AIM: To assess the clinical effects, feasibility and safety of modified laparoscopic anterior resection of the rectum for rectal prolapse in elderly patients.

METHODS: The clinical data for 20 elderly patients suffering from rectal prolapse who underwent modified laparoscopic anterior resection of the rectum (laparoscopic group) and 20 elderly patients who underwent modified anterior resection of the rectum (open group) from 2005 to 2013 were collected. Comparative analysis of the two surgical groups was done.

RESULTS: Surgery was successful in all of the 40 cases. The mean length of the resected specimen was 21.7 cm ± 2.2 cm vs 22.3 cm ± 2.1 cm and showed no significant difference between the two groups. Mean intraoperative blood loss (118.0 mL ± 40.8 mL vs 156.0 mL ± 33.5 mL), time to recovery of intestinal function (2.3 d ± 0.9 d vs 3.9 d ± 0.7 d), mean duration of postoperative hospital stay (6.3 d ± 1.1 d vs 9.9 d ± 1.7 d) and mean operational time (146.0 min ± 22.3 min vs 115.0 min ± 16.5 min) differed significantly between the two groups. There was also a significant difference between the two groups in the rate of complications (15% vs 45%). All the cases were followed for 36.0 mo ± 11.3 mo and the recurrence rate was 10.0% vs 5.0%, showing no significant difference between the two groups.

CONCLUSION: Modified laparoscopic anterior resection of the rectum for rectal prolapse in elderly patients is safe, effective, and satisfactory, with low recurrence rate and minimal invasiveness. Laparoscopic procedure should be considered first for rectal prolapse in elderly patients.

Chronic severe constipation: current pathophysiological aspects, new diagnostic approaches, and therapeutic options

Chronic constipation is a considerable problem because it significantly affects the quality of a patient's life. Constipation can be diagnosed at every age and is more frequent in women and among the elderly. In epidemiological studies, its incidence is estimated at 2-27% in the general population. Chronic constipation may be primary or secondary. However, primary constipation (functional or idiopathic) can be classified into normal transit constipation, slow transit constipation, and pelvic outlet obstruction. In this review we make an attempt to present the current pathophysiological aspects and new therapeutic options for chronic idiopathic constipation, particularly highlighting the value of patient assessment for accurate diagnosis of the cause of the problem, thus helping in the choice of appropriate treatment.

Short-term outcome of laparoscopic versus robotic ventral mesh rectopexy for full-thickness rectal prolapse. Is robotic superior?

PURPOSE

Short term morbidity, functional outcome, recurrence and quality of life outcomes after robotic assisted ventral mesh rectopexy (RVMR) and laparoscopic ventral mesh rectopexy (LVMR) were compared.

METHODS

This study includes 51 consecutive patients having operations for external rectal prolapse (ERP) in a tertiary centre between October 2009 and December 2012. Of these, 17 patients had RVMR and 34 underwent LVMR. The groups were matched for age, gender, body mass index (BMI), and American Society of Anesthesiologists (ASA) grades. The same operative technique and mesh was used and follow up was 12 months. Data was collected on patient demographics, surgery duration, blood loss, duration of hospital stay and operative complications. Functional outcomes were measured using the faecal incontinence severity index (FISI) and Wexner faecal incontinence scoring. Quality of life was scored using SF36 questionnaires pre and postoperatively.

RESULTS

All patients were female except three (median 59, range 25-89). There was one laparoscopic converted to open procedure. RVMR procedures were longer in duration (p = 0.013) but with no difference in blood loss between the groups. The average duration of stay was 2 days in both groups. There were six minor postoperative complications in LVMR procedures and none in the RVMR group. Pre and postoperative Wexner and FISI scoring were significantly lower in the RVMR group (p = 0.042 and p = 0.024, respectively). SF-36 questionnaires showed better scoring in physical and emotional component in RVMR group (p = 0.015). There was no recurrence in either group during follow-up.

CONCLUSIONS

Both LVMR and RVMR are similar in terms of safety and efficacy. Although not randomized, this data may suggest a better functional outcome and quality of life in patients having RVMR for ERP.

Robot-assisted or conventional laparoscoic rectopexy for rectal prolapse? Systematic review and meta-analysis

AIM

The use of robotic technology has proved to be safe and effective, arising as a helpful alternative to standard laparoscopy in a variety of surgical procedures. However the role of robotic assistance in laparoscopic rectopexy is still not demonstrated.

METHODS

A systematic review of the literature was carried out performing an unrestricted search in MEDLINE, EMBASE, the Cochrane Library, and Google Scholar up to 30th June 2014. Reference lists of retrieved articles and review articles were manually searched for other relevant studies. We meta-analyzed the data currently available regarding the incidence of recurrence rate of rectal prolapse, conversion rate, operative time, intra-operative blood loss, post-operative complications, re-operation rate and hospital stay in robot-assisted rectopexy (RC) compared to conventional laparoscopic rectopexy (LR).

RESULTS

Six studies were included resulting in 340 patients. The meta-analysis showed that the RR does not influence the recurrence rate of rectal prolapse, the conversion rate and the re-operation rate, whereas it decreases the intra-operative blood loss, the post-operative complications and the hospital stay. Yet, the RR resulted to be longer than the LR. Post-operative ano-rectal and the sexual functionality and procedural costs could not meta-analyzed because the data from included studies about these issues were heterogeneous and incomplete.

CONCLUSION

The meta-analysis showed that the RR may ensure limited improvements in post-operative outcomes if compared to the LR. However, RCTs are needed to compare RR to LR in terms of short-term and long-term outcomes, specially investigating the functional outcomes that may confirm the cost-effectiveness of the robotic assisted rectopexy.

Laparoscopic resection rectopexy versus laparoscopic ventral rectopexy for complete rectal prolapse

BACKGROUND

Laparoscopic resection rectopexy (LRR) and laparoscopic ventral rectopexy (LVR) are favored for the treatment for rectal prolapse (RP) in the USA and Europe, respectively. This study aims to compare these two surgical techniques.

METHODS

All patients who underwent LRR because of RP between January 2000 and January 2012 at Cleveland Clinic Florida (Weston, FL, USA) were identified, and all relevant characteristics were entered in a database. This same analysis was also conducted for all patients who underwent LVR in the Meander Medical Center (Amersfoort, the Netherlands) between January 2004 and January 2012. These two cohorts were retrospectively compared with regard to complications, functional results and recurrence.

RESULTS

Twenty-eight patients (all female, mean age 50.1 years) were included in the LRR cohort at a mean follow-up of 57 (range 2-140; standard deviation (SD) ± 41.2) months. The LVR group consisted of 40 patients (36 females and 4 males) with a mean age of 67.0 years and a mean follow-up of 42 (range 2-82; SD ± 23.8) months. A significant reduction in constipation was observed in both cohorts after surgery: 57 versus 21% after LRR and 55 versus 23% after LVR (both P < 0.05). The incidence of incontinence also significantly decreased in both groups: 15% after LVR (55% before surgery) and 4% after LRR (61 % before surgery). Direct comparison of these two techniques showed a trend to significance (P = 0.09). Significantly, more complications occurred after LRR (n = 9: 1 major, 8 minor) then after LVR (n = 3: 2 major, 1 minor) (P < 0.05).

CONCLUSIONS

Both LVR and LRR are effective for the treatment for RP. Although both techniques offer significant improvements in functional symptoms, continence may be better after LRR. However, LRR also had a higher complication rate then did LVR.