Laparoscopic treatment of rectal prolapse: experience gained in a prospective multicenter study

Outcomes for men undergoing rectal prolapse surgery - a systematic review

AIM

Rectal prolapse is considered rare in men but the prevalence can be high in certain populations. It is unclear which surgical approach offers lower recurrence rates and better functional outcomes in men. The aim of this work was to determine the recurrence rates, complications and functional outcomes after prolapse surgery in men.

METHOD

The MEDLINE, EMBASE and Scopus databases were systematically searched to identify studies on outcomes following surgical management of full-thickness rectal prolapse in men (over 18 years of age) published between 1951 and September 2022. Outcomes of interest included recurrence rate after surgery, bowel function, urinary function, sexual function and postoperative complications.

RESULTS

Twenty-eight studies involving 1751 men were included. Two papers focused exclusively on men. Twelve studies employed a mixture of abdominal approaches, ten employed perineal approaches and six compared both. The recurrence rate varied across studies, ranging from 0% to 34%. Sexual and urinary function were poorly reported, but the incidence of dysfunction appears low.

CONCLUSION

The outcomes of rectal prolapse surgery in men are poorly studied with small sample sizes and variable outcomes reported. There is insufficient evidence to recommend a specific repair approach based on the recurrence rate and functional outcomes. Further studies are required to identify the optimal surgical approach for rectal prolapse in men.

European Society of Coloproctology guidance on the use of mesh in the pelvis in colorectal surgery

This is a comprehensive and rigorous review of currently available data on the use of mesh in the pelvis in colorectal surgery. This guideline outlines the limitations of available data and the challenges of interpretation, followed by best possible recommendations.

Anatomo-functional outcomes of the laparoscopic Frykman-Goldberg procedure for rectal prolapse in a tertiary referral centre

Rectal prolapse is a common disorder that represents a burden for patients due to the associated symptoms that may include both incontinence and constipation. Currently, a huge variation in techniques exist. The aim of this study was to evaluate the anatomo-functional results of the laparoscopic Frykman-Goldberg procedure (LFGP) for the treatment of both internal (IRP) and complete rectal prolapse (CRP). Between July 2004 and October 2019, 45 patients with IRP and CRP underwent a LFGP. The Cleveland Clinic Constipation Score (CCCS), Obstructed Defecation Syndrome Score (ODSS) and Vaizey Score (VS) were assessed preoperatively, 3 months before the procedure, 12 months after the procedures and at the final follow-up visit. The patients' mean age was 51.4 ± 17.9 (15-93) years, and the mean follow-up was 9.24 ± 4.57 (1.6-16.3) years. The VS, CCCS and ODSS significantly improved (p = 0.008; p < 0.001; p < 0.001) from median preoperative values of 3, 20 and 18 to 2, 6 and 5, respectively. Furthermore, the improvements in scores during follow-up remained constant and significant over time when considering the two groups separately (time effect for ODSS p < 0.001, for VS p = 0.026, for CCCS p < 0.001) and when the patients were divided by age (< 40, 41-60 and > 60; p < 0.001). The overall complication rate was 8.9% (4/45), and no intraoperative complications or anastomotic leakage occurred. Conversion to the open approach was not necessary in any case. The overall success rate was 97.7%, and only one recurrence in the IRP group occurred after 14 months. LRGP can be considered a safe, effective and long-lasting procedure in young patients with IRP or CRP, a history of ODS and a redundant sigmoid colon.

Surgical Treatment of Rectal Prolapse in the Laparoscopic Era; A Review of the Literature

Rectal prolapse is associated with debilitating symptoms including the discomfort of prolapsing tissue, mucus discharge, hemorrhage, and defecation disorders of fecal incontinence, constipation, or both. The aim of treatment is to eliminate the prolapse, correct associated bowel function and prevent new onset of bowel dysfunction. Historically, abdominal procedures have been indicated for young fit patients, whereas perineal approaches have been preferred in older frail patients with significant comorbidity. Recently, the laparoscopic procedures with their advantages of less pain, early recovery, and lower morbidity have emerged as an effective tool for the treatment of rectal prolapse. This article aimed to review the current evidence base for laparoscopic procedures and perineal procedures, and to compare the results of various techniques. As a result, laparoscopic procedures showed a relatively low recurrence rate than the perineal procedures with comparable complication rates. Laparoscopic resection rectopexy and laparoscopic ventral mesh rectopexy had a small advantage in the improvement of constipation or the prevention of new-onset constipation compared with other laparoscopic procedures. However, the optimal surgical repair has not been clearly demonstrated because of the significant heterogeneity of available studies. An individualized approach is recommended for every patient, considering age, comorbidity, and the underlying anatomical and functional disorders.

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.

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.

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.

Laparoscopy for pelvic floor disorders

Surgical treatment of pelvic floor disorders has significantly evolved during the last decade, with increasing understanding of anatomy, pathophysiology and the minimally-invasive 'revolution' of laparoscopic surgery. Laparoscopic pelvic floor repair requires a thorough knowledge of pelvic floor anatomy and its supportive components before repair of defective anatomy is possible. Several surgical procedures have been introduced and applied to treat rectal prolapse syndromes. Transabdominal procedures include a variety of rectopexies with the use of sutures or prosthesis and with or without resection of redundant sigmoid colon. Unfortunately there is lack of one generally accepted standard treatment technique. This article will focus on recent advances in the management of pelvic floor disorders affecting defecation, with a brief overview of contemporary concepts in pelvic floor anatomy and different laparoscopic treatment options.

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

BACKGROUND

Rectal prolapse is commonly seen in patients with significant co-morbidities. Multiple approaches have been described, including the use of laparoscopy. The purpose of this study was to determine if laparoscopic approaches for repair of rectal prolapse are associated with less short-term morbidity than open approaches.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent laparoscopic or open rectopexy (R) or sigmoid resection and rectopexy (SR + R) between 2005 and 2008. Co-morbidities analyzed included diabetes, body mass index, chronic obstructive pulmonary disease, hypertension, cardiac (history of congestive heart failure, myocardial infarction, peripheral vascular disease, previous percutaneous cardiac intervention or surgery), and neurologic disorder (history of transient ischemic attack or cerebrovascular accident). Postoperative complications analyzed included surgical-site infections (SSIs), pneumonia, reintubation, pulmonary embolus, stroke, myocardial infarction, and sepsis. The χ (2) or t test/ANOVA were used to assess significance for categoric and continuous variables, respectively. Logistic regression analysis was used to determine risk factors for morbidity after rectal prolapse repair.

RESULTS

Altogether, 685 patients underwent surgical treatment of rectal prolapse. Most patients underwent open SR + R (open: 247 SR + R, 193 R; laparoscopic: 161 SR + R, 84 R). All patients had similar co-morbidity profiles. Patients undergoing laparoscopic R were significantly older (mean age 61.4 years) than those in the other three groups (p = 0.04). Operating time ranged from 128 min (open R) to 185 min (laparoscopic SR + R; p < 0.001). Open SR + R and open R were associated with significantly more morbidity than laparoscopic SR + R and R [odds ratio (OR) 0.42, 95 % confidence interval (CI) 0.22-0.83, p = 0.01]. Comparing all four procedures, there was a trend to decreased overall morbidity with laparoscopic R, but without statistical significance (OR 0.31, 95 % CI 0.07-1.40, p = 0.13). Length of hospital stay (LOS) and SSI rates were significantly lower with laparoscopic R than with the other three procedures.

CONCLUSIONS

Patients who undergo laparoscopic rectopexy have a shorter LOS and lower SSI rate than patients who undergo other abdominal procedures for repair of rectal prolapse. Further study is necessary to determine the long-term outcomes from laparoscopic rectopexy, but in high-risk patients the laparoscopic approach can decrease perioperative risk.

Focus on abdominal rectopexy for full-thickness rectal prolapse: meta-analysis of literature

BACKGROUND

Laparoscopic rectopexy to treat full-thickness rectal prolapse has proven short-term benefits, but there are few long-term follow-up and functional outcome data available. Using meta-analysis techniques, this study was designed to evaluate long-term results of open and laparoscopic abdominal procedures to treat full-thickness rectal prolapse in adults.

METHODS

A literature review was performed using the National Library of Medicine's PubMed database. All articles on abdominal rectopexy patients with a follow-up longer than 16 months were considered. The primary end point was recurrence of rectal prolapse, and the secondary end points were improvement in incontinence and constipation. A random effect model was used to aggregate the studies reporting these outcomes, and heterogeneity was assessed.

RESULTS

Eight comparative studies, consisting of a total of 467 patients (275 open and 192 laparoscopic), were included. Analysis of the data suggested that there is no significant difference in recurrence, incontinence and constipation improvement between laparoscopic abdominal rectopexy and open abdominal rectopexy. Considering non-comparative trials, the event rate for recurrence was similar in open and laparoscopic suture rectopexy studies and in open and laparoscopic mesh rectopexy trials. Improvement in constipation after the intervention was not statistically significant except for open mesh repair; postoperative improvement in incontinence was statistically significant after laparoscopic procedures and open mesh rectopexy.

CONCLUSIONS

Laparoscopic abdominal rectopexy is a safe and feasible procedure, which may compare equally with the open technique with regard to recurrence, incontinence and constipation. However, large-scale randomized trials, with comparative, strong methodology, are still needed to identify outcome measures accurately.

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.

Abdominal resection rectopexy with an absorbable polyglactin mesh: prospective evaluation of morphological and functional changes with consecutive improvement of patient's symptoms

BACKGROUND

The pathophysiology of rectal prolapse and intussusception has not yet been clarified. This is reflected in the multiplicity of surgical procedures. The aim of this prospective study was to measure morphological and functional changes of the pelvic floor and the rectum before and after resection rectopexy.

METHODS

A total of 21 patients (mean age 60 years; 2 men, 19 women) with manifest rectal prolapse and rectoanal intussusception underwent sigmoidectomy and rectopexy with an absorbable polyglactin mesh graft. The following analyses were performed preoperatively and, on average, 15 months (range 6-21 month) postoperatively: radiologic defecography, rectal volumetry, sphincter manometry, and evaluation of clinical symptoms.

RESULTS

Postoperatively there was no patient with rectal prolapse, and only one with an intussusception. Rectal compliance increased from 6.4 to 10.2 ml/mmHg. Rectal volumetry showed a decrease of the thresholds for the sensation of "desire to defecate" and "maximal tolerated volume" (100-75 ml, 175-150 ml). Postoperatively, there was a higher level of the pelvic floor during contraction. The anorectal angle, vector volume, radial asymmetry, sphincter length, and resting and squeezing pressures were unchanged. Surgery improved rectal evacuation (p = 0.03), continence (p = 0.01), stool consistency (p = 0.03), and warning period (p = 0.01). Patients' personal assessment showed an improved overall satisfaction.

CONCLUSIONS

Resection rectopexy is a reliable method for treating rectal prolapse and rectoanal intussusception with clear improvement of the patient's clinical symptoms. The restored anorectal function can be attributed to improved rectal compliance, a lower sensory threshold, an elevation of the pelvic floor during squeezing, and an improved rectal evacuation.

Recurrence and functional results after open versus conventional laparoscopic versus robot-assisted laparoscopic rectopexy for rectal prolapse: a case-control study

PURPOSE

This study was designed to evaluate recurrence and functional outcome of three surgical techniques for rectopexy: open (OR), laparoscopic (LR), and robot-assisted (RR). A case-control study was performed to study recurrence after the three operative techniques used for rectal procidentia. The secondary aim of this study was to examine the differences in functional results between the three techniques.

MATERIALS AND METHODS

All consecutive patients who underwent a rectopexy between January 2000 and September 2006 enrolled in this study. Peri-operative data were collected from patient records and functional outcome was assessed by telephonic questionnaire.

RESULTS

Eighty-two patients (71 females, mean age 56.4 years) underwent a rectopexy for rectal procidentia. Nine patients (11%) had a recurrence; one (2%) after OR, four (27%) after LR, and four (20%) after RR. RR showed significantly higher recurrence rates when controlled for age and follow-up time compared to OR, (p = 0.027), while LR showed near-significant higher rates (p = 0.059). Functional results improved in all three operation types, without a difference between them.

CONCLUSIONS

LR and RR are adequate procedures but have a higher risk of recurrence. A RCT is needed assessing the definitive role of (robotic assistance in) laparoscopic surgery in rectopexy.

"Fast-track" rehabilitation after colonic surgery in elderly patients--is it feasible?

BACKGROUND AND AIMS

The aim of the "fast-track" rehabilitation after elective colonic surgery is to lower the extent of general complications. Elderly patients may especially profit from this multi-modal peri-operative treatment including enforced early mobilisation and oral nutrition.

MATERIALS AND METHODS

In this prospective study using a well-defined post-operative multi-modal treatment programme, we examined the feasibility of this so-called fast-track rehabilitation in elderly patients. The programme employed combined thoracic peri-dural analgesia, early enforced mobilisation and rapid oral nutrition.

RESULTS

Seventy-four consecutive patients older than 70 years with benign or malignant disease of the large intestine were operated on. All patients were treated peri-operatively using the "fast-track" rehabilitation programme. Of the patients, 84% were able to have liquids orally on the day of surgery and 86% had solid food on the 1st post-operative day. The median time until the first bowel movement was 2 days. Only 12 (16%) patients had a total of 16 local complications, including 2 (3%) patients with anastomotic leakages. Nine patients (12%) had a total of 14 general complications; mortality rate was 1% (n=1). Patients were discharged from the hospital 5 (5th-95th percentile=4-6 days) days after surgery.

CONCLUSION

Using the "fast-track" rehabilitation programme on elderly patient is not only feasible but may also lower the number of general complications and the duration of the hospital stay.

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.

Surgical management of rectal prolapse

This article reviews the pathogenesis, clinical presentation and surgical management of rectal prolapse. Full-thickness prolapse of the rectum causes significant discomfort because of the sensation of the prolapse itself, the mucus that it secretes, and because it tends to stretch the anal sphincters and cause incontinence. Treatment of rectal prolapse is primarily surgical. Perineal surgical repairs are well tolerated, but are generally associated with higher recurrence rates. Abdominal repairs involve fixing the rectum to the sacrum by using either mesh or sutures, and tend to have the lowest recurrence rates. If significant preoperative constipation is present, a sigmoid resection can be performed at the time of rectopexy. For many patients, diarrhea and incontinence improve after surgery. Laparoscopic repair of rectal prolapse has similar morbidity and recurrence rates to open surgery, with attendant benefits of reduced length of hospital stay, postoperative pain and wound complications.

Laparoscopic Rectopexy without Resection: A Worthwhile Treatment for Rectal Prolapse in Patients without Prior Constipation

Anterior resection with rectopexy is considered by many to be the best operation for rectal prolapse. It is feared that if sigmoid redundancy created by rectal mobilization is not resected, colonic motility (specifically constipation) could be disabling. We contend that resection is not necessary in patients without preexisting constipation. We tested this hypothesis using a laparoscopic approach to minimize hospital stay. Twelve patients were treated (eight women); mean age was 45 years (range, 25–82 years). No patient had preexisting constipation; one had irritable bowel syndrome. Three patients had prior prolapse operations. Full rectal mobilization was undertaken down to the levator hiatus; neither the mesenteric vessels nor the lateral ligaments were divided. Rectopexy to the presacral fascia was done with one to two Nurolon sutures on either side of the rectum. There were no complications; mean hospital stay was 4 days. Mean follow up was 32 months (range; 3–75 months); there have been no recurrences. Only the patient with irritable bowel syndrome developed significant constipation. We conclude: 1) rectopexy can be safely done laparoscopically, 2) resection is not required in the absence of prior constipation, and 3) rectal mobilization and rectopexy does not predispose to future constipation in these selected patients.

Laparoscopic rectal prolapse surgery combined with short hospital stay is safe in elderly and debilitated patients

BACKGROUND

We report the results of patients treated from January 2000 to June 2004 for full-thickness rectal prolapse with trans-abdominal surgery in Helsinki.

METHODS

Sixty-five of 75 patients were treated laparoscopically, with a 6% conversion rate. Ten patients were operated on openly. Half of the patients were scored as American Society for Anesthesiologists III or IV.

RESULTS

The operation time was similar in the laparoscopic and the open rectopexy procedures (p = 0.15), whereas laparoscopic resection rectopexy was more time-consuming compared to the open procedure (p = 0.007). Intraoperative bleeding during laparoscopic surgery was minimal in comparison to open surgery (p = 0.006). Patients treated laparoscopically had a shorter median hospital stay than those treated with an open procedure (rectopexy, 3 and 7 days, respectively; resection rectopexy, 4 and 7.5 days, respectively) (p < 0.00001). There was no mortality and minor morbidity. During follow-up, there were two prolapse recurrences. All surgical techniques improved fecal continence considerably. Eighty-four percent of rectopexy patients and 92% of resection rectopexy patients considered the surgical outcome to be excellent or good.

CONCLUSIONS

Both rectopexy and resection rectopexy cure prolapse with good results and can be performed safely in older and debilitated patients. The laparoscopic approach enables a shortened hospital stay and is well tolerated in elderly patients.

Laparoscopic suture rectopexy in the treatment of persisting rectal prolapse in children

BACKGROUND

The repair of choice for persistent rectal prolapse (PRP) in children is disputed. Laparoscopic suture rectopexy (LSRP) is effective in adults, but its usefulness in pediatric PRP is unknown. We compared LSRP with posterosagittal rectopexy (PSRP).

METHODS

Sixteen children, with a median age of 6.5 years (range, 0.8-16.8) and duration of symptoms of 2.8 years (range, 0.5-10.2), underwent surgery for PRP. Eight (1991-2000) had PSRP, and eight (2002-2005) had LSRP. Three patients with LSRP were healthy; the others had mental retardation and epilepsy (n = 1), cerebral palsy (n = 1), Aspeger's syndrome (n = 1), meningomyelocele (n = 1), and bladder extrophy (n = 1). Preoperative cologram (n = 6), sigmoideoscopy (n = 3), and anorectal manometry (n = 2) were normal in patients with LSRP. In LSRP, the rectum was mobilized and sutured to the sacral periosteum.

RESULTS

Median operation time for LSRP was 80 min (range, 62-90) and for PSRP 40 min (range, 25-70) (p < 0.05); median hospital time was 6 days (range, 3-8) for LSRP and 6 days (range, 3-9) for PSRP (not significant). Six patients with LSRP had a median follow-up of 13 months (range, 4-24). None have had recurrences, and two patients (33%) require laxatives. Of the patients with PSRP, two (25%) had recurrence and underwent abdominal rectopexy with sigmoid resection.

CONCLUSION

Medium-term results indicate that LSPR is effective in pediatric PRP. Constipation is the only postoperative problem in a significant proportion of patients.

["Fast-track" colonic surgery-first experience with a clinical procedure for accelerating postoperative recovery]

OBJECT

The aim of multimodal perioperative treatment concepts is to lower the extent of general complications after elective colonic resection and "traditional" perioperative therapy and to allow hospital discharge only a few days following the operation.

MATERIALS AND METHODS

In this prospective study, we examined a new perioperative treatment plan for accelerating postoperative recovery and evaluated the results. This so-called "fast-track" program employs combined thoracal peridural analgesia, forced mobilization, and rapid renourishment within the clinic.

RESULTS

Sixty-four consecutive patients with benign or malignant disease of the large intestine aged an average of 66 years (range 54-71) were operated on. Thirty received conventional resection and 34 were operated on laparoscopically and treated perioperatively using the fast-track program. The hospital diet was given in all cases on the 1st postoperative day, and the first bowel movement occurred on the 2nd day (range 2-3). The patients could be released on the 4th postresection day (range 4-5). General and local postoperative complications were observed in five patients each (8%), including two cases of anastomotic insufficiency.

CONCLUSION

In colonic surgery, the "fast-track" method accelerated convalescence, lowered the number of general complications, and reduced the duration of hospital stay. Therefore, evaluation of "fast-track" concepts is warranted in other types of elective abdominal surgery.

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.

The Impact of Minimally Invasive Surgical Techniques

The use of minimally invasive techniques (MIT) in patient care is well documented in ancient history; however, it was not until the 1990s that advancements in technology enabled surgeons to realize the true potential of this approach. The minimally invasive approach has revolutionized surgical care, significantly reducing postoperative pain, recovery time, and hospital stays with marked improvements in cosmetic outcome and overall cost-effectiveness. It is now used around the world and in all major fields of surgery, compelling changes in training programs in order to assure quality control and patient safety. The bond between surgeons practicing minimally invasive surgery (MIS) and the high-tech industry is of utmost importance to future developments. Surgical robotic systems represent the most technologically advanced product of this collaboration, and their potential application in MIS shows much promise. As technology advances, additional developments in MIT are likely.