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

Reduced port laparoscopic rectopexy for full-thickness rectal prolapse

BACKGROUND

Laparoscopic rectopexy is an established treatment option for full-thickness rectal prolapse. Recently, reduced port surgery (RPS) has emerged as a novel concept, offering reduced postoperative pain and improved cosmetic outcomes compared with conventional multiport surgery (MPS). This study aimed to evaluate the feasibility and safety of RPS for full-thickness rectal prolapse.

METHODS

From October 2012 to December 2018, 37 patients (MPS: 10 cases, RPS: 27 cases) underwent laparoscopic rectopexy for full-thickness rectal prolapse. Laparoscopic posterior mesh rectopexy (Wells procedure) is the standard technique for full-thickness rectal prolapse at our hospital. RPS was performed using a multi-channel access device, with an additional 12-mm right-hand port. Short-term outcomes were retrospectively compared between MPS and RPS.

RESULTS

No significant differences were observed between MPS and RPS in the median operative time, the median blood loss volume, the postoperative complication rates, and median hospital stay duration after surgery.

CONCLUSION

Reduced port laparoscopic posterior mesh rectopexy may serve as an effective therapeutic option for full-thickness rectal prolapse. However, to establish the superiority of RPS over MPS, a prospective, randomized, controlled trial is warranted.

Easy modified wells method for rectal prolapse with using bilayer mesh

BACKGROUND

In recent years, many laparoscopic procedures have been reported for the treatment of rectal prolapse, and the Wells method is safe and has relatively good results for rectal prolapse, which is common in the elderly. In this report, we have developed a simpler method to perform the Wells method.

METHODS

In our procedures, easy modified Wells method is performed laparoscopically, but the use of a bilayer mesh makes it easier to perform without the need to suture the retroperitoneum. We performed the method for six cases. All patients are female and average age is 86 ± 4.6. Max length of rectal prolapse is 3 cm-7 cm.

RESULTS

The median operative time was 191 ± 26 min. No recurrent rectal prolapse was encountered during follow-up period. The average defecation frequency per week before surgery was 5.3 ± 1.9 and after surgery was 3.7 ± 2.1.

CONCLUSION

Easy modified Wells method can be performed with safety and without difficulty. This method has shown acceptable results in recurrence rates and defecation frequency after surgery.

Improvement of Rectal Prolapse Using an Over-the-scope Clip System

Rectal prolapse is typically treated surgically, and internal therapy has not been reported. We encountered a case of rectal prolapse that improved with an over-the-scope clip (OTSC) system. An 81-year-old woman complaining of anorectal pain underwent colonoscopy, and rectal prolapse was observed prior to colonoscopy. Unfortunately, rectal perforation occurred while attempting endoscopic reversal. The OTSC system was used to close the rectal perforation and subsequently improved her rectal prolapse, probably because the rectal wall was anchored to the retroperitoneum. This is the first report to show that rectal prolapse can be endoscopically improved and that an OTSC system might be a viable alternative method for managing inoperable rectal prolapse.

Comparison of Safety and Efficacy between Laparoscopic Ventral Rectopexy and Delorme's Procedure for External Rectal Prolapse in Nonagenarians

Objectives

This study evaluates the safety and efficacy of laparoscopic ventral rectopexy (LVR) in nonagenarian patients with external rectal prolapse (ERP) compared to Delorme's procedure.

Methods

We conducted a retrospective analysis of prospectively collected data, including nonagenarian patients who underwent either LVR or Delorme's procedure, comparing outcomes such as morbidity, length of hospital stay (LOS), and recurrence rates.

Results

Between September 2009 and August 2023, 22 patients (median age 91, range 90-94 years) underwent LVR, while 12 patients (median age 91, range 90-96 years) received Delorme's procedure. Baseline characteristics, including sex ratio, parity, American Society of Anesthesiology grade, and Body Mass Index, did not significantly differ between the groups. LVR had a significantly longer operating time but lower blood loss than Delorme's procedure. Postoperative LOS was significantly shorter for LVR patients (median 1, range 1-3 days) compared to Delorme's procedure patients (median 2.5, range 1-13 days; P = 0.001). Notably, no significant morbidity occurred in the LVR group, while one case of delirium and another of solitary rectal ulcer syndrome were observed in the Delorme's procedure group. Recurrence rates were lower in the LVR group, with no recurrences during a median follow-up of 23 months (range 1-65 months), compared to one recurrence at 2 months during a median follow-up of 34 months (range 1-96 months) in the Delorme's procedure group.

Conclusions

LVR is a safe and effective surgical option for nonagenarian ERP patients, showing favorable outcomes in terms of morbidity, LOS, and recurrence rates compared to Delorme's procedure.

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.

Complications of Mesh Sacrocolpopexy and Rectopexy: Imaging Review

Sacrocolpopexy and rectopexy are commonly used surgical options for treatment of patients with pelvic organ and rectal prolapse, respectively. These procedures involve surgical fixation of the vaginal vault or the rectum to the sacral promontory with mesh material and can be performed independently of each other or in a combined fashion and by using an open abdominal approach or laparoscopy with or without robotic assistance. Radiologists can be particularly helpful in cases where patients' surgical histories are unclear by identifying normal sacrocolpopexy or rectopexy mesh material and any associated complications. Acute complications such as bleeding or urinary tract injury or stricture are generally evaluated with CT. More chronic complications such as mesh extrusion or exposure with or without fistulization to surrounding structures are generally evaluated with MRI. Other complications can have a variable time of onset after surgery. Patients with suspected bowel obstruction are generally evaluated with CT. Those with suspected infection, abscess formation, and discitis or osteomyelitis may be evaluated with MRI, although CT evaluation may be appropriate in certain scenarios. The authors review the sacrocolpopexy and rectopexy surgical techniques, discuss appropriate imaging protocols for evaluation of patients with suspected complications, and illustrate the normal appearance and common complications of these procedures. ^© RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Transanal rectopexy for external rectal prolapse

PURPOSE

The surgical management of patients with full-thickness rectal prolapse (FTRP) continues to remain a challenge in the laparoscopic era. This study retrospectively assesses a cohort of patients undergoing a transanal suture sacro rectopexy supported by sclerosant injection into the presacral space under ultrasound guidance.

METHODS

Patients with FTRP underwent a sutured transrectal presacral fixation of 2/3 of the circumference of the rectum from the third sacral vertebra to the sacrococcygeal junction through a side-viewing operating proctoscope. The procedure was supplemented by ultrasound-guided injection into the retrorectal space of a 2 mL solution of sodium tetradecyl sulfate/polidocanol mixed with air. Patients were functionally assessed before and 6 months after surgery with the Agachan constipation score and the Pescatori incontinence score.

RESULTS

There were 36 adult patients (26 males; the range of age, 23-92 years). The mean operative time was 27 minutes (range, 23-50 minutes) with no recorded perioperative morbidity. The median follow-up was 66 months (range, 48-84 months) with 1 (2.8%) recurrence presenting 18 months after surgery. There were 19 patients (52.8%) who presented with incontinence before surgery with 17 out of 19 (89.5%) reporting improvement in their Pescatori score (P<0.001). No patient had worsening incontinence and there were no de novo incontinence cases. Constipation scores improved in 23 out of 36 patients (63.9%) with a mean score reduction difference of 7.91 (P=0.001).

CONCLUSION

Transanal sutured sacral rectopexy with supplemental presacral sclerosant injection is safe and effective in the management of FTRP with sustained improvement in bowel function.

Effect of the Gant-Miwa-Thiersch Procedure for Rectal Prolapse on the Mesorectum

Rectal prolapse (RP) most commonly occurs among elderly women and is caused by vulnerable suspensory tissue in the pelvis. In Japan, the Gant-Miwa-Thiersch procedure (GMT) is recommended for elderly people with poor general health. We retrospectively analyzed clinical data from 12 patients who underwent GMT at our hospital from September 2005 to July 2021 and investigated the effect of GMT on the mesorectum using abdominal-pelvic computed tomography (CT) performed for other diseases. The median age of the cohort was 82 years, and 92% of the subjects were women. The median RP length was 5 cm, and the median follow-up period was 60 months. Recurrence was observed in 1 of 12 patients (8.0%). CT conducted before and more than 6 months after GMT revealed no abnormal findings in the mesorectum, whereas CT within 5 months after GMT revealed hyperdense fat in the mesorectum in all three patients (100%; P < 0.05). The RP recurrence rate after the GMT was low. The mechanism of the effect of GMT may involve not only a direct mucosal plicating effect but also adhesional rectosacral fixation due to the presence of inflammation extending to the mesorectum.

Mesh erosion into the rectum after laparoscopic posterior rectopexy: A case report

Introduction

Rectal prolapse typically presents in elderly women with protruding full-thickness rectum from the anus. Rectopexy using mesh is known to be a highly curative treatment for rectal prolapse, however, this procedure carries the risk of severe complication as mesh erosion.

Presentation of case

A 78-year-old woman who had undergone laparoscopic posterior rectopexy 4 years earlier visited the outpatient clinic with a complaint of bloody stool. A colonoscopy and computed tomography revealed that part of the mesh had migrated into the rectal lumen at 8 cm from the anal verge. Based on the above findings, a diagnosis of mesh erosion into the rectum was made. Complete removal of the mesh and tacker with rectal resection was performed. Before rectopexy, the patient had severe fecal incontinence, and her anal sphincter function was decreased, therefore, Permanent colostomy was indicated instead of anastomosis. In the resected specimen, the mesh was folded and placed in the mesenteric fat of the posterior wall of the rectum, with the corner of the edge of the mesh protruding into the inside lumen.

Discussion

Mesh erosion typically occurs when using mesh made of synthetic mesh and non-absorbable threads; it might induce chronic irritation and friction due to mesh shrinkage.

Conclusion

To prevent mesh erosion, it is important to pay attention to the mesh materials used and ensure secure fixation.

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Mesh erosion into rectum after Laparoscopic posterior rectopexy was reported.

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Complete removal of the mesh and tacker with rectal resection was needed.

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Colostomy was made because of existence of severe fecal incontinence, preoperatively.

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Paying attention to the Shrinkage and secure fixation of synthetic mesh.

The Minimal Important Difference of the Fecal Incontinence Quality of Life (FIQL) Questionnaire for Patients with Posterior Compartment Prolapse: A Prospective Cohort Study

Objectives:

The minimally important difference (MID) of the Fecal Incontinence Quality of Life (FIQL) scale has never been determined. Thus, in this study, we aimed to estimate the MID of the Japanese FIQL for patients with posterior compartment prolapse (PCP).

Methods:

For 3-months after surgery, we followed a prospective cohort of 136 patients with PCP combined with fecal incontinence (FI) who had undergone ventral rectopexy between 2012 and 2018. Usable data from 114 patients were analyzed. Patients have both completed the FIQL and the 36-Item Short Forum Health Survey (SF-36) before and after surgery. Distribution-based MID values were estimated at 1/2 SD and the standard error of measurement (SEM) for domain and total scores across time points. Changes in the domain scores anchored to changes in a SF-36 overall health assessment question were used to estimate anchor-based MID. To be interpreted as true change, the median, anchor-based MID values that were greater than the corresponding SEM were proposed as estimates of the MID for the FIQL.

Results:

Distribution-based MID of 1/2 SD for each domain and total score ranged between 0.3 and 0.4, whereas SEM ranges were between 0.2 and 0.3. The anchor-based approach resulted in the median MID estimates of 0.4 to 1.0. Final estimates of MID for each FIQL and total score were as follows: lifestyle (0.6-1.1), coping/behavior (0.8-1.4), depression/self-perception (0.4-0.8), embarrassment (1.0-1.6), and total score (0.7-1.1).

Conclusions:

The results provide a basis for clinically important differences in FIQL scores after surgery for patients with PCP and FI.

A Case of Robotic Posterior Rectopexy for Full-thickness Rectal Prolapse

We describe our experience with robotic posterior rectopexy for a patient with full-thickness rectal prolapse. To our knowledge, this is the first report of such a case in the literature. A 94-year-old woman presented with a history of gradually worsening rectal prolapse. On examination, we found that the rectum was completely prolapsed, and we observed a prolapsed intestinal tract. Surgery was indicated and robotic rectopexy was performed without intraoperative complications. The postoperative course was uneventful, and she was discharged 10 days after the operation. One year later, there were no signs of recurrence. Robotic surgery has become common in recent years. We used robotic surgery for rectopexy, including the suturing procedure. Suturing in robotic surgery is easier than that in laparoscopic surgery, and we demonstrated that robotic rectopexy could be safely and easily performed. The trial was registered in the UMIN clinical trial registry (number 000040378).

Clinical outcome of the Gant-Miwa-Thiersch procedure for colonic mucosal prolapse after intersphincteric resection-a single-center report from Japan

Introduction

Dysfunctions such as mucosal prolapse occur after intersphincteric resection (ISR) to treat lower rectal cancer, even when it is possible to preserve the anus.

Method

We analyzed the data of 12 patients with rectal or colonic prolapse who underwent the Gant-Miwa-Thiersch procedure between March 2017 and May 2021.

Result

There were no severe postoperative complications or recurrences.

Case presentation

A 75-year-old Japanese man initially underwent ISR and had mucosal prolapse nine months after his initial operation. We performed the Gant-Miwa-Thiersch procedure for colonic mucosal prolapse after ISR.

Surgical procedure

Our procedure is a perineal plication method of prolapsed colonic mucosa with nylon wiring (The Gant-Miwa procedure), using a 1-nylon wire encircled three times to straighten the anal canal, with a cord inserted above the internal sphincter muscle (Thiersch procedure).

Discussion

Mucosal plication is performed via the Gant-Mowa or Delorme procedure to reduce the risk of recurrence. However, mucosal plication can be performed many times. Our Thiersch procedure involves encircling and straightening the anal canal with a 1-nylon wire to fix the new internal anal sphincter. In conclusion, the Gant-Miwa-Thiersch procedure for rectal and colonic mucosal prolapse, especially after ISR, is a viable treatment option.

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Our procedure is The Gant-Miwa procedure, using a 1-nylon wire encircled three times (Thiersch procedure).

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Mucosal plication is performed via the Gant-Mowa or Delorme procedure to reduce the risk of recurrence.

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The Gant-Miwa-Thiersch procedure for rectal and colonic mucosal prolapse, especially after ISR, is a viable treatment option.

Meta-analysis on current status, efficacy, and safety of laparoscopic and robotic ventral mesh rectopexy for rectal prolapse treatment: can robotic surgery become the gold standard?

PURPOSE

Robotic-assisted surgery and robotic-assisted ventral mesh rectopexy are gaining attention in the treatment of rectal prolapse and increased positive findings are proposed. The objective of this meta-analysis was to investigate whether robotic-assisted ventral mesh rectopexy is comparable with the conventional laparoscopic approach surgery.

METHODS

Five major databases (PubMed, Sciencedirect, Web of Science, Embase, and Cochrane Library) were searched for eligible studies. Observational studies of the effect and safety of robotic-assisted and laparoscopic approaches on ventral mesh rectopexy were included. Odd ratios (OR) and weight mean difference (WMD) were used for dichotomous data and continuous data analysis. Clinical outcomes, functional outcomes, and cost-effectiveness data were extracted for meta-analysis.

RESULTS

Compared to the laparoscopic approach, a significant shorter length of hospital stay (LOS), lesser intraoperative blood loss, and lower post-operative complication rate of RVMR group were observed. However, operation time of RVMR was significant increased. The expense of RVMR was higher than LVMR; mean Wexner scores and fecal incontinence were lower in RVMR group while there were no statistical differences.

CONCLUSION

The result of the current analysis revealed that the robotic-assisted ventral mesh rectopexy is effective and feasible in the treatment of rectal prolapse. However, long-term follow-up and results are needed for the promotion of this approach. There is a long way for robotic-assisted surgery to become a gold standard in rectal surgery.

Surgical Techniques for Rectal Prolapse

Complete rectal prolapse or rectal procidentia is a debilitating disease that presents with fecal incontinence, constipation, and rectal discharge. Definitive surgical techniques described for this disease include perineal procedures such as mucosectomy and rectosigmoidectomy, and abdominal procedures such as rectopexy with or without mesh and concomitant resection. The debate over these techniques regarding the lowest recurrence and morbidity rates, and the best functional outcomes for constipation or incontinence, has been going on for decades. The heterogeneity of available studies does not allow us to draw firm conclusions. This article aims to review the surgical techniques for complete rectal prolapse based on the current evidence base regarding surgical and functional outcomes.

Laparoscopic Versus Open Rectopexy for Rectal Prolapse: A Randomized Controlled Trial

Introduction

Most of the patients with rectal prolapse complain of fecal incontinence followed by constipation. Surgery is the only definitive treatment option for rectal prolapse. There are two approaches: either transanal/perineal or transabdominal. The abdominal procedures can be done in the open laparotomy method or laparoscopically. Suture rectopexy is a very old and popular method of treating rectal prolapse. Nowadays, rectopexy by laparoscopic approach is considered the gold standard treatment for rectal prolapse. The study has been conducted to compare both the procedures and their outcomes in terms of conditions associated with rectal prolapse.

Methods

All consecutive patients with full-thickness rectal prolapse who had attended the surgery outpatient department were included in the study. The patients had undergone either open suture rectopexy or laparoscopic rectopexy after randomization. Assessment of postoperative pain, mean days of hospital stay, constipation, and incontinence score along with operative time, recurrence within six months of follow-up, and time to resume bowel activity were done. The patients were followed up for 18 months at regular intervals.

Results

A total of 58 patients were included in the study: 27 in the open group and 31 in the laparoscopic group. The operative time was 102 minutes versus 129 minutes (p=0.0001) in the open and laparoscopic groups, respectively. The laparoscopic group had an earlier resumption of bowel activity (3.1 days vs. 1.4 days [p=0.0001]); fewer days of hospital stay (6.8 days vs. 2.5 days [p=0.0001]), less postoperative pain (mean visual analogue scale score for pain on postoperative day one 4.0 versus 3.1 [p=0.0035] and on postoperative day two 3.8 versus 2.2 [p=0.0001]). There was no significant difference in postoperative constipation score and incontinence score between the two groups.

Conclusion

Laparoscopic rectopexy results in lesser postoperative pain, lesser hospital stay, and better patient satisfaction than open rectopexy.

Laparoscopic approach to recurrence following multiple surgeries for external rectal prolapse: a case report

Introduction

The optimal procedure for recurrent external rectal prolapse remains unclear, particularly in laparoscopic approach. In addition, pelvic organ prolapse (POP) is sometimes concomitant with rectal prolapse. We present a case who underwent laparoscopic procedure for the recurrence of full-thickness external rectal prolapse coexisting POP.

Case presentation

An 81-year-old parous female had a 10-cm full-thickness external rectal prolapse following the two operations: the first was perineal recto-sigmoidectomy and the second was laparoscopic posterior mesh rectopexy. Imaging study revealed that the recurrent rectal prolapse was concomitant with both cystocele and exposed vagina, what we call POP. We planned and successfully performed laparoscopic ventral mesh rectopexy (LVMR) with laparoscopic sacrocolpopexy (LSC) using self-cut meshes without any perioperative complication.

Conclusion

This is the first report of LVMR and LSC for recurrent rectal prolapse with POP following the perineal recto-sigmoidectomy and laparoscopic posterior mesh rectopexy. Even for recurrent rectal prolapse with POP, our experience suggests that LVMR and LSC could be utilized.