Nonresectional and Resectional Rectopexy

Donato F. Altomare

Pierpaolo Sileri

INTRODUCTION

Full-thickness rectal prolapse (FTRP) is a disabling condition, well known since ancient times, which, unlike hemorrhoids, can affect also four-footed mammalians. Its etiology is poorly understood and, consequently, its appropriate surgical treatment is one of the most controversial issues in colorectal surgery, with many options having been proposed. Prolapse recurrence and the functional considerations of constipation and fecal incontinence (FI) are concerns in the management of these patients.

PREOPERATIVE PLANNING

Preoperative planning, including the choice of a perineal or an abdominal approach (robotic, laparoscopic, hand-assisted or open techniques), with the use or not of a mesh (biologic or unresorbable), should be individualized on the basis of history and both physical and functional evaluation. Considerations include general status of health, body mass index, and American Society of Anesthesiology grade.

Elderly frail patients are often selected for a perineal approach, possibly under spinal anesthesia. The addition of a sigmoid resection may be indicated in the patient with constipation or dolichocolon. A nonabsorbable mesh is discouraged if an anastomosis is planned because of the high risk of septic complication. Although a biologic absorbable mesh should lower this risk, this theory has never been clearly demonstrated.

FI is reported to improve in some patients with intact anal sphincters following abdominal rectopexy, particularly when it is caused by the inhibition of the anal resting tone by the prolapse itself. Anorectal manovolumetry and transanal ultrasound may be of great help in the evaluation of patients with incontinence to help select the most appropriate treatment.

Some patients with prolapse also complain of obstructed defecation and/or of perineal descent, which can be evaluated by a dynamic videoproctography. The occurrence of an associated enterocele and/or rectocele could discourage a perineal approach and suggest an abdominal approach combined with repair of the middle and posterior pelvic compartments.

Finally, the association of rectal prolapse with genital prolapse or cystocele should be an indication for a combined operation with the help of a urogynecologist.

SURGERY

General Considerations and Prescriptions

Surgery for FTRP can be performed by open surgery through either a midline or Pfannenstiel incision, by laparoscopy, hand-assisted surgery, or a robotic approach.

The operation is performed following a mechanical cathartic and oral antibiotic bowel preparation. A general anesthetic with perioperative parenteral antibiotic prophylaxis and urinary catheterization are employed.

Irrespective of the surgical approach, a partial (anterolateral) or full mobilization of the rectum following the mesorectal plane is the first surgical step. This surgical maneuver must respect the pelvic innervation to help prevent the sexual problems of impotence and retrograde ejaculation and to minimize the new onset or exacerbation of FI and constipation. The use of radiofrequency or ultrasound devices instead of diathermy has facilitated this step. The depth of rectal mobilization has
been an issue of debate among colorectal surgeons because the division of the lateral ligaments of the low rectum has been blamed to cause de novo constipation. Therefore, the lateral ligaments are spared in most of the modern techniques of rectal mobilization for prolapse.

The pelvic brim must be exposed to allow safe suturing of the mesh to the sacral periosteum with nonabsorbable sutures, avoiding the presacral vein and artery and preventing any damage to the hypogastric nerves during the rectal mobilization. This step of the rectopexy can be made easier and faster by the use of self-retaining titanium pins (ProTack 5-mm Instrument by Covidien-Medtronic, Minneapolis, MN).

An issue of debate is the economic impact of the laparoscopic approach, which is today preferred over the open approach. Despite the use of disposable devices and the longer operating time, a randomized controlled trial has demonstrated that the laparoscopic approach is more advantageous than the open because of a significantly shorter hospitalization. Conversely, the robotic approach has proved to be more expensive compared with laparoscopy, even if the better ergonomic instrument performance can facilitate suturing the mesh.

Main Surgical Options in the Treatment of Full-Thickness Rectal Prolapse by Abdominal Approach

Rectal Mobilization Without Rectopexy

Adhesions inevitably follow any surgical dissection in the pelvis, and may provide passive fixation of the mesorectum to the sacrum. The need for suturing or placement of a mesh to treat rectal prolapse has been questioned since 2001.

In this operation, the rectum is fully mobilized from the sacrum following the “holy plane” of the technique for anterior resection of the rectum for cancer. The rectum is not sutured to the sacrum and is left inside the pelvis after accurate hemostasis. The peritoneum is usually closed with absorbable continuous sutures and the placement of a pelvic drainage is not always necessary.

RESULTS A study from Nelson in 2001 reported three recurrences in 13 patients after 3 years’ follow-up, whereas no recurrences were reported in another study of 32 patients who underwent rectal mobilization without rectopexy after a long-term follow-up. This issue was recently clarified by a prospective randomized controlled multicenter trial on 252 patients operated for full-thickness external rectal prolapse, showing that the 5-year recurrence rates in the no-rectopexy group was significantly higher than those in the rectopexy group (8.6% vs. 1.5%) (log-rank, P = 0.003).

Suture Rectopexy

Direct suture rectopexy without the use of mesh is a further surgical option to be considered when the risk of infection of the mesh is increased, for example, in case of an inadvertent intraoperative rectal perforation or concomitant sigmoid resection with anastomosis.

TECHNIQUE The surgical technique of full circumferential mobilization of the rectum from the sacrum down to the levator muscles does not differ from other techniques for rectopexy, but in this case the posterior wall of the mesorectum is sutured without tension to the sacral promontory using four to six nonabsorbable sutures.

RESULTS One of the few studies on a large series of patients with suture rectopexy with long-term follow-up shows that the recurrence rate increased to 20% after 10 years. Nevertheless, the patient’s quality of life and fecal continence improved significantly without significant exacerbation of constipation.

Ripstein Procedure

First described by Ripstein and Lanter, it is no longer one of the most commonly used techniques in the United States. They started using a fascia lata sling to fix the rectum to the sacrum, but later other mesh materials like Teflon, Marlex mesh, and Gore-Tex were used.

TECHNIQUE The rectum is fully mobilized down to the tip of the coccyx, and the dissection goes posteriorly to free the rectum from the sacrum. The upper portions of the lateral ligaments are divided. Anterior mobilization is done by continuing the two lateral incisions to meet anteriorly in the deepest part of the cul-de-sac. A 5-cm rectangular mesh is placed around the rectum 5 cm below
the sacral promontory, and secured to the presacral fascia by nonabsorbable sutures 1 cm from the midline on both sides.

Care should be taken to avoid injury to the presacral blood vessels. It is also important to apply traction on the rectum to bring the redundant rectum cephalad, because redundant rectum below the mesh can cause recurrence. The sling should allow passage of two fingers between the rectum and the presacral fascia to prevent constipation or fecal impaction.

RESULTS The largest series by Ripstein was on 289 patients, in which the authors reported 0% recurrence, 0.3% mortality because of pulmonary embolism, and 3% need for further rectosigmoid resection. The largest pooled data (1,111 patients) were collected by Gordon and Hoexter through a questionnaire to the members of the American Society of Cataract and Refractive Surgery, reporting a 2.3% recurrence rate, 16.5% of sling-related complications, and an overall re-intervention of 4.1%. In a review on the Ripstein procedures by Madiba and Wexner, a recurrence rate 0-13% and a mortality rate 0-3% are reported.

Only gold members can continue reading. Log In or Register to continue