Chapter 6



Laparoscopic rectopexy for complete rectal prolaps




Q.A.J. Eijsbouts, M.A. Cuesta, R.J.F. Felt-Bersma



“Laparoscopic Surgery” McGraw-Hill International, editor J. Cueto

(in press)



Introduction

Complete rectal prolaps is defined as the protrusion of all layers of the rectal wall through the anal sphincter complex. About 75% of patients with rectal prolapse suffer from anal incontinence [1, 2]. The standard treatment for complete rectal prolapse consists of either transabdominal or perineal surgery. With regard to this, more than 50 different operative procedures have been described. Until recently, abdominal rectopexy has been advocated as the treatment of choice for complete rectal prolapse. Recurrence rates are low (0-8%) [2, 3] and continence improves in the majority of patients (50- 88%) [1, 4, 5]. As most patients are elderly and not always fit enough to undergo an abdominal procedure, various perineal approaches are preferred. They have recurrence rates varying from 0 to 21 %, depending on the type and the extent of the operation [6-9]. A possible alternative is laparoscopic rectopexy, which has been performed in our department since 1991 [10]. This method, being the laparoscopic counterpart of the abdominal Ripstein procedure, aims to combine the good functional outcome of abdominal procedures with the low postoperative morbidity of minimally invasive surgery. Laparoscopic rectopexy has been proven technically feasible [10-12]. However, postoperative results including manometric and/or endosonographic findings have not been published until now.


The purpose of this study was to evaluate the clinical outcome of laparoscopic rectopexy and to determine whether clinical improvements are associated with changes in manometric and endosonographic findings.


Materials and methods

Between June 1991 and September 1997, 28 consecutive patients (25 women) referred to our clinic with complete rectal prolapse were treated by laparoscopic rectopexy according to a modified sling repair procedure. The median age of the patients was 73 years (range 57-86 years). A detailed history, physical examination (inspection, digital examination and proctoscopy), manometry and endosonography were performed preoperatively and three months postoperatively. Seventeen patients had normal bowel habits and eleven had constipation. Twenty-one had different grades of fecal incontinence.


One patient had undergone two operations for fistula in ano and fourteen patients had abdominal hysterectomy because of leiomyomas and prolapse.

Continence was scored according to Parks [13], grade 1 meaning full continence, grade 2 difficult control of flatus and diarrhea, grade 3 no control of liquid stools and grade 4 meaning no control of solid stools.

Anal manometry, rectal sensitivity and anal endosonography

Anorectal function tests were performed according to the technique published by our group elsewhere (30).


Operative procedure

All patients received low-dosage subcutaneous heparin and had a preoperative mechanical cleansing of the bowel. After introducing an indwelling catheter, patients are placed supine with the legs in leg rests to allow for inspection and digital examination during the operation. The video monitor is placed between the legs. The surgeon and the second assistant (camera) stand on the right side of the patient, being the operating nurse on his right side and the first assistant in front of them. Pneumoperitoneum was established using a Veress needle introduced via a subumbilical wound. The needle was then replaced with a 10 mm trocar in order to introduce the laparoscope. Three auxiliary trocars were placed under direct vision: two in the right iliac fossa and another one in the left iliac fossa [10] (Fig. 1).


The patients were placed in a moderately steep Trendelenburg tilt. If present the uterus was fixed to the ventral abdominal wall using a temporary suture (Fig. 2). The sigmoid and rectum were subsequently mobilized, with care taken to identify the ureters. Anteriorly, the rectum was mobilized up to the high limit of the vagina; posteriorly, the presacral space was entered and dissected to the level of the coccyx. The lateral ligaments and the nervi erigentes were left intact (Fig. 3). The limit of the posterior dissection was determined by rectal examination. Following this, a 4x8 cm polypropylene mesh tightly rolled, introduced like a cigarette, was introduced into the abdomen and attached to the promontorium and presacral fascia using an endoscopic ‘hernia’ stapler device. (Ethicon, Cincinnati, OH, USA) (Fig. 4). After determining that the mesh was firmly attached to the sacrum, the rectum was held under tension and the mesh was fixed to the anterolateral wall of the rectum using three non-absorbable seromuscular sutures on each side, so that one-third of the circumference of the bowel was left free (Fig. 5).

TROCARFI6


Results

There were no major peroperative complications. One patient had a transient brachial plexus apraxia due to hyperextension of the upper arm during the operation. The median duration of the procedure was 2 hours 45 minutes (2 hours 10 minutes - 4 hours 30 minutes). There were no conversions during surgery. Blood losses were less than 100cc in each case. Commencement of bowel movements appeared at 24 hour postoperatively, with passage of stools at the fourth postoperative day (2-7 days). No wound complications occurred, and median hospital stay was 10 days (6-11 days) and postoperative stay was seven days (5-10 days).

COMPILAT FIG4EN5R


No recurrences occurred during a median follow-up of 18 months (4-24 months). Three patients needed additional rubber band ligation of persisting anal mucosal prolapse (two patients at two months, one patient at one year after surgery). Seven out of 28 patients were continent before surgery and remained so afterwards. There was a marked increase in continence in sixteen of twenty-one patients who suffered from either grade 4 or grade 3 incontinence before operation. One patient showed only a mild improvement and four patients did not improve, remaining incontinent for liquid stools. Eleven out of 28 patients had constipation before the rectopexy and remained so after the surgical procedure. Three patients suffered from postoperative constipation. In all these patients, constipation was treated successfully with a fiber enriched diet and/or bulk forming agents.


Anal manometry

Postoperatively, the basal pressure increased significantly from 20 mmHg to 25 mmHg (p.01), whereas the squeeze pressure did not change after operation.


Rectal sensitivity

Rectal sensitivity did not change significantly after laparoscopic rectopexy.



Anal endosonography

Preoperative endosonography showed asymmetry of the internal anal sphincter in the majority of patients. Also, thickening of the internal anal sphincter was found (IST 3.0 mm). After surgery, IST decreased significantly (p=0.02) as compared to preoperative values, but the asymmetrical aspect of the internal anal sphincter persisted. The external anal sphincter was normal before and after surgery.


Discussion

Laparoscopic rectopexy is a feasible and effective treatment for complete rectal prolapse. In this group of patients, the procedure was associated with only one minor complication. The postoperative recovery of these patients was rapid, with resumption of bowel function and normal activities within a few days after surgery. The median hospital stay was 10 days. This is shorter than the 16 days recorded approximately ten years ago in our department [l4] and less than the 13 to 15 days reported by McKee et al for different open procedures [15]. However, the median hospital stay of 10 days did certainly not reflect the full advantages of laparoscopic surgery regarding postoperative recovery. These elderly patients (median 73 years) were often single and admission was frequently prolonged on a social indication to allow for arranging of additional help at home after their hospital stay. Blaker et al. [l6] have compared laparoscopic assisted and open resection rectopexy. Hospital stay was significantly shorter than for the laparoscopic assisted group (four days versus eight days).


One difference with the open procedure is the fixation of the mesh, which is performed using ‘hernia’ staplers in the laparoscopic version of rectopexy. So far, this modification of the technique has not been associated with increasing recurrence rates as compared with the 0-8% described for the open procedures [2, 3]. Continence improved in sixteen of twenty-one preoperatively incontinent patients and this is comparable with the open technique [l, 4, 5]. Both manometric basal pressure representing internal anal sphincter function, and squeeze pressure, representing external anal sphincter function, are strongly associated with fecal incontinence [l7]. An increase in squeeze pressure after abdominal rectopexy has been described by Delemarre et al. [l8]. In our patients improved continence was associated with a small but significant increase in basal pressure suggesting a restoration of the internal anal sphincter. An increase in this basal pressure has been previously described after open procedures [l, l9-22]. It is believed that the improvement of this after surgery might be due to relieve of rectoanal inhibition, which is induced by the prolapsed bowel distending the lower rectum [5, 21, 22]. Also of importance might be the simple anatomical restoration of the prolapsed bowel, which prevents further dilatation of the anal sphincters [1]. A major drawback of abdominal rectopexy is constipation. Previous studies have reported an increased incidence of postoperative constipation (up to 50%), probably related to the division of the lateral ligaments [23, 24]. Three of our patients developed mild constipation postoperatively, which was treated successfully with a fiber enriched diet and intermittent use of bulk forming agents. These satisfactory results regarding postoperative constipation can be explained by the fact that we did not dissect the lateral ligaments and the nervi erigentes. This is sustained by our finding that the rectal sensitivity, which has been proven to be impaired after lateral ligament division [24], was not changed significantly in our patients after the operation. We feel that it is important to spare the lateral ligaments. Although the St.-Mark’s group found a higher recurrence rate after not dividing these ligaments [23], we found no complete recurrences. These results were confirmed by Scaglia et al. [24]. There are no reports of anal endosonography in rectal prolapse. This technique has been proven of value in the assessment of anal sphincter defects and is capable of performing excellent images of the internal as well as the external anal sphincter [25-27]. The asymmetry and the thickening of the internal anal sphincter with the underlying thickened submucosa supplies a rather striking image. Thickening of the internal anal sphincter could be expected in these elderly patients, since evidence exists that it is a physiological process of aging [28, 29]. However, the decrease of internal sphincter (IST) after surgery suggests a partially reversible process, for example edema, which might occur as a result of irritation of the rectum protruding into the anal canal. Decrease of IST after surgery gives us further evidence toward restoration of internal anal sphincter function. These results confirm the previously obtained in our department with a reduced number of patients [30]. In conclusion, laparoscopic rectopexy is a technically feasible method, which resulted in improved continence in the majority of our patients. This was associated with a significant increase in continence grade in our patients without important worsening of constipation’s rate. Anorectal function study demonstrated a (partial) recovery of the internal anal sphincter. Moreover, laparoscopic rectopexy combines the low morbidity of minimally invasive surgery with the good clinical outcome of abdominal rectopexy.


References

1.    Madden MV, Kamm MA, Nicholls RJ, Santhanam AN, Cabot R, Speakman CTM (1992) Abdominal rectopexy for complete prolapse: Prospective study evaluating changes in symptoms and anorectal function. Dis Colon Rectum 35:48-55.

2.    Keighley MRB, Fielding JWL, Alexander-Williams J (1983) Results of Marlex mesh abdominal rectopexy for rectal prolapse in 100 consecutive patients. Br J Surg 70:229-232.

3.    Tjandra JJ, Fazio VW, Church JM, Milsom JW, Oakley JR, Lavery IC (1993) Ripstein procedure is an effective treatment for rectal prolapse without constipadon. Dis Colon Rectum 36:501-507.

4.    McCue JL, Thomson JPS (1991) Clinical and functional results of abdominal rectopexy for complete rectal prolapse. Br J Surg 78:921-923.

5.    Duthie GS, Bartolo DCC (1992) Abdominal rectopexy for rectal prolapse: A comparison of techniques. Br J Surg 79: 107-113.

6.    Ramanujam PS, Venkatesh KS, Fietz MJ (1994) Perineal excision of rectal procidentia in elderly high risk patients. A ten-year experience. Dis Colon Rectum 37: 1027-1030.

7.    Lechaux JP, Lechaux D, Perez M (1995) Results of Delorme’s procedure for rectal prolapse. Advantage of a modified technique. Dis Colon Rectum 38:301-307.

8.    Johansen OB, Wexner SD, Daniel N, Nogueras JJ, Jagelman DG (1993) Perineal rectosigmoidectomy in the elderly. Dis Colon Rectum 36:767-772.

9.    Graf W, Ejerblad S, Krog M, Pahlman L, Gerdin B (1992) Delorme’s operation for rectal prolape in elderly or unfit patients. Eur J Surg 158:555-557.

10.    Cuesta MA, Borgstein PJ, De Jong D, Meijer S (1993) Laparoscopic rectopexy. Surg Laparoscopy Endosc 3:456-458.

11.    Berman IR (1992) Sutureless laparoscopic rectopexy for procidentia: Technique and implications. Dis Colon Rectum 35:689-693.

12.    Cuschieri A, Shimi SM, Vander VG, Banting S, Wood RAB (1994) Laparoscopic prosthesis fixation rectopexy for complete rectal prolapse. Br J Surg 81: 138139.

13.    Parks AG (1975) Anorectal incontinence. Proc R Soc Med 68:681-690.

14.    Hoitsma HFW, Meijer S, Klinkenberg-Knol EC, Den Otter G (1984). The treatment of complete rectal prolapse by transabdominal posterior rectopexy. Neth J Surg 36:73-76.

15.    McKee RF, Lauder JC, Poon FW, Aitchison MA. Finlay IG (1992) A prospective randomized study of abdominal rectopexy with and without sigmoidectomy in rectal prolapse. Surg Gynecol Obstet 174: 145-148.

16.    Blaker R, Senagore AJ, Luchtefeld MA (1995) Laparoscopic assisted vs. open resection. Rectopexy offers excellent results. Dis Colon Rectum 38: 199-201.

17.    Felt-Bersma RJF, Klinkenberg-Knol EC, Meuwissen SGM (1990) Anorectal function investigations in incontinent and continent patients. Differences and discriminatory value. Dis Colon Rectum 33:479-486.

18.    Delemarre JBVM, Gooszen HG, Kruyt RH, Soebhag R, Geesteranus AM (1991) The effect of posterior rectopexy on fecal continence. A prospective study. Dis Colon Rectum34:311-316.

19.    Broden G, Dolk A, Holmstrom B (1988) Recovery of the internal anal sphincter following rectopexy: A possible explanation for continence improvement. Int J Colorectal Dis3:23-28.

20.    Williams JG, Wong WD, Jensen L, Rothenberger DA, Goldberg SM (1991) Incontinence and rectal prolapse: A prospective manometric study. Dis Colon Rectum 34:209-216.

21.    Farouk R, Duthie GS, Bartolo DCC, MacGregor AB (1992) Restoration of continence following rectopexy for rectal prolapse and recovery of the internal anal sphincter electromyogram. Br J Surg 79:439-440.

22.    Farouk R, Duthie GS, MacGregor SAB, Bartolo DCC(1994) Rectoanal inhibition and incontinence in patients with rectal prolapse. Br J Surg 81 :743-746.

23.    Speakman CT, Madden MV, Nicholls RJ, Kamm MA (1991) Lateral ligament division during rectopexy causes constipation but prevents recurrence: results of a prospective randomized study. Br J Surg 78: 1431-1433.

24.    Scaglia M, Fasth S, Hallgren T, Nordgren S, Oresland T, Hulten L (1994) Abdominal rectopexy for rectal prolapse: influence of surgical technique on functional outcome. Dis Colon Rectum 37: 185-189.

25.    Bartram CI (1992) Anal endosonography. Ann Gastroenterol Hepatol 28: 185-189.

26.    Cuesta MA, Meijer S, Derksen EJ, Boutkan H, Meuwissen S (1992) Anal sphincter imaging in fecal incontinence using endosonography. Dis Colon Rectum 35:59-63.

27.    Felt-Bersma RJF, Van Baren R, Koorevaar M, Strijers RL, Cuesta MA (1995) Unsuspected sphincter defects shown by anal endosonography after anorectal surgery: a prospective study. Dis Colon Rectum 38:249-253.

28.    Nielsen MB, Hauge C, Rasmussen OO, Sorensen M, Pedersen JF, Christiansen J (1992) Anal sphincter size measured by endosonography in healthy volunteers. Effect of age, sex and parity. Acta Radiol 33:453-456.

29.    F Burnett S, Bartram CI (1991) Endosonographic variations in the normal internal anal sphincter. Int J Colorectal Dis 6:2-4.

30.    Poen AC, de Brauw LM, Felt-Bersma RJF, de Jong D, Cuesta MA. Laparoscopic rectopexy for complete rectal prolapse. Results regarding clinical outcome and anorectal function tests. Surg Endosc 1996;10:904-908.