of the minimally invasive or the laparoscopic approach and its use in patients with rectal prolapse.
Preoperative Investigations and Management
Preoperative investigations are important to ensure that patients receive the appropriate treatment or procedure. Flexible sigmoidoscopy or colonoscopy is necessary to exclude any pos- sibility of a malignant or benign lesion that may act as a lead point for intussusception. In addi- tion, other conditions such as solitary rectal ulcer, suggestive of internal rectal prolapse, should be excluded.
Prolonged constipation prior to rectal prolapse is suggestive of colonic inertia, thus mandating a combined approach of resection with rec- topexy.3–5In patients with suspected incontinence, anal ultrasonography, manometry, and pudendal nerve latency tests should be performed prior to the procedure. It is suggested that these patients would benefit mostly from a suture rectopexy without the addition of bowel resection.6These tests may be of some predictive value and serve as a point of reference in monitoring postoperative improvement. Also, they may dictate the prefer- ence of one method over the other.
The objectives of the surgical treatment are to eliminate the rectal prolapse and improve any condition associated with it; thus it is up to the surgeon to decide what should be the most appropriate course of investigation and surgical management.
Rectal prolapse is regarded as a combined anatomic and functional disorder. This condi- tion is usually accompanied by constipation or incontinence, thus requiring different treatment approaches.
Full-thickness rectal prolapse (FTRP) may be approached transabdominally, by rectopexy, by colonic resection, or by a combination of the two, or perineally, either by a Delorme’s proce- dure or a perineal rectosigmoidectomy. Methods described for rectopexy entail a variety of slings, sutures, and even special screws, which are applied in different ways. All of these variations are amenable for the conventional open tech- nique or the minimally invasive approach. The minimally invasive approach offers less postop- erative pain, better cosmetic results, and shorter hospital stay, thus making it more appealing.1It is well recognized that performing laparoscopic colorectal surgery requires training and has a considerable learning curve. The advent of tech- nology and the emergence of surgical robotics such as the Da Vinci telemanipulator, equipped with stereoptic vision and working tips with seven degrees of freedom, provide surgeons with dexterity enhancement and a shorter learning curve (Fig. 22.1). Thus, colorectal procedures (among others) can now be safely performed with results that are comparable to the con- ventional laparoscopic technique, using skills acquired in a much shorter period of time.2
This chapter summarizes the current data available on surgical management of full- thickness rectal prolapse, highlighting the basic steps in each of the major laparoscopic proce- dures. This review is intended to provide an idea
22
Laparoscopic Surgery for Rectal Prolapse
Ara Darzi and Yaron Munz
207
Laparoscopic Suture Rectopexy
The laparoscopic approach provides improved visibility and magnification within the confines of the pelvic space, where important structures such as the ureters and the hypogastric nerves run. In the posterior approach (most commonly practiced) the posterior part of the rectum is fixed to the sacral promontory.
The patient is placed in the supine position and anesthetized. Then the procedure is begun.
Initially a 10-mm port is inserted at the umbili- cus, and pneumoperitoneum is achieved. Then, two additional working ports are positioned, a 10-mm port on the right and slightly caudal to the umbilicus and a 5-mm port to the left of the umbilicus. Before the dissection is carried out, any organ that may come in the way is pulled out of the pelvis and if needed tacked in to the abdominal wall. Dissection begins at the right side medially to the right ureter. Once the peri- toneum is cut, gas infiltrates into the retrorectal space, thus simplifying the dissection, and pro- viding an avascular plane. Dissection is contin- ued down to the pelvic floor, dividing the lateral stalks while avoiding contact with the sacral nerves. Dissection is continued anteriorly and posteriorly to the rectum and is completed on the left side. Now the rectum is fully mobilized
208 Constipation
down to the pelvic floor, and once it is retracted out of the pelvis, nonabsorbable sutures are inserted at both sides of the posterior third of the rectal circumference fixing it to the sacral promontory. No more than two stitches are needed and the procedure is completed (Fig. 22.2). This procedure is relatively simple to perform and can often be successfully under- taken even in the hands of the noncolorectal specialist surgeon. Relatively good posto- perative functional results are in favor of this procedure as long as careful patient selection is applied.7
Laparoscopic Anterior Resection
The idea behind this approach is that resection of redundant bowel reduces postoperative constipation while fibrosis associated with the healing process of the anastomosis will fix the bowel to the sacrum. However, this approach is subjected to higher morbidity due to an increased risk for anastomotic leakage (2–12%).
Technically, this procedure is more demanding when attempted laparoscopically.
The patient is positioned in the modified Lloyd Davis position with the legs slightly flexed.
Figure 22.1. Port positioning for robotic-assisted laparoscopic suture rectopexy. The patient is placed in the lithotomy Trendelenburg position to accommodate the robotic slave-cart. Ports are placed similarly to the conventional laparoscopic procedure. The surgeon is seated at the master console, equipped with stereoptic vision and working tips with seven degrees of freedom of motion.(Courtesy of St. Mary’s Hospital, London, UK, 2002.)
Figure 22.2. Robotic-assisted suturing of the mesorectum to the sacral promontorium. Stereoscopic vision together with powerful magnifica- tion and wrist-like working tips provide the surgeon with marked enhancement of dexterity, making intracorporeal suturing and knot tying as easy as if it were performed by hand. Two sutures only are placed fixing the posterior rectum to the sacrum. (Courtesy of St. Mary’s Hospital, London, UK, 2002.)
this procedure is not much different from the pro- cedures mentioned above and can be carried out safely using the laparoscopic approach.9–11
Postoperative Outcome
Evaluation of the postoperative outcome of sur- gical treatment for rectal prolapse is based not only on morbidity and recurrence rates but also on functional outcome.12 There are a large variety of surgical solutions for this disorder, suggesting that no single solution can provide 100% of success.
At the moment there are not enough data to support or refute any of the procedures; thus we have to make our decisions regarding the pre- ferred type of procedure based on clinical and laboratory evidence, combined with results from the current literature.13It is believed that post- operative constipation is attributed primarily to the preoperative condition of the patient, the type of rectopexy chosen, whether or not the lateral stalks were divided, and whether or not the procedure included bowel resection.14
A prolonged history of constipation prior to the operation would suggest colonic inertia, pos- sibly mandating bowel resection in combination or without rectopexy. Conversely there are not enough data to support preservation of the lateral stalks, although there is a sound theoret- ical basis to support it. When addressing incon- tinence in these patients, there is a 50% to 75%
postoperative improvement.15 It is generally accepted that in patients suffering from significant incontinence, rectopexy without resection should be preferred. If continence is not improved postoperatively there are a range of treatments that can be offered to the patients such as biofeedback and sphincter repairs.
Addressing recurrence rates after the different procedures mentioned above reveals a confus- ing pattern. Apparently, more physiologically appropriate solutions are characterized by a rel- atively higher recurrence rate compared to less physiologically suitable procedures with lower recurrence rates. Suture rectopexy with lateral stalks division is associated with a 2% to 6%
recurrence rate, whereas when the lateral stalks are preserved the recurrence rate rises to 10%.
Resection procedures are characterized by even higher recurrence rates, up to 12%, and are also subjected to the risk of anastomotic leakage.
Port positioning is the same as previously men- tioned, and additional ports are placed in the right side to allow the use of endo-staplers and other instruments such as the harmonic scalpel.
Once the redundant bowel is identified, dis- section is started from left lateral toward the center, avoiding damage to the left ureter. The mesentery of the sigmoid colon is then divided using the harmonic scalpel, and the blood vessels are stapled or sealed by the LigaSure device (Valleylub, Boulder, Co). The distal end of the resection is set at the level of the rectosig- moid junction or lower, if needed. The bottom end is then divided using an endo-stapler, and thus the majority of the procedure is completed.
Next, the dissected bowel is delivered out of the abdomen through a small left lower abdominal incision and the resection is completed. The anvil of the end-to-end anastomotic stapler is placed and secured in the proximal end, and the bowel is returned to the abdominal cavity. The abdominal wound is closed and pneumoperi- toneum is reestablished.
Before reuniting the bowel ends, attention is paid to ensuring a tension-free anastomosis. The EEA stapler is then transanally introduced and the anastomosis is performed. The procedure is completed after the anastomosis is tested for air- tightness. Although relatively standard, anterior resection is generally regarded as insufficient as a stand-alone procedure, and most surgeons would advocate completion with a rectopexy of some sort.8
Laparoscopic Rectopexy and Sigmoid Resection
The combined procedure follows the principle of providing remedial surgical treatment for each of the disorders/malfunctions in the proposed mechanism of full-thickness rectal prolapse.
This procedure entails full mobilization of the rectum without division of the lateral stalks and followed by a posterior rectopexy, fixing the rectum to the sacral promontory.
Before the resection of the redundant large bowel, the endopelvic fascia is anteriorly sutured to the rectum, thereby obliterating the pouch of Douglas. Resection of large bowel can include just a redundant sigmoid loop or be extended to as much as a subtotal colectomy in cases of proven colonic inertia. From the technical point of view
Laparoscopic Surgery for Rectal Prolapse 209
Conclusion
After carefully reviewing the current literature it is clear that at present there are not enough data to accept an ideal approach for the surgical treat- ment of full-thickness rectal prolapse. There is a need for longitudinal, structured, and standard- ized studies and randomized clinical trials comparing the different methods of surgery, thus putting to the test theoretical mechanisms suggested as the cause of this disorder. Con- versely, there are enough data to support the use of the minimally invasive approach in appropri- ately selected patients. This method provides the surgeon with means that enhance vision and therefore accuracy. There is no doubt that mas- tering the skills required for laparoscopic col- orectal surgery may take years; however, once surgeons have completed their learning phase, the advantages to patients as well as to health care services are tremendous.16,17 As all the abdominal procedures included in the surgical armamentarium for rectal prolapse are amenable for the laparoscopic approach, these should become the methods of choice, per- formed in centers of excellence around the world, thus providing the best of care combined with the highest level of patient safety.
It is clear that sound clinical judgment and strict criteria for patient selection are the key factors for success in any surgical procedure, as it is in the case of rectal prolapse. Therefore, it was not the intention of the authors to recom- mend or dismiss any of the suggested pro- cedures, but rather to provide readers with sufficient data for selection of the most appro- priate procedure for their patients.
References
1. Rose J, Schneider C, Scheidbach H, et al. Laparoscopic treatment of rectal prolapse: experience gained in a prospective multicenter study. Langenbecks Arch Surg 2002;387:130–137.
210 Constipation
2. Munz Y, Moorthy K, Kodchanndka R, et al. Robotic assisted suture rectopexy. Am J Surg 2004;187(1):88–92.
3. Berman IR, Manning DH, Harris MS. Streamlining the management of defecation disorders. Dis Colon Rectum 1990;33:778–785.
4. Madbouly KM, Senagore AJ, Delaney CP, Duepree HJ, Brady KM, Fazio VW. Clinically based management of rectal prolapse. Surg Endosc 2003;17:99–103.
5. Benoist S, Taffinder N, Gould S, Chang A, Darzi A. Func- tional results two years after laparoscopic rectopexy.
Am J Surg 2001;182:168–173.
6. Briel JW, Schouten WR, Boerma MO. Long-term results of suture rectopexy in patients with fecal incontinence associated with incomplete rectal prolapse. Dis Colon Rectum 1997;40:1228–1232.
7. Heah SM, Hartley JE, Hurley J, Duthie GS, Monson JR.
Laparoscopic suture rectopexy without resection is effective treatment for full-thickness rectal prolapse.
Dis Colon Rectum 2000;43:638–643.
8. Ignjatovic D, Bergamaschi R. Preserving the superior rectal artery in laparoscopic [correction of laparo- scopis] anterior resection for complete rectal prolapse.
Acta Chir Iugosl 2002;49:25–26.
9. Baker R, Senagore AJ, Luchtefeld MA. Laparoscopic- assisted vs. open resection. Rectopexy offers excellent results. Dis Colon Rectum 1995;38:199–201.
10. Bachoo P, Brazzelli M, Grant A. Surgery for complete rectal prolapse in adults. Cochrane Database Syst Rev 2000;CD001758.
11. Bruch HP, Herold A, Schiedeck T, Schwandner O.
Laparoscopic surgery for rectal prolapse and outlet obstruction. Dis Colon Rectum 1999;42:1189–1194.
12. Aitola PT, Hiltunen KM, Matikainen MJ. Functional results of operative treatment of rectal prolapse over an 11-year period: emphasis on transabdominal approach.
Dis Colon Rectum 1999;42:655–660.
13. Douard R, Frileux P, Brunel M, Attal E, Tiret E, Parc R.
Functional results after the Orr-Loygue transabdomi- nal rectopexy for complete rectal prolapse. Dis Colon Rectum 2003;46:1089–1096.
14. Mollen RM, Kuijpers JH, van Hoek F. Effects of rectal mobilization and lateral ligaments division on colonic and anorectal function. Dis Colon Rectum 2000;43:
1283–1287.
15. Zittel TT, Manncke K, Haug S, et al. Functional results after laparoscopic rectopexy for rectal prolapse. J Gas- trointest Surg 2000;4:632–641.
16. Marusch F, Gastinger I, Schneider C, et al. Experience as a factor influencing the indications for laparoscopic colorectal surgery and the results. Surg Endosc 2001;
15:116–120.
17. Schlachta CM, Mamazza J, Seshadri PA, Cadeddu M, Gregoire R, Poulin EC. Defining a learning curve for laparoscopic colorectal resections. Dis Colon Rectum 2001;44:217–222.
