Laparoscopic Rectopexy

Updated: Oct 23, 2018
  • Author: Leandro Feo, MD; Chief Editor: Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS  more...
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Overview

Background

Rectal prolapse is a debilitating condition that affects 1% of people older than 60 years. Surgical approaches to its treatment include a perineal approach and an abdominal approach. [1] Laparoscopic rectopexy was initially described in the early 1990s and has since become the abdominal procedure of choice for rectal prolapse. [2] This review describes three of the current laparoscopic approaches in the management of rectal prolapse and rectocele.

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Indications

Once rectal prolapse is diagnosed, surgical repair is indicated to prevent worsening fecal incontinence and discomfort.

Laparoscopic rectopexy has been recommended as the first option for rectal prolapse. [3]

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Outcomes

Abdominal rectopexy yields low recurrence rates (< 5%) and some improvement of incontinence. However, this approach can cause constipation and does not resolve existing constipation, [4, 5] possibly owing to rectal denervation after the posterolateral dissection of the rectum.

In contrast, perineal approaches, including Altemeier and Delorme procedures, are associated with a higher recurrence rate but lower morbidity than open abdominal approaches. Although these are considered safer operations, with the rate of recurrence approaching 18% and minimal improvement in continence, better alternatives have been investigated. [4]

The small incisions, lack of anastomosis, and low recurrence rates of the minimally invasive approach have reduced the morbidity of the abdominal approach without affecting efficacy. In a randomized control trial, laparoscopic rectopexy had fewer complications, shorter length of hospital stay, and decreased in pain compared with open abdominal rectopexy. [6] In addition, it was comparable to perineal procedures in terms of morbidity.

Compared with the classic open posterior rectopexy, laparoscopic rectopexy has similar functional outcomes with respect to constipation. Satisfactory long-term results have been reported with laparoscopic "ventral" rectopexy, and new constipation is prevented because of the lack of posterior dissection. [7, 8, 9, 10, 3]

In a prospective study of 224 patients who underwent laparoscopic ventral mesh rectopexy, McLean et al assessed long-term clinical outcomes, patient-reported functional and quality-of-life outcomes, and urinary and sexual dysfunction. [11]  No mortality was reported. The overall complication rate was 10.7%, mesh-related morbidity was 0.45%, and vaginal suture-related morbidity was 1.33%. The overall recurrence rate was 11.4%. Significant improvements in patient-reported functional outcomes were seen for both constipation and fecal incontinence symptoms.Significant improvements in quality-of-life outcomes persisted in patients with constipation, fecal incontinence and prolapse.

Madbouly et al compared functional outcomes, recurrence rates, and quality of life for laparoscopic ventral rectopexy (n = 41) versus laparoscopic Wells rectopexy (n = 33) in patients with complete rectal prolapse. [12]  Both procedures successfully and safely corrected prolapse and prevented recurrence, though laparoscopic ventral rectopexy was associated with significantly longer operating time and length of stay. Laparoscopic ventral rectopexy appeared to be more suitable for patients with a high constipation score and abnormal perineal descent.

Compared with the results of laparoscopic rectopexy, the results of robotic rectopexy have been similar in terms of length of stay, postoperative pain, recurrence rates, and mortality. In contrast, robotic rectopexy has been associated with a longer operating time and higher costs. [13, 14, 15, 16]  However, a randomized controlled trial that included 30 patients reported no significant difference in operating time between robot-assisted and conventional laparoscopic ventral rectopexy. [17]

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