Laparoscopic Rectopexy

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, 2] Laparoscopic rectopexy was initially described in the early 1990s and has since become the abdominal procedure of choice for rectal prolapse.[3] This review describes three of the current laparoscopic approaches in the management of rectal prolapse and rectocele.

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.[4]

Modifications of classic laparoscopic suture rectopexy have been developed. Pandey et al compared modified laparoscopic suture rectopexy with classic laparoscopic suture rectopexy in children and determined that the former was associated with shorter operating times, reduced blood loss, and less constipation at 3-month follow-up.[5]  

Mesh erosion is one of the distressing problems associated with laparoscopic ventral mesh rectopexy (LVMR).[6]  Minimally invasive organ-preserving techniques—such as transanal or transvaginal trimming or excision of exposed mesh and sutures (with or without transanal endoscopic microsurgery [TEMS] or transanal minimally invasive surgery [TAMIS]) and laparoscopic pelvic assessment and detachment of mesh from the sacral promontory—are used for the management of mesh erosions.  These techniques are multistaged and require months to complete; however, they are effective and feasible.

Laparoscopic pelvic organ prolapse suspension surgery (POPS) has been employed to treat rectal prolapse. In a study comparing POPS (n = 60) with LVMR (n = 60) in patients with this condition, Farag et al found that whereas postoperative pain and length of hospital stay were not significantly different between the two groups, the POPS group had a shorter operating time and the LVMR group had lower complication and recurrence rates.[7] The authors suggested that POPS could be an easier and faster alternative to LVMR.

Abdominal rectopexy yields low recurrence rates (< 5%) and some improvement of incontinence. However, this approach can cause constipation and does not resolve existing constipation,[8, 9] 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.[8]

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.[10] 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.[11, 12, 13, 14, 4]

In a prospective study of 224 patients who underwent LVMR, McLean et al assessed long-term clinical outcomes, patient-reported functional and quality-of-life outcomes, and urinary and sexual dysfunction.[15]  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.

Tsunoda et al assessed 58 patients who underwent laparoscopic ventral rectopexy for external rectal prolapse on the basis of the Fecal Incontinence Severity Index, the Constipation Scoring System, and quality-of-life (QoL) instruments both before and after operation.[16]  The median Fecal Incontinence Severity Index and Constipation Scoring System scores were significantly reduced at 3 months and remained so for 4-5 years. The midterm analysis revealed low morbidity, low recurrence, and an improvement in function and fecal incontinence-specific QoL.

A systematic review and meta-analysis (17 studies; N = 1242) by Emile et al addressed predictors of recurrence of full-thickness external rectal prolapse after LVMR.[17] Male sex and the length of the mesh were found to be significant contributors to recurrence. There was a 71% inprovement in constipation rates after LVMR, as well as a 79.3% improvement in fecal incontinence rates. The low recurrence and complications rates make LVMR an effective and safe treatment option. 

Madbouly et al compared functional outcomes, recurrence rates, and QoL for laparoscopic ventral rectopexy (n = 41) versus laparoscopic Wells rectopexy (n = 33) in patients with complete rectal prolapse.[18]  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.

Hidaka et al compared the long-term functional outcomes of LVMR with those of laparoscopic posterior sutured rectopexy (LPSR) for rectal prolapse, using multiple questionnaires assessing prolapse recurrences and mesh-related complications.[19]  LVMR was found to be superior to LPSR with respect to long-term functional outcomes.

Tsiaousidou et al assessed the safety of the use of biologic mesh in 86 patients who underwent LVMR for rectal prolapse; of these, 40 were treated for obstructive defecation, 38 for mixed symptoms (obstructive defecation and incontinence), five for pain and bleeding, and three for incontinence.[20]  Median Wexner score for constipation decreased from 14.5 preoperatively to 4 postoperatively and median Wexner score for fecal incontinence from 11 preoperatively to 2 postoperatively. There were four recurrences, two instances of suture erosion through the rectum, and one case of diskitis. There were no mesh complications or deaths.

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.[21, 22, 23, 24]  However, a randomized controlled trial that included 30 patients reported no significant difference in operating time between robot-assisted and conventional laparoscopic ventral rectopexy.[25]

In a multicenter comparative matched-pair study (N = 401), Laitakari et al compared the midterm functional and QoL outcomes of LMVR (n = 214) with those of robotic ventral mesh rectopexy (RMVR; n = 187).[26]  Postoperative QoL measures did not differ between groups. The RVMR group had a lower median postoperative Wexner Incontinence Score (5 vs 8), a lower incidence of significant ongoing incontinence symptoms (30.6% vs 49.0%), and a lower median level of postoperative fecal incontinence discomfort on the visual analogue scale (11 vs 39). RVMR patients had a shorter hospital stay (2.2 vs 3.8 days) but a higher frequency of de-novo pelvic pain (31.8% vs 11.8%).

A Foley catheter is inserted for the duration of the case but is removed before extubation. Clippers are used to remove abdominal wall hair.

The authors routinely use a 30° laparoscope to enter the abdominal cavity with the Hasson technique. Three 5-mm ports are required. The pexy is supported with polypropylene mesh. For robotic cases, the da Vinci surgical system is used.

Commonly used synthetic meshes are associated with a risk of erosion into adjacent pelvic organs with consequent complications. A study by Alemrajabi et al found polyvinylidene fluoride (PVDF) mesh to be a safe, effective, and cheaper alternative to more commonly used synthetic meshes for laparoscopic ventral mesh rectopexy (LVMR) in patients with obstructive defecation syndrome (ODS).[27]

A 2022 systematic review and meta-analysis of 32 studies by van der Schans et al, intended to compare the use of synthetic and biologic meshes in LVMR, was unable to determine whether one type was superior to the other in this setting.[28]

In preparation for the procedure, the patient is kept on NPO (nil per os) status, beginning the night before surgery. The authors do not perform bowel preparation in these patients. Prophylactic antibiotics are given per Surgical Care Improvement Project (SCIP) criteria.

Anesthesia

The procedure is performed with general anesthesia to allow abdominal muscle paralysis and thereby to optimize pneumoperitoneum.

Positioning

The authors position the patient in the lithotomy position with the arms tucked bilaterally. The patient is secured to the bed, as a steep Trendelenburg position will be required. Special attention is given to the legs, avoiding excessive posterior or lateral compression, so as to reduce the risk of any injuries to the calf muscle and lateral superficial peroneal nerve.

As per protocol in the authors’ institution, patients are started on a clear liquid diet after the procedure and advanced as tolerated. Patients may be discharged home the same day after meeting standard discharge criteria (diet tolerance, adequate urination, adequate pain control). Frail patients are observed overnight and discharged home on the first postoperative morning. Patients are discharged with standard wound care instructions, a stool softener, and nutritional instructions for a high-fiber diet and ample fluid intake.

Follow-up visits occur in the office 1 week, 1 month, and 3 months postoperatively. Questions regarding continence, the presence of prolapse, and constipation are reviewed.

An ideal surgical procedure for rectal prolapse would have low recurrence rates and low morbidity and provide some improvement in fecal incontinence. The minimally invasive approach to rectopexy attempts to achieve these results. Laparoscopic rectopexy is an adaptation of the classic open posterior rectopexy. The three minimally invasive approaches discussed in this article are as follows:

• Laparoscopic rectopexy with posterior mesh fixation
• Robotic rectopexy - This technique is essentially the same as the laparoscopic approach, but the use of the robot facilitates suturing
• Laparoscopic "ventral" rectopexy - This approach, first described by D’Hoore et al in Belgium, focuses the dissection in the rectal-vaginal septum

The patient is placed in the lithotomy position with arms tucked in order to facilitate inspection and rectal examination during the procedure. The abdominal cavity is entered by using the Hasson approach, which is the authors’ favored approach. Accordingly, Optiview entry or Veress needle entry is perfectly acceptable. Once the camera port is inserted and the abdomen is insufflated, a right-lower-quadrant (RLQ) port and a right-upper-quadrant (RUQ) port are placed. The authors prefer a 12-mm port in the RLQ to facilitate placement of the mesh.

A 30° scope is introduced into the umbilical port. To improve exposure, an additional port can be placed on the left flank. If the patient has a uterus that is affecting exposure, it can be retracted with a stitch to the anterior abdominal wall.

Dissection is started posteriorly. The plane between the mesorectum and retroperitoneum is identified; the retroperitoneum is usually whiter than the mesorectum. An energy device is used to enter the posterior pelvic plane under the superior rectal artery, and the left ureter and hypogastric nerve plexus are identified; dissection is extended downward through the presacral anatomic space, all the way to the pelvic floor. The dissection must be carried below the rectosacral (Waldeyer) fascia. Often, to facilitate exposure, the right lateral stalk of the rectum is also mobilized.

Once the right stalk and posterior areas are mobilized, dissection proceeds anteriorly into the rectovaginal plane. This location often contains a hernia sac; retracting the rectum cephalad and cervix anteriorly facilitates exposure. Subsequently, the rectum is mobilized anteriorly to the upper limit of the vagina. During this approach, the nervi erigentes and left lateral ligament are spared.

The rectum is then pulled out of the pelvis, and where the fixation will occur is assessed. A window is made on the left side of the rectum to facilitate the rectopexy. The authors prefer posterior placement of mesh. A small rectangular sheet of polypropylene mesh is inserted via the RLQ port and is placed all the way down to the pelvic floor, extending cephalad behind the mesorectum. (Polyvinylidene fluoride [PVDF] mesh has been described as an option in patients with obstructive defecation syndrome [ODS].[27] )

The stalks are fixed to the sacrum, incorporating the mesh. Placement of a 5-mm suprapubic port is often necessary to facilitate fixation. The authors prefer using endoscopic tacks (Protack, US Surgical). The left-side tacks are placed first. An overly tight pexy must be avoided to prevent obstruction of the rectosigmoid junction. If suturing is chosen, the authors use a 0 Ethibond (Ethicon) suture.

The pexy should be 5 cm on each side, typically requiring three tacks spaced 1 cm apart or three sutures spaced similarly. It is important to identify the sacral venous plexus before tacking or suturing. The bony promontory is the ideal location for fixation.

If needed, a small incision can be made over the hypogastric area and fixation performed open.

The technique is similar to the laparoscopic rectopexy technique described above. The authors dock the robot between the legs, and port placements are similar. The authors usually need only two arms, but, in the case of a redundant sigmoid or floppy uterus, the third arm is used in the left flank to retract.

The authors prefer to use a 30° scope, though the angle may have to be rotated by the assistant in some cases. The authors use a Grapter in the right cephalad port and a Hook diathermy on the right caudal robotic arm. The planes are identified as mentioned above, and dissection is similar.

Once the dissection is complete, mesh is inserted via an accessory port. It is positioned the same way, and sutures are inserted and sewn into position as described. Abdominal wall wounds are closed in the usual manner.[29]

The authors do not routinely perform this approach.

Although earlier reports described a significant learning curve for laparoscopic ventral rectopexy, subsequent reports suggested a learning curve of 25-30 cases in the context of proctored adoption.[30]

Ports are inserted as described above. The lateral ligaments and hypogastric plexus are preserved.

Dissection is carried down in the anterior space via Denonvilliers fascia to the rectovaginal space. In some cases, the hernia sac can be redundant, associated with an enterocele, or both. In these cases, the peritoneal sac is resected. Posterior and lateral dissection is avoided.

Once the anterior space is mobilized, polypropylene mesh is secured to the anterior aspect of the rectum and then secured to the sacral promontory with 0 Ethibond suture. This elevates the anterior wall without any traction on the rectum. The posterior vaginal fornix is then lifted up and sutured to the mesh (anteriorly), aiding in the repair of rectocele, as well as prolapse.[31, 32]

Tsunoda et al described a technique of introducing the mesh at the distal dissection while performing laparoscopic ventral rectopexy.[33] In this technique, a nylon thread with straight needle was passed through the posterior wall of the vagina at the distal extent of the dissection, and this was caught in the abdominal cavity and fixed at the end of the mesh extracorporeally. The mesh was then introduced, pulled toward the pelvic floor, and settled at the pierced site by the perineal operator. This technique enables the  surgeon to confirm that the mesh is introduced and secured to the distal end.

This procedure has also been performed with robotic assistance.[34, 35]