Open and Laparoscopic Resection Rectopexy

Resection restopexy is the preferred surgical treatment for complete rectal prolapse. Rectal prolapse is defined as a protrusion of the rectum; complete or full-thickness rectal prolapse is also known as procidentia.

The underlying pathophysiology is complex, and the etiology is multifactorial. Chronic constipation, female gender, multiple pregnancies, previous pelvic surgery, pelvic floor disorders, and neurologic disorders are predisposing factors for rectal prolapse. Associated anatomic findings include a deep cul-de-sac (rectouterine or rectovesical) pouch, weak lateral rectal attachments, laxity of the levator ani, and weakness of the internal and external anal sphincter, which may be associated with pudendal nerve dysfunction.

Three types of rectal prolapse are recognized, as follows:

• Complete (or full-thickness) rectal prolapse - Protrusion of all the layers of rectal wall through the anal canal
• Mucosal (or partial-thickness) rectal prolapse - Protrusion of only the mucosal layer of the rectum through the anal canal
• Internal rectal prolapse - Intussusception of the rectum into the anal canal without protrusion to the exterior

In this article, the term rectal prolapse should be understood as referring to complete rectal prolapse.

Medical management has no role in the treatment of rectal prolapse. Surgical repair is the mainstay of therapy for complete rectal prolapse. Surgical options are broadly divided into an abdominal approach and a perineal approach. ^[1] Surgical options are also classified as anal encircling, fixation, resection, or combined (resection and fixation). (See Technical Considerations.)

Resection rectopexy has been the preferred surgical option and is indicated for patients with complete rectal prolapse associated with chronic constipation. It has been found to correct constipation symptoms better than suture rectopexy alone does. ^[2]

Other indications for resection rectopexy for rectal prolapse include significant sigmoid diverticular disease and excessively redundant sigmoid (which is at risk of volvulus).

The main contraindication for resection rectopexy is a patient's unsuitability for general anesthesia. Perineal procedures are better tolerated by such high-risk patients as they can be performed under sedation with regional anesthesia.

Although perineal approaches to rectal prolapse were previously favored for the elderly, more recent studies demonstrated that laparoscopy has made an abdominal approach beneficial and safe for this patient population. ^[3] A 2019 randomized prospective study compared transanal rectal resection with laparoscopic ventral rectopexy for obstructive defecation in elderly patients and reported significantly better results (improved long-term functional outcome, lower recurrence rates, and reduced complications) with the laparoscopic approach. ^[4]

The following three popular abdominal procedures are usually considered ^{[5, 6]} :

• Anterior resection - This involves resection of the sigmoid colon and proximal rectum and with creation of a descending colorectal anastomosis without any form of repair
• Rectopexy - In this procedure, the rectum is mobilized and fixated to the sacrum (posterior) or to Cooper ligaments (anterior), either by suturing or by tacking; in addition, a piece of mesh (fixated by various means) is often used to help create fibrosis so as to prevent recurrence
• Resection rectopexy - This involves resection of the sigmoid colon and creation of a descending colorectal anastomosis, as well as rectal mobilization and suture rectopexy

It has not been conclusively established whether any of these approaches is superior to the others. ^[7]

Resection rectopexy can be performed via either an open or a minimally invasive (ie, laparoscopic or robotic) approach. The use of laparoscopic resection rectopexy has been increasing since the introduction of laparoscopic surgery in the 1990s. ^[8] Operating times, complication rates, and recurrence rates are comparable, and laparoscopy has been linked with shorter hospitalization and earlier return to normal activities and work. ^{[9, 10]} The authors have been performing laparoscopic surgery in patients traditionally thought to be poor candidates for open abdominal surgery.

Preoperative workup and patient preparation are similar for open and laparoscopic resection rectopexy. Postoperative care and complications are also similar.

A US-Dutch study comparing laparoscopic resection rectopexy with laparoscopic ventral rectopexy for the treatment for rectal prolapse found that whereas both yield significant functional improvements, the former may result in better continence (though also a higher complication rate). ^[11]

A 2015 retrospective review of the National Surgical Quality Improvement Program (NSQIP) database found that laparoscopic rectal prolapse surgery was comparable to perineal surgery in terms of morbidity and mortality. ^[12]

A 2018 retrospective study compared resection rectopexy (n = 79) with ventral mesh rectopexy (n = 108) in patients with rectal prolapse, evaluating complications and prolapse recurrence rates. ^[13]  No significant differences were observed with regard to either complications or recurrence, and the authors were unable to establish superiority for either surgical technique.

A 2018 study involving 40 patients with rectal prolapse was performed to determine whether resection rectopexy improved the radiologic prolapse grade and thereby affected patients' symptoms and quality of life. ^[14]  Defecography revealed postoperative improvement in the prolapse grade and pelvic floor position. Clinical symptoms and quality of life improved in both the total population and the group with an improved radiologic prolapse grade (n = 30); however, the group without improved radiologic findings showed no improvement in symptoms or quality of life.