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 sex, 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 because 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]  A multicenter randomized trial from Sweden compared four surgical procedures for rectal prolapse—Delorme's procedure, Altemeier's procedure, suture rectopexy, or resection rectopexy—and found that whereas health change scores were significantly improved up to 1 year, there were no significant differences between the procedures with respect to degree of bowel function improvement, recurrence rate, or postoperative complications.[8]

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.[9] 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.[10, 11] 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).[12]

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.[13]

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.[14]  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.[15]  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.

A thorough history and a careful physical examination are essential, with special emphasis on cardiopulmonary status so as to optimize the patient's ability to tolerate surgical stress. Pelvic floor dysfunction should be studied with anal sphincter function testing and defecography. If colon dysmotility is suspected, a sitz marker or equivalent nuclear imaging study should be obtained.

The diagnosis of rectal prolapse is made through physical examination. Patients are usually able to force the prolapse out. The authors often have them push out the prolapse while on a commode and then confirm the diagnosis. Video or magnetic resonance defecography may be necessary to confirm the diagnosis. All patients should then undergo colonoscopy to rule out any occult pathology.

For patients with constipation, colonic transit studies (sitz markers or nuclear scan) should be performed to check for colonic inertia. For patients with fecal incontinence and obstructed defecation, anal manometry and endoanal ultrasonography (EAUS) can provide documentation of their preoperative physiologic status. Patients should receive counseling about the risks and complications of the surgical procedure.

Mechanical bowel preparation with a Nichols prep (oral antibiotics) is required. This is started on the day before the operation to clear the bowel of fecal material and decrease the bacterial load in the colon. The authors also perform rectal irrigation in the operating room. All oral intake is stopped the night before the procedure, and only essential medications are allowed on the morning of the operation with a sip of water. A standard enhanced recovery pathway should be followed.[16]

Preoperative intravenous (IV) antibiotics, which cover gram-negative and anaerobic organisms, are given within 1 hour of the incision time. Preoperative prophylaxis for deep vein thrombosis is imperative.

Anesthesia

After the patient is induced under general anesthesia, a muscle relaxant is administered, and an endotracheal tube is placed.

Positioning

A Foley catheter is inserted into the bladder for accurate measurement of urine output during the procedure and for decompression of the bladder. The authors remove the Foley catheter 24 hours after surgery. An orogastric tube is placed to decompress the stomach during the operation.

The patient is placed in a lithotomy Trendelenburg (modified Lloyd-Davis) position, with both arms tucked. The legs are placed on stirrups with adequate soft padding to prevent pressure sores on the skin and pressure-related nerve injury to the common peroneal nerves. Antiembolic stockings or compression devices are applied to the legs.

The entire abdomen is prepared with chlorhexidine antiseptic solution. Sterile draping is applied, ensuring adequate exposure of the abdomen and perineum.

For laparoscopic procedures, the operating surgeon and assistant stand on the patient's right side after the ports are placed. The cords should be run off the left side to allow free range of motion. The scrub nurse or technician is at the foot of the bed.

A lower midline laparotomy incision is made from umbilicus to pubis. Abdominal wall retractors (eg, Balfour or Bookwalter) are placed. If the uterus is present, the authors place a stitch through it and anchor it to the bladder blade to facilitate exposure.

A thorough exploration of the abdominal cavity is performed. Moist laparotomy pads are used to tuck the transverse colon and the small bowel loops cephalad and to the right, away from the operative field, for adequate exposure of the sigmoid colon and the mesenteric vessels. A St Mark retractor should be available if access to the pelvis is required.

The assistant holds the sigmoid colon and retracts it medially and upward. The surgeon then starts dissecting along the white line of Toldt (the line of attachment to the parietal peritoneum on the lateral side). The ureter is seen crossing the gonadal vessels at the level of the pelvic brim; it has a characteristic peristaltic movement, resembling the movement of an earthworm.

The medial border of the mesentery is then lifted off the retroperitoneal attachments; this helps in identification of the inferior mesenteric artery (IMA) and other vascular branches. The sigmoid branches of the IMA and the inferior mesenteric vein (IMV) are then ligated beyond the left colic branch and divided. An effort should be made to spare the superior rectal vessels.

Once the colonic segment is mobilized, the descending sigmoid junction is divided with a stapling device. The mesentery is divided, and the superior rectal artery is lifted up. The authors mobilize the rectum posteriorly down to the pelvic floor and then open the anterior cul-de-sac. Peritoneal incisions on the right and left sides are joined in front (anteriorly) in the deep rectovesical/rectouterine pouch. The rectum is now divided just above the pelvic floor.

The descending colon-to-rectum anastomosis is usually performed with a circular stapling device, such as an end-to-end anastomosis (EEA) stapler. The anvil of the EEA stapler is sutured to the distal end of the proximal portion of the colon. The surgeon then stands between the patient’s legs and passes the stapler through the anal canal into the rectum until it reaches the proximal end of the rectal stump.

At this point, the EEA stapler is opened, exposing the spike, which is then attached to the anvil at the other end of the colon. The stapler is then closed and fired to complete the anastomosis. The donuts obtained after stapling are checked to confirm that complete rings have been obtained.

The anastomosis is tested for leaks by placing the patient in the reverse Trendelenburg position and filling the pelvis with saline. A rigid sigmoidoscope may be passed through the anal canal to enable direct visualization of the anastomosis. The colon is clamped proximal to the anastomosis, and air is then insufflated into the rectum via the sigmoidoscope.

The colon is checked for adequate distention with air and for any bubbling of air in the pool of saline in the pelvis. The presence of a stream of bubbles indicates a positive leak test result, in which case an attempt must be made to identify and oversew the leak. In rare cases, a complete revision of the anastomosis is required.

Once the sigmoid colon is resected and sent to pathology, the suture rectopexy is performed. An area 4-5 cm below the sacral promontory is chosen for the inferiormost aspect of fixation. The rectum is pulled superiorly and posteriorly, and several sutures are placed on either side of it to attach it to the presacral fascia. Simple or mattress or running sutures (No. 1 or 2 polypropylene or polydioxanone) are placed on either side; these provide temporary fixation until fibrosis develops between the rectum and the fascia. Fixation of mesh varies.

The abdominal wall is then closed in layers. The fascia is closed with No. 1 polypropylene or polydioxanone continuous suture. The subcutaneous tissue can be approximated with 3-0 polyglactin interrupted ties. The skin can be closed with staples or with 4-0 poliglecaprone subcuticular sutures.

Drainage must also be adequately addressed.

The placement of ports is crucial for dissection of the tissues and is similar to that used in laparoscopic sigmoid resection. The camera port (5 or 10 mm, depending on the camera being used) is inserted in the periumbilical area with either the Hassan (open) or Optiview technique (with or without the Veress needle). The additional 5-mm ports are inserted under direct vision in the right upper quadrant (RUQ) and the left lower quadrant (LLQ). A 1-mm port is placed in the right lower quadrant (RLQ), 2 cm below and medial to the anterior superior iliac spine (ASIS).

The patient is then placed in a deep Trendelenburg position with a tilt to the right so that the small bowel is retracted to the RUQ. Of the two possible approaches, the authors prefer the medial-to-lateral approach.

The redundant sigmoid is lifted up, placing the mesentery on traction. The sacral promontory is a useful guide. The mesorectum is opened just in front of the promontory on the right and extended both superiorly and inferiorly. Care is taken to spare the hypogastric nerves in front and below the sacral promontory. Further dissection of the mesentery is carried out laterally, and retroperitoneal structures (eg, the ureters, the gonadal vessels and the iliac vessels) are identified and preserved.

Once this is done, the sigmoid vascular pedicle (distal to the left colic artery) is isolated and divided with either a Harmonic or LigaSure dissector or an endoscopic gastrointestinal anastomosis (Endo-GIA) stapler. Care is taken to spare the superior rectal vessels. The rectum is then mobilized from its attachments (Waldeyer and lateral rectal fascia and anterior cul-de-sac) and divided with an endoscopic linear stapler.

Next, the proximal sigmoid colon is mobilized until reach from the descending colon to the rectum is possible. Gas is then exsufflated through the ports, and a 5-cm extraction incision is made. The sigmoid colon can be exteriorized by making a Pfannenstiel incision or by widening the 5-mm port incision in the LLQ or the umbilical port. The proximal sigmoid colon is then divided, and an anvil is placed either with a purse-string device or a running 2-0 polypropylene suture.

The descending colon-to-rectum anastomosis is usually performed with a circular stapling device. The colorectal anastomosis is performed in much the same fashion as in the open technique and is also checked for any leaks. This is done laparoscopically once the abdomen has been reinsufflated after closure of the extraction site. The resected specimen is sent to pathology for histologic analysis.

Once the integrity of the anastomosis is confirmed, the rectopexy is performed by placing at least one stitch between each of the lateral stalks of the rectum to the presacral fascia laparoscopically. Alternatively, laparoscopic tacks can be used (the authors’ preference).

Once this is done, the ports are removed. The extraction site incision is closed in layers, in much the same manner as a laparotomy wound. The fascia of the 12-mm port is also closed separately to prevent hernia formation. The skin is closed with either skin staples or 4-0 poliglecaprone subcuticular sutures.

An approach has been described in which laparoscopic resection rectopexy is performed with natural orifice speciment extraction (NOSE).[17]  Compared with conventional laparoscopic resection rectopexy, this approach appears to be safe, with a comparable operating time and a comparable rate of postoperative complications, and potentially to offer a shorter postoperative recovery time.

Robotic-assisted laparoscopic resection rectopexy is comparable with regard to complications and recurrence rates, at least in short-term follow-up, and has been associated with higher costs and longer operating times.[18] The cost and longer duration of the robotic procedure have yet to be rigorously weighed against the shorter length of stay and reduced morbidity.

Postoperatively, the patient is extubated and transferred to the recovery room for appropriate monitoring before transfer to the floor. The patient is started on clear liquids and avanced as tolerated. Intravenous (IV) fluids and IV nonnarcotic pain medication are continued for as long as 24 hours. Antiembolic stockings are continued, and agents for prophylaxis of deep vein thrombosis (DVT), such as low-molecular-weight heparin (LMWH), are started on postoperative day 0.

After 24 hours, the patient is weaned off the IV fluids. The Foley catheter is removed on postoperative day 1. The patient is encouraged to ambulate and perform incentive spirometry to prevent atelectasis.

Daily laboratory tests, including at least a complete blood count (CBC) with differential and a basic metabolic panel, are performed for the first 48 hours or as indicated. Discharge criteria include tolerating liquids, passing flatus, and adequate analgesia and ambulation. High-fiber diet and soft laxatives are used to avoid constipation.

Follow-up in the office 14 days after surgery is the ideal for standard postoperative care.

Early complications of resection rectopexy include the following:

• General complications (eg, hemorrhage, DVT, pulmonary embolism [PE], urinary tract infection [UTI], atelectasis/pneumonia, myocardial infarction [MI], and congestive heart failure [CHF])
• Wound infection (both superficial and deep), wound dehiscence and evisceration
• Intraoperative complications (eg, ureteral or vaginal injury)
• Deep pelvic infection
• Presacral hemorrhage
• Prolonged paralytic ileus
• Anastomotic leakage

Late complications include the following:

• Anastomotic stricture
• Recurrence of rectal prolapse (0-10% for both open and laparoscopic techniques; likelihood of recurrence may be greater with increasing length of prolapsed rectum ^[19] )
• Bowel obstruction secondary to adhesions
• Incisional hernia
• Sexual/urinary dysfunction (due to autonomic nerve injury)
• Loss of rectal reservoir function, which may result in urgency and diarrhea

Although the list of possible complications is long, complication rates in expert hands are low. Surgical-site infection (SSI) is the most common postoperative complication. Patients and referring physicians should look at hospital data (eg, Leapfrog safety ratings) to evaluate outcomes.