Pelvic Floor Disorders: Surgical Approach

20. Rectopexy without Mesh

Steven D. Wexner  and Julie Ann M. Van Koughnett

(1)

Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA

Steven D. Wexner

Email: wexners@ccf.org

Abstract

Suture rectopexy is one of the most widely used abdominal approaches to the treatment of full-thickness rectal prolapse. Cutait is credited with the first description of suture rectopexy [12]. It is a safe procedure with low morbidity and mortality [23]. Other abdominal approaches have results that are comparable to suture rectopexy and are described elsewhere [34]. Recurrence rates after suture rectopexy for prolapse have been consistently reported to be less than 10%, which are lower than reported for perineal approaches [56]. Traditionally, suture rectopexy and other abdominal approaches such as mesh rectopexy have been used in relatively healthy patients. In older or frail individuals a perineal approach is more likely to be chosen, as the patient does not need to recover from an abdominal incision. This dogma has recently been challenged. In a review of the American College of Surgeons National Surgical Quality Improvement Participant data, suture rectopexy and other abdominal approaches were found to be safe and feasible in highrisk patients, including octogenarians and those with an American Society of Anesthesiologists score greater than 3 [2]. Technical factors may impact the success of suture rectopexy, such as the extent of rectal mobilization, choice of open or minimally invasive approach, and the decision to include colon resection as part of the surgical procedure.

20.1 Introduction

Suture rectopexy is one of the most widely used abdominal approaches to the treatment of full-thickness rectal prolapse. Cutait is credited with the first description of suture rectopexy [12]. It is a safe procedure with low morbidity and mortality [23]. Other abdominal approaches have results that are comparable to suture rectopexy and are described elsewhere [34]. Recurrence rates after suture rectopexy for prolapse have been consistently reported to be less than 10%, which are lower than reported for perineal approaches [56]. Traditionally, suture rectopexy and other abdominal approaches such as mesh rectopexy have been used in relatively healthy patients. In older or frail individuals a perineal approach is more likely to be chosen, as the patient does not need to recover from an abdominal incision. This dogma has recently been challenged. In a review of the American College of Surgeons National Surgical Quality Improvement Participant data, suture rectopexy and other abdominal approaches were found to be safe and feasible in highrisk patients, including octogenarians and those with an American Society of Anesthesiologists score greater than 3 [2]. Technical factors may impact the success of suture rectopexy, such as the extent of rectal mobilization, choice of open or minimally invasive approach, and the decision to include colon resection as part of the surgical procedure.

20.2 Surgical Approach

Suture rectopexy may be approached by open or minimally invasive techniques. The patient is placed in a modified lithotomy position. The open technique incision may be lower midline or Phannensteil. Laparoscopically, bilateral ports are required. The sigmoid colon and rectum are first identified and assessed for redundancy. The ureters must be identified and avoided during dissection. The peritoneal reflection is incised and rectal dissection is performed. The rectum is mobilized posteriorly through the avascular plane, with care taken to avoid hypogastric nerve injury and bleeding. A deep posterior rectal dissection to the level of the pelvic floor is important. Once posteriorly mobilized, lateral dissection of the rectum is done to the level of the lateral stalks. The lateral ligaments may or may not be divided, and the choice to divide the lateral ligaments is discussed later in this chapter. The rectum is then sutured to the sacral promontory using nonabsorbable sutures. One to three sutures are placed on each side, tacking the lateral rectal ligaments to the presacral fascia bilaterally. Great care must be taken not to penetrate the rectum with the sutures. If a resection is included, the rectopexy sutures should be placed several centimeters distal to the anastomosis to help avoid angulation of the anastomosis. In addition, the splenic flexure, inferior mesenteric artery and vein, and superior rectal artery and vein are preserved. Flexible endoscopy is performed to assess the anastomosis and as part of an air leak test after creation of the anastomosis. After verification of anastomotic integrity, the rectopexy sutures are tied and then endoscopy and air testing are repeated to ensure that the rectal lumen has not been narrowed by the rectopexy sutures. Although some angulation is expected, if stenosis is noted one or more of the rectopexy sutures should be removed and the endoscopy repeated.

20.2.1 Minimally Invasive Techniques

As with many operations, minimally invasive approaches have been developed for suture rectopexy for rectal prolapse. Laparoscopic rectopexy has been shown to have favorable results, with recurrence and complication rates comparable to open rectopexy in numerous prospective studies [710]. A recent meta-analysis found no significant difference in recurrence, as well as postoperative constipation and incontinence [5]. However, all of these studies have included relatively few patients. A Cochrane review of the literature concluded that no one technique of rectopexy is superior, with very few high-quality randomized studies available [3]. It is clear that laparoscopic rectopexy is safe, has good outcomes, and may be offered to patients requiring rectopexy [11]. As laparoscopy continues to grow in its use in colorectal surgery, more and more surgeons will likely offer their preferred method of rectopexy (suture or mesh) through a laparoscopic approach to facilitate faster recovery. More recently, the robotic platform has been used for suture rectopexy. In a small study of six patients, robotic-assisted rectopexy was found to be safe, with low morbidity, and no short-term recurrence [12]. Early experiences have found that the robotic approach is more expensive and takes longer than laparoscopic rectopexy [1213]. The robotic approach may potentially facilitate the suturing portion of the procedure through the use of the articulating instruments with their additional degrees of freedom compared to laparoscopic instruments. This feature may be especially helpful for those surgeons who do not perform frequent laparoscopic suturing and feel they are not facile with laparoscopic rectopexy. More long-term data are needed on the outcomes, cost effectiveness, and feasibility of robotic-assisted suture rectopexy.

20.2.2 Bowel Resection and Rectopexy (Frykman-Goldberg Procedure)

The practice of performing a bowel resection in addition to a suture rectopexy is sometimes utilized, especially in the setting of rectal prolapse combined with constipation. This is known as the Frykman-Golberg procedure [14]. Both anterior resection and sigmoid resection, along with rectopexy, have been described in an effort to reduce redundancy and possible torsion of the sigmoid colon, and to achieve a straighter colon with the intact splenic flexure providing an additional point of fixation. These proposed benefits have not been consistently borne out in the literature, with similar recurrence rates when compared to rectopexy alone [1516]. In the setting of severe constipation, resection of redundant colon does appear to be associated with reduction in constipation. Prospective studies have shown that laparoscopic and open resection combined with rectopexy are followed by significant improvement in constipation in select patients, but only one of these studies compared rectopexy alone with rectopexy plus resection [1618]. In general, a resection may be appropriate in patients left with significant potential redundancy of the sigmoid colon following rectopexy, putting them at risk for volvulus or kinking of the bowel above the rectopexy fixation point; this might lead to continued constipation.

20.2.3 Lateral Rectal Ligaments

The treatment of the lateral rectal ligaments as part of the rectal mobilization during rectopexy has been a point of debate. Numerous studies of both laparoscopic and open suture rectopexy have addressed the approach to the lateral ligaments [171924]. Pooled results show a trend toward improvement in constipation and continence with preservation of the lateral ligaments [6]. These findings may be due to presumed nerve injury that occurs with division of the ligaments, causing rectal denervation and constipation. Without ligament division, the risk of recurrent prolapse may be slightly higher, though there is insufficient evidence in the literature to make any definitive conclusions, especially since recurrence rates are low [3]. Thus, it is likely sufficient to preserve the distal lateral ligaments and ensure that only the anterior and posterior rectal planes are fully dissected to the levator muscles. This measure will avoid unwanted functional outcomes such as constipation and likely will not contribute to a clinically significantly higher risk of recurrent full-thickness prolapse.

20.3 Recurrent Rectal Prolapse

Overall outcomes of suture rectopexy for rectal prolapse are excellent. The primary outcome of interest is recurrent rectal prolapse, with constipation and incontinence being predominant secondary outcomes of interest. A recent randomized trial of various treatments of rectal prolapse, including rectopexy, resection rectopexy, and perineal approaches, found that no technique had a statistically superior recurrence rate [4]. However, that study did not attain the participant recruitment for which it was powered. The most recent meta-analysis published found that in studies of suture rectopexy with more than ten participants per study, the long-term recurrence rate ranged from 0% to 9% for the open approach and from 0% to 7% for the laparoscopic approach (nonsignificant difference) [5]. In the majority of larger studies, improvements are noted in validated postoperative constipation and continence scores [5]. A few studies have found worsened constipation, highlighting the necessity of a proper history preoperatively and consideration of adding a resection to the procedure and preserving the lateral ligaments at the time of surgery [56]. A transient reduction in continence may be seen in the early postoperative period, as the sphincter complex has been chronically dilated in many cases due to the mass effect of the prolapsed rectum. Long term, however, suture rectopexy almost always results in improved continence in pooled analyses [56]. All of these outcomes should be addressed with potential surgical candidates during preoperative discussions to plan for realistic outcomes.

20.4 Summary

In conclusion, suture rectopexy is a very effective and durable treatment for fullthickness rectal prolapse, with recurrence rates below 10%. It is also a safe procedure, with morbidity and mortality rates less than 1%. Proper technique is essential to achieve good results, and the surgical principles include rectal mobilization with complete anterior and posterior mobilization with preservation of the distal lateral stalks, bilateral multipoint fixation with nonabsorbable sutures, and intraoperative flexible endoscopy. The lateral rectal ligaments should be preserved. Laparoscopic and open approaches achieve similar outcomes, with faster recovery in the laparoscopic group. The robotic platform may theoretically make minimally invasive suture rectopexy easier for some surgeons. Although a sigmoid resection is not mandatory, it may be valuable in patients with very redundant colons or severe preoperative constipation. In addition to treatment of the rectal prolapse itself, most patients experience improvement in both constipation and continence following suture rectopexy. In patients who can tolerate an abdominal procedure, suture rectopexy is an excellent choice for the treatment of full-thickness rectal prolapse; surgeons treating rectal prolapse should be familiar with both the resectional and nonresectional techniques.

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