|Year : 2018 | Volume
| Issue : 4 | Page : 304-310
Laparoscopic ventral rectopexy: A viable option in procidentia with redundant sigmoid – An Indian perspective
Abhijit Chandra1, Prabhu Singh1, Saket Kumar1, Nikhil Chopra1, Vishal Gupta1, Pradeep Joshi1, Vivek Gupta2
1 Department of Surgical Gastroenterology, King George's Medical University, Lucknow, Uttar Pradesh, India
2 Department of Human Organ Transplant, King George's Medical University, Lucknow, Uttar Pradesh, India
|Date of Submission||09-Jun-2017|
|Date of Acceptance||09-Nov-2017|
|Date of Web Publication||3-Sep-2018|
Prof. Abhijit Chandra
Department of Surgical Gastroenterology, King George's Medical University, Ground Floor, Shatabdi Hospital-Phase I, Lucknow - 226 003, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Laparoscopic ventral mesh rectopexy (LVMR) has gained widespread acceptance for the management of complete rectal prolapse (CRP). However, there have been concerns considering its use in patients with a redundant sigmoid colon. This study was conducted to evaluate the anatomical and functional results following LVMR, particularly in cases of CRP with a redundant sigmoid colon.
Materials and Methods: Retrospective analysis of 25 patients who underwent LVMR from January 2011 to September 2016 was performed. Patients were divided into two groups according to the duration of follow-up. Group A (long-term) with follow-up >3 years and Group B (mid-term) <3 years.
Results: The study included 25 patients (M:F = 1.5:1) with a median age of 38 years. Eighty-eight percent of the patients had a redundant sigmoid colon. Significant improvement in post-operative Wexner score as compared to pre-operative values was seen in patients with pre-existing constipation (P < 0.0001). In patients presenting with faecal incontinence (FI), significant improvement in post-operative St. Mark's incontinence score was observed. Functional outcomes remain consistent in long-term follow-up (>3 years).
Conclusions: LVMR seems to be a feasible surgical procedure with minimum morbidity and good long-term functional outcomes. It provides satisfactory results in patients with redundant sigmoid colon and improves pre-existing constipation and FI.
Keywords: Constipation, laparoscopic ventral mesh rectopexy, rectal prolapse, redundant sigmoid colon
|How to cite this article:|
Chandra A, Singh P, Kumar S, Chopra N, Gupta V, Joshi P, Gupta V. Laparoscopic ventral rectopexy: A viable option in procidentia with redundant sigmoid – An Indian perspective. J Min Access Surg 2018;14:304-10
|How to cite this URL:|
Chandra A, Singh P, Kumar S, Chopra N, Gupta V, Joshi P, Gupta V. Laparoscopic ventral rectopexy: A viable option in procidentia with redundant sigmoid – An Indian perspective. J Min Access Surg [serial online] 2018 [cited 2020 Feb 20];14:304-10. Available from: http://www.journalofmas.com/text.asp?2018/14/4/304/228401
| ¤ Introduction|| |
Rectal prolapse was described as early as 1500 BC. Complete rectal prolapse (CRP) is a circumferential descent of rectum or sigmoid colon through the anal canal. Overall incidence is 0.25%–0.4% with 6 times more frequent in females. CRP is a complex disease with multifactorial aetiology that includes compartment pelvic floor disorder, intussusceptions, anatomical characteristics such as colonic redundancy, diastasis of the levator ani, deep pouch of Douglas or prolonged constipation.,
The objective of the surgical intervention is correction of the anatomical defect with minimal morbidity and good long-term outcomes. Transabdominal procedures predominate in the surgical treatment of rectal prolapse with superior functional results and low recurrence rates. An outcome with laparoscopic rectal surgery has been universally positive since its introduction by Berman in 1992. Laparoscopic access combines the advantage of reduced surgical stress, less post-operative pain, hasten recovery and shorter hospital stay. Laparoscopic ventral mesh rectopexy (LVMR) seems to emerge as an efficient procedure for the treatment of patients with full-thickness rectal prolapse based on the favourable outcome in terms of low recurrence rate, low de novo constipation rate, improvement of anal incontinence with minimal morbidity.
Surgeons across the world have come up with very good result in terms of ease and minimal post-operative recurrences. To evaluate the results of LVMR at our centre, the aim of this study was to evaluate demographic profile, aetiology and clinical presentation, long-term and midterm surgical and functional outcomes in the patients who underwent LVMR.
| ¤ Materials and Methods|| |
This is a retrospective study of prospectively recorded database (computerised) of patients who underwent LVMR for full-thickness rectal prolapse at tertiary health care centre from January 2011 to September 2016. Patients were also divided into two groups and results were compared as long-term and midterm outcomes. This was done to evaluate the consistency of functional outcomes.
- Group A-follow-up completed >3 years (n = 12)
- Group B-follow-up completed <3 years (n = 13) but a minimal 6-month follow-up.
Exclusion criteria included patients with:
- Not fit for laparoscopic surgery
- Non-consenting patient
- Complicated rectal prolapse
- Associated with mass in rectum/sigmoid
- Partial rectal prolapse
- Lost to follow up.
A comprehensive workup includes a detailed history, clinical assessment, contrast imaging and colonoscopy. It includes the duration of disease, symptoms such as constipation, faecal incontinence (FI), bleeding per rectum, per rectal and perineal examination in both left lateral and squatting position [Figure 1]a.
|Figure 1: (a) Full thickness rectal prolapse with multiple decubitus ulcers (b) barium enema showing redundant sigmoid colon (c and d) Showing pre- and post-operative resting and squeeze pressure (e) Showing pre- and post-operative Wexner score|
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For FI and constipation, St. Mark's incontinence score (SMIS) and Wexner constipation scoring system were used, respectively [Annexure 1] and [Annexure 2]., Pre- and post-operative anal canal manometry were done in patients with FI. Pre-operative incontinence was defined as SMIS >8, and pre-operative constipation as Wexner score >5. A disease-specific personal questionnaire was used along with continence scale to objectively assess patient satisfaction level following the procedure [Annexure 3].
Details of the demographics, presentation, risk factors, surgical details and outcome were evaluated. Follow-up records, data pertaining to therapies, and dates of the last contact were recorded. A patient was labelled ‘lost to follow-up’ if all attempts to establish contact with him/her fails. In addition, data of disease relapse and death, if any were also collected.
LVMR was performed as described by D'Hoore et al. and Chandra et al. Surgery was done under general anaesthesia with the patient in steep Trendelenburg's position after catheterisation and prophylactic intravenous antibiotics. Four ports were used including supra-umbilical camera port (30° telescope). After identification of recto-sigmoid junction, peritoneum over the right side of the sacral promontory was incised and extended distally along the side of the rectum and over the deepest part of the pouch of Douglas. Right hypogastric nerve and ureter were identified and safeguarded. No rectal mobilisation or lateral dissection was performed. A 3 cm × 17 cm strip of polypropylene mesh (Ethicon Endosurgery, Blue Ash, Ohio, USA) was applied using polypropylene sutures and tacker fixation device (Covidien, Dublin, Ireland). The mesh was fixed proximally to the sacral promontory using tackers while the distal end was fixed to rectum using seromuscular prolene sutures. In females, the distal part of the mesh was also sutured to the posterior vaginal fornix. This allowed the correction of vaginal vault prolapse. The lateral borders of the incised peritoneum were then closed over the mesh. The pelvic drain was kept in selected cases.
Follow-up and post-operative assessment
The anorectal function was assessed 3, 6 and 12 months and thereafter every 1 year post-operatively using the SMIS and Wexner constipation score as well as anal canal manometry. Patients were evaluated for the presence of recurrence, constipation whether reduced/worsen/de-novo/or no change, use of laxative, FI, urinary or sexual problem or dyspareunia.
Data were collected and statistically analysed using GraphPad Prism 5-0 (GraphPad Prism software, Inc., California, USA). Quantitative data were expressed as mean, median and range. Qualitative data were analysed using Chi-square test. Student's t-test and the paired t-test was used for quantitative data. Groups were compared using Student's t-test (unpaired). The value of P < 0.05 was considered as statistically significant.
| ¤ Results|| |
Demographics and clinical characteristics
Twenty-five patients with full-thickness rectal prolapse with M:F, 1.5:1 were included in the study. The median age of presentation was 38 years (range, 14–68 years). Duration of illness was 9.77 ± 7.03 years (mean ± standard deviation) (range; 0.4–29). Associated symptoms were constipation (52%), bleeding per rectum (28%) and FI (24%). The median duration of constipation was 4.74 years (range 4 month-18 years). The median duration of FI was 2 years. The most common cause of rectal prolapse was idiopathic (60%) followed by multiparous (28%) and congenital (12%). Pre-operative colonoscopic, barium enema [Figure 1]b and anal canal manometry findings are summarised in [Table 1]. Twenty-two patients (88%) had redundant sigmoid pre-operatively. Long-term outcomes were found to be satisfactory in these patients. All patients were able to tolerate full oral diet by post-operative day 4 (range 3–6).
|Table 1: Pre-operative colonoscopy, barium enema and anal canal manometry findings|
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Morbidity and mortality
No 30-day hospital mortality was recorded. Post-operative complications were transient urinary problems (n = 3), port site infection (n = 2), and re-exploration in one patient. Reexploration was done for missed small bowel injury. The patient was readmitted with features of sepsis and expired afterwards secondary to acute respiratory distress syndrome. There were no mesh-related complications till the longest follow-up.
Median follow-up was 33.5 months (range 6–82 months). All patients were available for follow-up. Functional outcomes were consistent with long-term follow-up.
There was a marked improvement in incontinence as assessed subjectively as well as objectively by SMIS and anal canal manometry [Table 2] and [Figure 1]c and [Figure 1]d.
|Table 2: Pre-operative and post-operative Wexner score, St. Mark's incontinence score and anal canal pressures|
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Post-operatively, 84% of these had improvement. There was a marked improvement in Wexner score [Table 2] and [Figure 1]e. Two patients complained of persistent constipation for which they required regular laxative use even after long-term follow-up.
Recurrence and new onset symptoms
Only one patient had a recurrence after 4 years of surgery. Recurrence was due to detachment of proximal fixation of mesh from the sacral promontory. He underwent open mesh posterior rectopexy. On personal questionnaire, patients were satisfied with the procedure. No new-onset constipation or FI, urinary problem developed in any patient. No female patients complained of sexual dysfunction and no male patient complained of ejaculatory or erectile difficulties post-operatively, till the longest follow-up of this study.
Intraoperative variables and post-operative outcomes were compared in Group A and B [Table 3]. Mean operative time decreased significantly in Group B that was indirect evidence of achieving learning curve. No intra-operative complications were recorded. None of the patients required intra-opearative blood transfusion in both groups. However, hospital stay was less in Group B as compared to A. Functional outcomes were consistent in long-term follow-up.
|Table 3: Comparison of pre-operative and post-operative variables of patients of long-term (Group A) and midterm follow-up (Group B)|
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| ¤ Discussion|| |
Minimal invasive surgery for rectal prolapse seems to be standard of care with advantage of less post-operative pain, early return of bladder and bowel function, enhanced recovery, less incidence of adhesions and incisional hernia and small scars. LVMR have advantage of minimally invasive surgery, restricted rectal mobilisation, and preservation of autonomic nerve plexus that turns to better post-operative functional outcomes.,,
In our series, males outnumbered females. This result is controversial from literature. However, this result might be erroneous due to small sample size. The median age in this study was 38 years which is younger than reported in the literature. Younger age of presentation in this study can be explained as most of the patients were male. As a matter of fact, when males are affected, they tend to be young and report significant bowel function symptoms, especially constipation or have a predisposing congenital disorder.
In our series, median duration of surgery in initial period (Group A) was slightly higher than reported (140 min) by D'Hoore et al. It may be due to the reason that laparoscopic surgery in the pelvis is quite challenging, particularly during initial learning curve due to more confined space. The operative time required for the surgery decreased over time (Group B).
Similarly, median post-operative hospital stay was slightly higher than reported in the literature (7 vs. 4 days). Longer duration of hospital stay in our series was because of patients insistence for hospital stay till suture removal, even though they fulfilled the discharge criteria.
FI was improved markedly. Similarly, other studies showed significant improvement in incontinence score.,, A systemic review reported improved FI in patients suffering from this condition. The rate of new-onset of FI after LMVR was low., There was a statistically significant improvement in both resting and squeeze anal canal pressure. Improvement in FI can be explained by anatomical correction of the rectum as before surgery the rectum constantly presents to the anal canal which, by reflex, causes the internal sphincter muscle to relax. This type of incontinence often improves after surgery.
In those patients who had constipation at the time of presentation, there was a statistically significant improvement in post-operative Wexner score as compared to preoperative scores. D'Hoore et al. reports constipation as presenting feature in 54% of patients with resolution of symptoms in 84% patients. Our functional results are very similar to these studies, improving constipation in the order of 84%, with no severe worsening or new onset of constipation. Similarly, in a series of 65 patients by Boons et al., 72% improvement in post-operative Wexner score was noticed. As in CRP, constipation is due to bunching up of the rectum, creating a blockage that is made worse with straining. Restoration of anatomical position of the rectum is reflected into improvement in constipation. Restoration of recto-anal inhibitory reflex can avoid paradoxical contraction of sphincter muscle as well. Three randomised trials have shown an improvement in constipation by avoiding division of the lateral ligaments.,, Resection of the sigmoid colon has been recommended in patients with redundant sigmoid to improve constipation. However, in our study, redundant sigmoid was present in 22 out of 25 patients. Still all patients had improved constipation scores in the follow-up, and none reported new onset constipation. This is probably due to the preservation of rectal autonomic innervations. In addition, LVMR eliminates the risk of an anastomotic leak, as seen in patients undergoing sigmoid colon resection.
In one patient, recurrence occurred after 3 years of surgery. This recurrence was due to detachment of mesh from the sacral promontory. Similarly, late detachment of mesh from sacral promontory was reported by van Geluwe et al. D'Hoore et al. and Faucheron et al. have reported recurrence rate of 4.7 and 4% respectively. Most recurrences occur within the first 2–3 years.,
There was no mesh-related complication in this study till the longest follow-up. This might be due to complete retroperitonealisation of mesh. Two recent papers highlight technical failures of LVMR and mesh-related complications rate of 1.2%.,
Follow-up colonoscopic examination after 3 months of surgery showed healed ulcer in those patients who had ulcers at initial presentation. In a series by Evans et al.reported healing of decubitus ulcer in 90% of patients at 3-year follow-up.
Results from our study at a mean follow-up of 33.5 months provide evidence that LMVR is an effective and feasible surgical intervention having all advantage of minimally invasive surgery with better long-term functional outcomes and acceptable morbidity and mortality rate.
| ¤ Conclusions|| |
LVMR seems to be the feasible surgical procedure for CRP. It has the advantage of minimally invasive surgery with minimum morbidity and good functional outcomes in terms of significant improvement in constipation and FI. This study is to provide evidence rather than opinion for the benefit of laparoscopic surgery. Still, the evidence is lacking. Further larger prospective randomised control trials are needed to prove as a gold standard surgical technique.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| ¤ Annexures|| |
Annexure 3: Personal interview questionnaire
Date: Name: Age
Sex: Date of surgery:
- 1. Are you satisfied with the outcome of your surgery:
- Do you feel your life has become better after surgery:
Yes/No/Has remained same
- Does part of your bowel ever pass through the anus and comes outside during or after defecation?
- To what extent does the constipation distress you following surgery:
Completely relieved/Partially relieved/remained same/Slightly worsened/Worsened much
- Ever have to push on the vagina or around the rectum to have or complete a bowel movement?
- To what extent does the anal/fecal incontinence distress you following surgery:
Completely relieved/Partially relieved/remained same/Slightly worsened/Worsened much
- Do you now feel more confident in your
- Daily life (walking/swimming/doing exercise/driving): Yes/No
- Family life (with spouse): Yes/No
- Social life: Yes/No
- Do you feel yourself a burden on others:
- Do you ever feel insecure/nervous or depressed?
No/Sometimes/Most of times
- To what extent do you feel yourself as an integral part of your family before and after the procedure:
- To what extent can you fulfill the needs of your family after the procedure:
- Will you advice this procedure to others (friends/relatives) with the same problem:
- Suppose if you have the same problem (like you had earlier), would you like to undergo this procedure again:
- Other comments:
Signature ––––––– (Name/Date)
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[Table 1], [Table 2], [Table 3]