|Year : 2017 | Volume
| Issue : 3 | Page : 208-216
Short-term surgical and functional outcome of laparoscopic ventral mesh rectopexy for management of complete rectal prolapse
Mostafa B Abdulwahab MD , Hussein Elgohary
Department of General Surgery, Faculty of Medicine, Benha University, Benha, Egypt
|Date of Submission||12-Dec-2016|
|Date of Acceptance||26-Dec-2016|
|Date of Web Publication||27-Jul-2017|
Mostafa B Abdulwahab
Villa 35, Alnarges 1, 5th Settlement, New Cairo, 13518
Source of Support: None, Conflict of Interest: None
There is no clear treatment of choice for the problem of complete rectal prolapse (CRP). The treatment of CRP in adults is essentially surgical. Surgical management is aimed at restoring physiology by correcting the prolapse and improving continence and constipation with acceptable mortality and recurrence rates.
The aim of this study was to determine the safety and outcome of laparoscopic ventral mesh rectopexy (LVMR) for the management of patients with CRP.
Patients and methods
The study included 33 patients with CRP: 20 females and 13 males. Female patients were significantly obese than male patients were; however, male patients were significantly older. A total of four female patients had associated vaginal vault prolapse. All patients underwent LVMR. Surgical outcome included intraoperative, postoperative, and follow-up data. Functional outcome was assessed at 6- and 12-month postoperatively and compared versus preoperative evaluation for severity of fecal incontinence (FI) using Vaizey score, frequency, and severity of constipation using Cleveland Clinic Constipation score, and effect of FI on patient’s quality of life (QOL) using the Fecal Incontinence Quality of Life Scale score.
All patients passed smooth uneventful operative and immediate postoperative course. No patient required conversion to laparotomy. Mean operative time was 151.9±31.6 (range: 120–240)min, and mean amount of intraoperative blood loss was 75.2±16 (range: 50–130)ml. Laparoscopic surgery provided its usual advantages concerning low postoperative pain score, and early ambulation, oral intake, and hospital discharge. Only three (9.1%) patients developed immediate postoperative complications. All patients showed significant functional improvement manifested as a significant decrease of Vaizey FI and Cleveland Clinic Constipation scores with a significant increase of Fecal Incontinence Quality of Life Scale score at 6-month postoperatively, and these scorings were progressively improved till 12-month postoperatively. Throughout the course of the 12-month postoperative follow-up, two female patients developed recurrent rectal prolapse for a frequency of 6.1%.
LVMR is a safe procedure for management of CRP within reasonable operative time and with minimal immediate postoperative morbidities. LVMR provided significant improvement of CRP-associated FI and constipation and its effect on patients’ QOL. LVMR was associated with low frequency of postoperative recurrence throughout the 12-month follow-up.
Keywords: complete rectal prolapse, functional outcome, laparoscopic ventral mesh rectopexy, quality of life
|How to cite this article:|
Abdulwahab MB, Elgohary H. Short-term surgical and functional outcome of laparoscopic ventral mesh rectopexy for management of complete rectal prolapse. Egypt J Surg 2017;36:208-16
|How to cite this URL:|
Abdulwahab MB, Elgohary H. Short-term surgical and functional outcome of laparoscopic ventral mesh rectopexy for management of complete rectal prolapse. Egypt J Surg [serial online] 2017 [cited 2017 Dec 12];36:208-16. Available from: http://www.ejs.eg.net/text.asp?2017/36/3/208/211709
| Introduction|| |
The term rectal prolapse (RP) includes three different entities: full-thickness RP, mucosal prolapse, and internal prolapse (rectal intussusception).
Complete rectal prolapse (CRP) is defined as the circumferential full-thickness protrusion of the rectal wall through the anus . Straight rectum, a lack of rectal fascial attachments to the sacrum, a redundant sigmoid colon, levator ani diastasis, an abnormally deep Douglas pouch, and a patulous anus may be considered either anatomical predisposing factors for the development of CRP or the result of prolapsing rectum ,.
The treatment of CRP in adults is essentially surgical. Surgical management is aimed at restoring physiology by correcting the prolapse and improving continence and constipation with acceptable mortality and recurrence rates .
Numerous surgical procedures have been suggested to treat RP; however, the controversy regarding ‘which operation is appropriate?’ cannot be answered definitely . According to the approach used to repair the RP, surgical treatments can be divided into two categories: abdominal procedures, which are generally better for young fit patients, and perineal procedures, which are preferable for patients who are not fit for abdominal procedures, such as elderly frail patients with significant comorbidities. The abdominal procedures have a lower recurrence and a higher morbidity rate than the perineal procedures .
Laparoscopic RP surgery including both rectopexy and resection rectopexy can cure prolapse with good results and can be performed safely in older and debilitated patients . Although both techniques offer significant improvements in functional symptoms, laparoscopic resection rectopexy had a higher complication rate than laparoscopic rectopexy did. .
Because of the acceptable anatomical results, fewer complications, low recurrence rate, good functional results, and low mesh-related morbidity in the short to medium term, laparoscopic ventral mesh rectopexy (LVMR) has been popularized in the past decade. LVMR is performed for patients with CRP and internal prolapse .
The current study aimed to determine the safety and outcome of LVMR for the management of patients presented with CRP.
| Patients and methods|| |
The current prospective study was conducted at Department of General Surgery, Benha University Hospital, and Al-Adwani General Hospital, Taif, KSA, after obtaining approval from the local ethical committee and after fully informed written consent was signed by the patients. This study was carried out on 33 consecutive adult patients with CRP since January 2012 till June 2016.
All patients underwent clinical examination including collection of demographic data and past medical history and obstetric history for female patients. All patients underwent laboratory and radiological workup for assuring the diagnosis and defining other prolapsed organs, and also to assure inclusion criteria and fitness for surgery. Then, patients were prepared and underwent preoperative flexible colonoscopy.
Patients with recurrent RP, colorectal malignancy, ulcerative colitis, previous laparotomy for any previous cause, contraindication for abdominal insufflation, or bleeding diathesis were excluded from the study.
All patients received general inhalational anesthesia with endotracheal intubation. Using the 4-port technique, the camera is placed at the umbilicus, and two 5-mm trocars are placed in the left and right lower quadrants at the midclavicular lines. A 12-mm trocar is inserted in the suprapubic region just to the right of the midline. After pneumoperitoneum conduction up to 15 mmHg, patients were positioned in Trendelenburg position, and the small intestine is retracted cephalad. The rectosigmoid junction was identified and retracted to the left. A peritoneal incision was performed extending from the right side of the sacral promontory to the anterior peritoneal reflection distally ([Figure 1]a); then, the right hypogastric nerve and ureter were identified and safeguarded ([Figure 1]b). Using combined blunt and sharp dissections, a wide plane was developed in the rectovaginal/rectovesical space ([Figure 1]c). Prolapsed rectum was reduced, but no posterior rectal mobilization or lateral dissection was conducted ([Figure 1]d). After completion of dissection ([Figure 1]e), a strip of Prolene Mesh (Ethicon Endosurgery, Blue Ash, Ohio, USA), ∼3×17 cm, was prepared and inserted into the pelvic cavity through the 12-mm trocar site. One end of the mesh was fixed to the anterior surface of the most distal part of the rectum and to pelvic floor muscle laterally using polypropylene sutures ([Figure 1]f). Full-thickness bite into the rectal wall was avoided to prevent mesh contamination. Finally, the proximal end of the mesh was fixed to the sacral promontory using Tackers (Covidien, Dublin, Ireland). During fixation of the mesh, proximal traction on the rectum is avoided, as the rectum should not be placed under tension. In female patients, the distal part of the mesh was also fixed to the posterior vaginal fornix for correction of vaginal vault prolapse if present. The peritoneum was then reapproximated to completely cover the mesh ([Figure 1]g).
|Figure 1 (a) Peritoneal dissection down to the sacral promontory. (b) Dissection of the right ureter. (c) Dissection of the peritoneal reflection of the rectovesical pouch. (d) Reduction of the prolapsed rectum. (e) Complete peritoneal dissection down to the sacral promontory and preparation of the cavity. (f) Application and spreading of the Prolene Mesh to the rectum. (g) Closure of the peritoneal reflection after assurance of fixation and hemostasis.|
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- Surgical outcome
- Intraoperative collected data included conversion rate to laparotomy, operative time, intraoperative blood loss, and frequency of intraoperative complications.
- Postoperative data included pain assessment using 1–10 pain visual analogue scale scoring, time till first ambulation and oral feeding resumption, postoperative hospital stay, and frequency of postoperative complication.
- Postoperative follow-up extending for 12 months for frequency of recurrence, partial or complete
- Functional outcome was assessed at 6- and 12-month postoperatively and compared versus preoperative evaluation for the following:
- The severity of fecal incontinence (FI) was evaluated using Vaizey score  for a total score ranging between 0 (perfect continence) and 24 (total incontinence). Details of Vaizey score are shown in [Table 1].
- Evaluation of frequency and severity of constipation was done using Cleveland Clinic Constipation (CCC) score  for a total score ranging between 0 (no constipation) and 25 (severe constipation since long duration). Details of items are shown in [Table 2].
- The effect of FI on patient’s quality of life (QOL) was done using the Fecal Incontinence Quality of Life Scale (FIQL) , which consists of four subscales − lifestyle, coping/behavior, depression/self-perception, and embarrassment − including 29 questions. Responses to the questions are graded from 1 ‘strongly agree’ to 4 ‘strongly’ disagree. The obtained numerical values of all responses were added and then divided by the number of items. Higher scores indicate a better QOL.
Obtained data were presented as mean±SD, median, range, numbers, and percentages. Results were analyzed using one-way analysis of variance with post-hoc Tukey’s honest significant difference test and c2 test. Statistical analysis was conducted using the SPSS (version 15, 2006) for Windows statistical package. P-value less than 0.05 was considered statistically significant.
| Results|| |
The study included 33 patients who had CRP with a mean age of 59.5±14.5 (range: 25–78) years. There were 20 females and 13 males, with mean BMI of 27.4±2 (range: 23.4–30.8)kg/m2. Female patients were significantly obese than male patients were; however, male patients were significantly older. A total of four female patients had associated vaginal vault prolapse. Overall, 10 patients had additional morbidity with nonsignificantly higher frequency in female than in male patients. Details of patients’ enrollment data are shown in [Table 3].
All patients passed smooth uneventful operative and immediate postoperative course. No patient required conversion to laparotomy. All surgeries were conducted through a mean operative time of 151.9±31.6 (range: 120–240)min. Laparoscopic surgery provided its usual advantages regarding low postoperative pain scores and a minimal number of patients requesting rescue analgesia ([Figure 2]), and early ambulation, first oral intake, and hospital discharge as shown in [Table 4].
|Figure 2 Postoperative pain scores and frequency of patients requested rescue analgesia throughout the first 24 hours postoperatively.|
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Only three (9.1%) patients developed immediate postoperative complications: one diabetic patient developed hyperosmolar ketoacidotic coma on the second postoperative day and required admission to general ICU to receive intensive insulin therapy. She was discharged from the ICU after 3 days after proper adjustment of her blood glucose and was discharged uneventfully on the eighth postoperative day. Another 67-year-old patient developed acute myocardial infarction, which necessitated immediate ICU admission; fortunately, the patient responded well to thrombolytic therapy and stayed for 2 days and completed his immediate postoperative care free of complications and was discharged on the ninth postoperative day. The third patient had a delayed return of intestinal motility and developed manifestations of intra-abdominal infection. Computed tomography imaging defined pelvic collection that was drained laparoscopically. The patient was maintained on intravenous fluid and supportive therapy with appropriate antibiotic therapy; he responded to the applied therapy, and constitutional manifestations completely resolved. He was discharged on the tenth postoperative day to be re-evaluated for his prolapse. No operative or immediate postoperative mortality was reported.
All patients showed progressive improvement of their functional complaints. FI evaluated using Vaizey incontinence score showed a progressive significant decrease compared with the preoperative scoring. At the end of the 12-month postoperative follow-up, only five (15.2%) patients were still complaining of liquid and gas incontinence, which occurred rarely, but for the fear of soiling, they were still taking constipating drugs and wore pads. Details of frequency among incontinence scores determined at 6- and 12-month postoperative compared with preoperative frequency are shown in [Table 5]. Total incontinence scores calculated at 6- and 12-month postoperatively were significantly decreased compared with preoperative score, with significantly lower 12-month postoperative score compared with 6-month score as shown in [Figure 3].
|Table 5 Patients’ frequency according to Vaizey incontinence score determined at 6- and 12-month postoperatively compared with preoperative frequency|
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|Figure 3 Mean functional evaluation scoring of studied patients at 6- and 12-month postoperatively compared with preoperative scoring. CCC, Cleveland Clinic Constipation; FIQL, Fecal Incontinence Quality of Life Scale.|
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A total of 23 (69.7%) patients complained of preoperative constipation with varying degrees of difficulty in evacuation and sense of incomplete evacuation since a median duration of constipation of 3 years (range: 0–13) years. Postoperatively, all patients showed progressive improvement of their constipation. At the end of 12-month follow-up, only 14 (42.4%) patients still had constipation of score 1, and 10 (30.3%) of them still had an occasional failure of evacuation and six (18.2%) of them were still using laxatives. Details of frequency among CCC scores determined at 6- and 12-month postoperatively compared with preoperative frequency are shown in [Table 6]. Total CCC scores calculated at 6- and 12-month postoperatively were significantly decreased compared with preoperative score, with significantly lower 12-month postoperative score compared with 6-month score as shown in [Figure 3].
|Table 6 Patients’ frequency according to Cleveland Clinic Constipation score determined at 6- and 12-month postoperatively compared with preoperative frequency|
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CRP-associated FI and constipation had a bad effect on patient’s QOL; however, the applied surgical procedure induced significant improvement of patient’s QOL as manifested by significantly higher FIQL score determined at 6- and 12-month postoperatively compared with preoperative FIQL score, with significantly higher score at 12-month compared with score determined at 6-month postoperative as shown in [Figure 3].
Throughout the 12-month postoperative follow-up, two patients developed recurrent RP for a frequency of 6.1%. One female patient developed recurrent vaginal vault prolapse, cystocele, and partial rectocele secondary to committing an obstructed labor despite the instruction not to have a vaginal delivery. Another female patient developed recurrence of CRP secondary to getting excessively obese owing to her sedentary life. One male patient died secondary to developing acute myocardial infarction that failed to respond to treatment.
| Discussion|| |
The current study reported a significantly higher frequency of female patients among the studied patients, and four (20%) female patients had an associated vaginal vault prolapse. The reported higher frequency of CRP among female patients could be attributed to previous obstetric trauma-inducing weakness of pelvic floor with subsequent laxity of suspensor ligaments leading to pelvic descent and organ prolapse. The reported association of vaginal vault prolapse and CRP goes in hand with Adjoussou et al.  who reported that colorectal symptoms, such as defecation dysfunction and anal incontinence occurred in 25.1 and 18.5% of women with genital prolapse, respectively. Also, Meister et al.  identified the duration of pushing during vaginal delivery and infant births weight as significant risk factors for sustaining laceration and obstetric anal sphincter injury, predisposing to genitourinary and RP.
Interestingly, studied females were more obese with significantly higher BMI than males; this implies a relationship between obesity and development and/or aggravation of RP. In support of this concept, Cuicchi et al.  found that after a mean BMI reduction of 10 kg/m2, the prevalence of pelvic floor dysfunction decreased to 48%, and the rates of resolution of urinary incontinence, FI, and pelvic organ prolapse were 84, 85, and 74%, respectively. Also, multiple recent studies ,, documented that urinary incontinence, FI, and sexual dysfunction are more prevalent in patients with obesity, and weight loss by surgical and nonsurgical methods plays a major role in the improvement of these symptoms in such patients.
All surgeries were conducted uneventfully with no intraoperative morbidities, mortality, or conversion to laparotomy within appropriate operative time (151.9±31.6 min) and with minimal blood loss (75.2±16 ml). Moreover, laparoscopic surgery provided its usual advantages concerning low postoperative pain score, and early ambulation, oral intake, and hospital discharge. Similarly, Magruder et al.  reported that patients who undergo laparoscopic rectopexy have a shorter length of hospital stay and lower surgical site infection rate than patients who undergo other abdominal procedures for RP repair. Bjerke and Mynster  reported a median operative time of 135 min (range: 90–215)min, a median length of stay of 2 days (range: 1–14) days, and 30-day morbidity and mortality rates of 15 and 4%, respectively, after LMVR.
The reported surgical data coincided with that recently reported by Chandra et al.  who reported a median operative time of 200 min (range: 180–350)min, median postoperative hospital stay of 4 days (range: 3–12) days, and no operative mortality or mesh-related complication was encountered after LVMR. Also, Pucher et al.  documented that LVMR had safety learning course and is an effective and safe treatment for RP with in-hospital morbidity and mortality rates of 3.2 and 0%, respectively. Keskin et al.  also documented that laparoscopic rectopexy should be considered as the first option in the treatment RP owing to its favorable early-term outcomes and acceptable rate of long-term recurrence.
In support of the favorable outcome of LMVR, Liu et al.  retrospectively compared laparoscopic versus open mesh rectopexy for total RP and reported insignificant intergroup differences in operative duration, postoperative complication, rate of long-term recurrence, and improvement of incontinence and constipation, but perioperative blood loss, time to first flatus, and hospital stay were significantly shorter in the laparoscopic rectopexy group.
Moreover, the applied surgical procedure induced significant functional improvement manifested as a significant decrease of FI and CCC scores with significant increase of FIQL score at 6-month postoperatively, and these scorings were progressively improved till 12-month postoperatively. The reported functional improvement is similar to that stated by Consten et al.  in their report where the rates of FI and obstructed defecation decreased significantly after LVMR compared with the preoperative incidence (11.1 vs. 37.5% for FI and 15.6 vs. 54.0% for constipation); they concluded that LVMR is safe and effective for the treatment of different RP syndromes.
The obtained results are also in line with that recently documented in literature, wherein Chandra et al.  reported that at a median follow-up of 22 months, Wexner constipation score improved significantly from 17 to 6 and FI severity index score from 24 to 2 with no de-novo constipation or FI during the follow-up, and all patients expressed satisfaction with the outcome of their treatment; therefore, Chandra et al.  concluded that LVMR is an effective surgical option for CRP especially in patients having a bulky redundant colon. Also, Tsunoda et al.  reported improved incontinence and constipation in 77 and 59% of patients, respectively; significantly reduced FI severity index and Constipation Scoring System scores; and significantly improved scale scores on the three kinds of QOL instruments compared with the preoperative scores at 1 year after LVMR, and they concluded that LVMR improves both generic and symptom-specific QOL with good functional results. Moreover, Horisberger et al.  documented that 2 years after LVMR, constipation and QOL improve significantly in patients with complex pelvic organ prolapse.
In support of the reported advantages of LVMR, Bloemendaal et al.  documented that laparoscopic RP correction following emergency admission is both feasible and safe, so it can be considered for both recurring cases and cases with multiple comorbidities. Also, Ahmed reported improvement in incontinence and constipation in 60 and 75% of patients, respectively, with no recurrence detected 6 months after single-port LVMR.
From the obtained results, we conclude that LVMR is a safe procedure for the management of CRP within reasonable operative time and minimal immediate postoperative morbidities. LVMR provided significant improvement of CRP-associated FI and constipation and its effect on patients QOL. LVMR is associated with low frequency of postoperative recurrence throughout the 12-month follow-up.
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Conflicts of interest
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]