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Laparoscopic Rectal Prolapse Surgery

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17/03/2006


What is a rectal prolapse?

Rectal prolapse is a common condition in which the rectum looses its internal support and falls in on itself or turns itself inside out.

The overall incidence of rectal prolapse in the UK is approximately 5 per 1,000 people. The incidence of the disorder increases to 10 per 1,000 among patients older than 65. Most patients with rectal prolapse are women; the ratio of male-to-female patients is one in six.

In the earliest phases of this condition the rectum does not stick out of the body, but as it worsens it may protrude.  A complete rectal prolapse occurs when the rectum protrudes through the anus. If rectal prolapse is present, but the rectum does not protrude through the anus, it is called occult rectal prolapse, or rectal intussusception. In females, a rectocele occurs when the rectum protrudes into the posterior (back) wall of the vagina 

The amount of prolapse ranges from Mucosal prolapse (shown in these two illustrations). 

Symptoms include leakage of mucus and or stool, faecal urgency, pelvic floor - rectal - vaginal discomfort, painful intercourse and eventually a full thickness prolapse.  In the early stage patients may be misdiagnosed as having haemorrhoids.




As the condition progresses patients may develop an occult prolapse i.e., one that is only seen during a carefully performed "defecatory sigmoidoscopy", a defecating proctogram or an examination under anaesthesia.  










The final stage is a full thickness rectal prolapse (shown below).











Whilst rectal prolapse is much more common in women we see an increasing number of men (shown here with the prolapsed reduced) with this condition.  When these patients are laparoscoped the patients pelvis is not dissimilar to a post hysterectomy female pelvis!  The proctograms are also interesting in that they closely resemble a rectocele!

Traditionally male rectal prolapse is treated using a Delorme's peranal rectal mucosectomy/muscle plication.  Whilst this procedure avoids damaging the pelvic nerves it reduces rectal capacity and compliance which leads to poor function.  The longevity of the repair is only a few years.  We have been performing laparoscopic ventral rectopexy on male patients with good effect for over 10 years.  All are potent and there have been no recurrences.



Why does it occur?
It may follow a lifelong habit of straining at stool or as a delayed result of stresses involved in childbirth. It also seems to be part of the aging process. Treatment depends on several factors:

  • Patient’s age
  • Physical condition
  • Extent of the prolapse
  • Other associated problems

What about surgery?
Surgery is generally not performed unless the symptoms of the prolapse have begun to interfere with daily life.  Because of the numerous defects that can cause rectal prolapse, there are more than 50 operations that may be used to treat the condition.  A perineal or abdominal approach may be used. While open abdominal surgery is associated with a higher rate of complications and a longer recovery time, the results are generally longer lasting. Perineal surgery is generally used for older patients who are unlikely to tolerate the abdominal procedure well.

Abdominal and Laparoscopic approach (traditional)
Rectopexy and anterior resection are the two most common abdominal operations used to treat rectal prolapse.  In performing a sstandard/traditional rectopexy, the rectum mobilised from surrounding tissues and the sides of the rectum lifted and fixed to the sacrum (lower backbone) with stitches or with a non-absorbable piece of mesh.  Anterior resection removes the S-shaped sigmoid colon; the two cut ends are then reattached. This straightens the lower portion of the colon and makes it easier for stool to pass. Rectopexy and anterior resection may also be performed in combination and may lead to a lower rate of prolapse recurrence.

Perineal approach
Perineal repair of rectal prolapse involves a surgical approach around the anus and perineum. The surgery can be performe under general or regional anaesthesia.  The most common perineal repair procedures are the Altemeier and Delorme procedures.

During the Altemeier procedure (also called a proctosigmoidectomy), the prolapsed portion of the rectum and sigmoid colon is removed and the cut ends reattached. The weakened structures supporting the rectum may be stitched into a more anatomical position. This is a very major procedure.

The Delorme procedure involves the resection of only the mucosa (inner lining) of the prolapsed rectum. The exposed muscular layer is then folded and stitched up and the cut edges of mucosa stitched together.

What about morbidity and mortality i.e., risks?
The approximate recurrence rates for the most commonly performed surgeries as reported by several studies are as follows:

  • Altemeier procedure: 5–54%
  • Delorme procedure: 5–26%
  • anal encirclement: 25%
  • standard rectopexy: 2–10%
  • anterior resection: 7–9%
  • rectopexy with anterior resection: 0–4%
  • laparoscopic ventral rectopexy: 0.25%

Abdominal operations are associated with a higher rate of complications than perineal repairs; rectopexy, for example, has a reported morbidity of between 3–29%, and anterior resection a rate of 15–29%.  The complication rate for combined rectopexy and anterior resection is slightly lower at 4–23%. Approximately 25% of patients undergoing a Delorme procedure will eventually require surgery to treat complications associated with the procedure.

What is a laparoscopic ventral (anterior)mesh rectopexy?


Laparoscopic ventral rectopexy is an operation in which stitches are used to secure the rectum, vagina and womb in their proper positions. 



What happens?
You will be given an enema to clear out your bowels. Under a general anaesthetic a small incision is made in the bellybutton to allow insertion of the laparoscope. Two further incisions are made in the lower right hand side of the abdomen.

The right hand side of the rectum is mobilised down to the top of the vagina. The rectovaginal septum is then mobilised right down to the pelvic floor or perineum. The front of the rectum and the back wall of the vagina (and womb if present) is then supported by a piece of mesh which is sutured to the front of the rectum/back of the vagina. This mesh is then attached to the front of the sacrum/lower spine. The pelvic peritoneum is then closed over the mesh.

Occasionally a drain is placed in the pelvis to stop a haematoma collecting. The small incisions are then closed and infiltrated with a local anaesthetic. You will be allowed to eat and drink once you have recovered from the anaesthetic. If the urinary catheter was not removed in theatre it will be removed the following morning and you will then be encouraged to mobilise.  Walking really does help speed up the recovery.

Most patients normally go home on either the second or third postoperative day. As some, patients continue to have some problems going to the toilet and need a period of retraining we send you home with some Glycerine suppositories, a small Microlax enema and a supply of senna tablets. If you feel uncomfortable, take two senna tablets just before you go to bed and after your breakfast, pop in two suppositories. If they don’t work try the small enema.
 
A number of patients experience severe pain in the lowere right hand side port site/wound.  It will settle down.  If it is incapacitating a night-time dose of 25mg amitriptyline will help

What are the benefits?


1) Three tiny scars instead of one large abdominal scar.
2) Early introduction of diet within 24 hrs.
3) A very short hospital stay (2-3 days).
4) Reduced postoperative pain and fewer complications.
5) Shorter recovery time and quicker return to daily activities.
6) No risk of an incisional hernia.
7) As the rectum is not mobilised from the sacrum, its nerve supply is left intact so making constipation and evacuatory dysfunction less likely than a more conventional operation.

8) The surgery works! The risk of failure @ 5 years is < 2% [this figure is 30% for a Delorme's rectal mucosectomy] 


How safe is laparoscopic rectopexy?

If performed by experts in this field, the operation is as safe if not safer than 'open' surgery.

Rectal prolapse is frequently associated with - rectocele, vaginal vault prolapse and urinary stress incontinence. Operations to correct these can be carried out at the same time.

How successful is treatment?

Preoperative picture

Success depends upon a number of factors, including the status of the patient’s anal sphincter muscle prior to surgery, whether the prolapse is internal or external, the overall condition of the patient and the surgical operation used. Constipation and straining must be avoided in the immediate postoperative period.  Senna and or Movicol can be used as necessary.  Very occasionaly a patient will need the aid of an enema. 






Postoperative picture (additional PPH carried out 8 weeks later)

As general rule some 90% of patients are completely relieved of symptoms. Occasionally women develop a worsening of their stress incontinence following correction of their rectal and vaginal prolapse. This can usually be corrected by further surgery – Tension Vaginal Tape.

Bristol Laparoscopic Associates have been performing this novel surgery since 1998 and have the largest UK experience of >1000 laparoscopic prolapse surgery.   A similar approach was been adopted by the Oxford pelvic floor surgeons in 2002.


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SPIRE Hospital, Bristol. 
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Contact: Claire Trenberth - 0117 9804051
claire.TRENBERTH@spirehealthcare.com
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