open approaches for rectal prolapse john hartley academic surgical unit university of hull

Open Approaches for Rectal Prolapse

John Hartley

Academic Surgical Unit

University of Hull

Open procedures for rectal prolapse

Open operations for rectal prolapse

• Perineal operations inferior to abdominal procedures, but definite role

• Delorme’s procedure – simple but high recurrence rate, can be repeated

• Perineal rectosigmoidectomy – more complex but lower recurrence rate

• “If the patient is fit enough and life expectancy > 5yrs abdominal approach preferred”

Keighley and Williams 2nd Edition 2001


Major colorectal procedures – Consultant and higher trainees

Procedures for prolapse

Perineal Abdominal

JH 2002-2004 281 10 1

HST yr 6 198 6 4

HST yr 6 191 8 1

HST yr 4 87 3 1

The realities – Yorkshire colon and rectal surgery


A range of possibilities:

• Exclusion procedures

• Pelvic floor repair

• Anterior or posterior rectopexy

• Resection – alone or with rectopexy


Sigmoid exclusion procedure (Lahaut’s

operation)

• Rectum fully mobilised in pelvis

• Rectosigmoid sutured to posterior rectus sheath

• Sigmoid extra-peritonealised behind rectus muscle


Lahaut’s operation• 33 pts• 1 death (3%)• No recurrences• 11 of 12 pts improved continence• One faecal fistula (?ischaemic)• One obstructionMortensen et al Ann R Coll Surg Engl 1984:66:1718


Pelvic floor repair via the abdomen• Full anterior and posterior mobilisation of the

rectum• Repair of pelvic floor posterior (originally ant and

post) to rectum• Difficult access• Pelvic floor thin and attenuated• Largely replaced by rectopexy

Pelvic floor repair for prolapse

Results of abdominal pelvic floor repair for prolapse

Authors Procedure N Mortality Recurrence (%)

Comments

Snellman 1961 Ant. repair 42 0 4 (10)

Porter 1962 Ant. Repair 46 0 23 (50)

Kupfer and Goligher 1970

Post. Repair 63 1 5 (8) Mucosal recurrence

Klaaborg et al 1985

Post. repair 23 0 3 (13)

Hughes and Gleadell 1962

Ant and post. Repair

84 1 5 (6)

From Keighley and Williams 2001

Open procedures for rectal prolapse

Rectopexy• Probably the operation of choice• Recurrence rates approx. 2%• Continence restored in 60-80% with rectopexy

alone• How should rectum be fixed?• When should resection be added?


Anterior rectopexy (Ripstein procedure)

• Full mobilisation of rectum

• Fixation to sacral promontary by sling (polypropylene, teflon or fascia)

• Principle complication – fibrous stricture

Anterior rectopexy

Anterior rectopexyN Mortality

(%)Recurrence (%)

Comments

Gordon and Hoexter 1978

1111 4 (0.3) 26 (2) Impaction 14, stricture 20 (1.8%)

Morgan 1980 64 2 (1.6) 2 (3) Stenosis

Launer 1982 54 0 4 (7) Stricture 9 (17%)

Holmstrom 1986 108 3 (2.8) 5 (4) Stricture 4

Tjandra 1993 142 1 (0.1) 10 (8) 1/3 recurrences >10 yrs post op



Posterior rectopexy• Posterior aspect of fully mobilised rectum

attached to sacrum• Lateral peritoneum divided, posterior

mobilisation to tip of coccyx, division of lateral ligaments

• No anterior restriction, distensible rectum• Mesh to sacrum and lateral aspects rectum

Posterior rectopexy

Posterior rectopexy

Method of fixation• Teflon• Polypropylene (marlex)• Polyvinyl alcohol sponge (Well’s procedure)

- infection (recurrence)• Vicryl• Gore-Tex• SIMPLE SUTURES

Sutured posterior rectopexy

Posterior rectopexy (suture only)

N Mortality (%) Recurrence (%)

Loygue 1971 146 2 (1.3) 5 (3)

Carter 1983 32 0 0

Goligher 1984 52 0 1 (2)

Graham 1984 23 1 (4.3) 0

Blatchford 1989 42 0 2 (5)

Sayfan 1997 19 0 0


Prosthetic vs suture posterior rectopexy (no resection)

Ivalon sponge (n=31) Sutures alone (n=32)

Hospital stay (days) 14 (8-52) 14 (8-50)

Mortality 0 0

Complications 6 (19%) 3 (9%)

Recurrent prolapse 1 (3%) 1 (3%)

Late postop incontinence 6/10 2/10

Postop constipation 15 (48%) 10 (31%)

Novell et al. Br J Surg 1994;81:904-906.

Division of lateral ligaments in mesh posterior rectopexy

Lateral ligaments divided (n=14)

Lateral ligaments preserved (n=12)

Preop Postop Preop Postop

Continence score

3 2 4 2

Time straining (%)

54 54 12 56

No. constipated

3 10 6 7

Rectal prolapse

14 0 12 6

Speakman et al. Br J Surg 1991;78:1431-1433


Resection alone• Sigmoid or partial rectal resection (n=113)• Incontinence:

- Improved 23 (20%)- Same 13 (11%)- Worse 10 (9%)

• Sepsis morbidity: 52% after “low” and 19% after high anastomosis

• Recurrence at 10 yrs 14% after “high” and 9% after “low” resections

Schlinkert et al Dis Colon Rectum 1985:28:409-412

Resection Rectopexy

Resection Rectopexy• Aims to achieve low recurrence rates and avoid long

term constipationUniversity of Minnesota series• 138 pts• Anastomotic leaks in 5 (4%)• Recurrent prolapse in 2 (1.4%)• Continence improved in all but 1 pt• Constipation improved in 56% same in 35% worse

in 9%

Watts et al. Dis Colon Rectum 1985;28:96-102.

Rectopexy +/- ResectionPreop status and outcome Marlex rectopexy

(n=16)Rectopexy and sigmoidectomy (n=13)

Incontinent preop 12 9

Unchanged or worse 3 3

Continence restored 9 6

Constipated preop 3 5

Unchanged or worse 3 1

Constipation improved 0 4

Normal bowel habit preop 13 8

Unchanged 9 8

Became constipated 4 0

Sayfan et al. Br J Surg 1990;77:143-145.

Rectopexy +/- Resection

Constipation (%) Incontinence (%)

Preop Postop Preop Postop

Rectopexy (n=129)

47 (36) 42 (33) 48 (37) 25 (19)

Resection rectopexy (n=18)

12 (67) 2 (11) 5 (28) 3 (17)

Tjandra et al. Dis Colon Rectum 1993:36;501-507


Summary• Lower recurrence rates but higher morbidity

than perineal procedures• Fixation superior to pelvic floor repair, or

resection alone• Posterior fixation superior results• Sutures alone comparable to mesh fixation• Less constipation with concomitant resection


Conclusions

Sigmoid resection with sutured rectopexy

offers:

• Low risk of recurrence

• The long term avoidance of constipation

• PROCEDURE OF CHOICE

• (why not laparoscopically?)

open approaches for rectal prolapse john hartley academic surgical unit university of hull

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