Page 27 - WJOLS - Laparoscopic Journal

WJOLS

Surgical Approaches for Rectal Prolapse and their Comparative Study
Two case controlled studies compared open and lapa- laparoscopic procedures are safe for this group of patients
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roscopic surgery for rectal prolapse. Kairaluoma et al and if they offer a good alternative to perineal procedures.
used different procedures in 106 patients (LRR, suture For ventral rectopexy, a recent French study evalu-
rectopexy, Wells rectopexy). A longer operation time (170 ated 4303 patients from a national database. Patients
vs 100.5 min) but a shorter hospital stay (5 vs 7 days) was aged more than 70 years were compared to patients
found for laparoscopy. Functional outcome, recurrence younger than 70 years. Elderly patients had more minor
rates and complications did not differ between case- and complications (urinary, wound complications) and a
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control-group. Kariv et al found similar results. In this longer hospital stay, but major complication rate and
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study, also different techniques were applied. One third mortality were not different. Another study used
of patients in each group had resection rectopexy res- a modified laparoscopic Orr-Loygue technique in 46
pectively suture rectopexy respectively mesh rectopexy elderly patients (median age 83 years) with rectal pro-
(predominantly Ripstein anterior rectopexy for open lapse. A significant cardiac morbidity was observed.
surgery, Well’s procedure in laparoscopic surgery). Incon- Two patients died of cardiac arrest. Two patients were
tinence and constipation improved in all patients, with a re-operated for recurrent prolapse after 2 months. The
significant higher improvement in the laparoscopic group reasons for the recurrences were mesh dislocations.
(74 vs 54%). A likely explanation for this finding was the Faecal incontinence improved significantly (Wexner-
much more frequent use of the Ripstein procedure in the Score decreased from 19 to 5 points after 1 year).
open surgery group where the circular anterior mesh Constipation did not improve. Most patients were satis-
placement can result in a stenosis which obviously in fied with the operation, but there was no association seen
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turn contributes to the occurrence of constipation. For between satisfaction and functional result. 30
this reason, a circular mesh placement is now considered A German study from 2012 studied the outcome of
obsolete by most authors. LRR in elderly patients (> 75 years). The complication rate
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de Hoog et al compared open rectal prolapse sur- was slightly increased compared to the younger popula-
gery to a conventional laparoscopic and a robot-assisted tion. Incontinence and constipation improved in half of
approach in a prospective non-randomized setting. Half the patients irrespectively of age. 31
of the patients were operated with the Well’s procedure, Dyrberg used a laparoscopic dorsal mesh rectopexy in
the other half with a ventral rectopexy. While the func- 81 older patients with FRP. A remarkable major compli-
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tional outcome (incontinence, constipation) improved cation rate of 14.8% was reported. Port site hernias with
significantly in all three groups, the recurrence rates dur- consecutive ileus and postoperative hemorrhage each
ing a 2-year follow-up were significantly increased in the occurred in 5% of patients. The 13.5% of recurrences were
robot-assisted (20%) and the conventional laparoscopic observed at a median follow-up of 2 years.
group (27%) vs 2% in the open group.
In a recent meta-analysis, 12 comparative studies TYPICAL COMPLICATIONS AND
comprising 688 patients (330 with laparoscopic rectopexy) THEIR MANAGEMENT
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were analyzed. A drawback of this meta-analysis was A study in a tertiary referral center analyzed the typical
that only one study was randomized and that several complications after mesh rectopexy: Mesh fistulation or
different procedures (resection, non-resection) were used erosion of the rectum, vagina or the bladder, rectovaginal
even within studies. Nevertheless a significant shorter fistula, early symptomatic recurrence, rectal stricture
hospital stay was found for the laparoscopic group, and chronic pelvic pain were observed. In this study,
while no differences between the open and laparoscopic all complications could be managed laparoscopically. 33
approach were found for complication rates, postopera- The reasons for early recurrence were in all 27 cases,
tive functional outcome, recurrence rates and mortality. an inadequate technique during the prior operation
A meta-analysis from 2012 showed the same results. 27 (only limited or no ventral dissection, no sutures in the
rectovaginal space, detachment or incorrect position of
LAPAROSCOPIC RECTOPEXY IN the staples, wrong placement of the mesh to the lateral
ELDERLY PATIENTS
instead the anterior rectal wall with development of an
It is thought that the group of elderly patients especially enterocele). These cases were treated by placement of a
profits from laparoscopic surgery. A recent systematic new mesh and fixation with staples and sutures. Recto-
review showed significant advantages in short-term vaginal fistulas were treated with removal of the mesh
outcome in laparoscopic colorectal surgery for elderly and abdominal or transvaginal fistula repair. Rectal in-
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people. As the incidence of rectal prolapse and pelvic juries and strictures were operated by anterior resection
floor disorders increases with age it is important to know if and a placement of a bio-mesh. In all patients with rectal
World Journal of Laparoscopic Surgery, September-December 2015;8(3):90-95 93