Page 28 - WJOLS - Laparoscopic Journal

Inamull Hasan SA Shaikh
strictures the mesh had been stapled to the mid-sacrum CONCLUSION
rather than to the promontory. Erosions of the vagina The evaluation of the different operation techniques is
or the bladder were managed by mesh removal, defect difficult, as the quality of available studies is low and
repair and insertion of a bio-mesh. All women with this outcome parameters are not defined consistently.
complication were postmenopausal and had previous The laparoscopic approach for rectal prolapse is
hysterectomy. In patients that complained about chronic equivalent to the open approach in terms of functional
pain unresponsive to pain medication, the mesh showed
an excessive inflammation. A replacement of the mesh and clinical outcome. The recurrences rates do not seem
by a teflon-coated mesh improved symptoms. After to differ, although single studies suggest higher recur-
rence rates after laparoscopic surgery. Advantages are
revisional surgery, quality of life and bowel function
improved significantly. a shorter hospital stay. It has to be remarked that the
Two case reports describe a mesh fistulation in the evidence is based on only two randomized and a few
rectum. 34,35 Typical symptoms were recurrent fever, prospective and comparative case-controlled studies with
pelvic pain and rectal bleeding. Diagnosis was made by significant heterogeneity in patient characteristics and in
flexible sigmoidoscopy. In one case, therapy was anterior applied surgical procedures, making a relevant selection
rectum resection, in the other case, the mesh was extrac- bias very probably.
ted laparoscopically and a loop-ileostomy was performed. Regarding complications and conversion rates all
36
Tranchart et al observed six rectal mesh migrations laparoscopic procedures provide similar good results
after 312 laparoscopic ventral mesh rectopexies (1.9%). with each having their typical complications (anasto-
The median time interval between surgery and onset motic leakage, mesh complications). Recurrence rates for
of symptoms was 53 months (4–124 months). The treat- all methods are below 10% within a follow-up of up to
ment was transanal partial mesh resection, in one case 5 years but studies that extended follow-up to 10 years
where a recto-cutaneous fistula was present, a deviat- found recurrence rates of up to 20%.
ing colostomy was added. A recurrent mesh migration L aparoscopic resection rectopexy and LVR improve
was again treated with partial mesh resection. After a both constipation and faecal incontinence in a similar
median follow-up of 40 months all patients were free of degree, but randomized studies are missing. Laparos-
complaints and showed no recurrent mesh, migration. copic suture rectopexy (LSR) and Laparoscopic posterior
As a rare but serious complication lumbosacral discitis rectopexy (LPR) have about the same effect on inconti-
at the site of rectal fixation was observed after ventral nence, but they tend to have a lesser effect on consti-
rectopexy and resection rectopexy. Only four cases are pation, in some studies these operations even worsened
reported in literature. Patients presented typically 1 to constipation in a relevant number of patients.
3 months after the initial operation with severe lower back As high quality evidence is missing, an individua-
pain, fever and malaise. An magnetic resonance imaging lized approach is recommend for every patient consi-
(MRI) revealed the diagnosis. A contrast enema was help- dering age, individual health status and the underlying
ful to rule out a rectal fistula. Broad spectrum iv-antibiotics morphological and functional disorders. Moreover, as
covering colonic flora are the treatment of first choice. In most operations actually show acceptable results, the
some cases, antibiotic treatment was not sufficient, and choice of procedure also depends on the experience and
removal of mesh or suture material was necessary, in learning curve of the surgeon.
one case with a deviating colostomy. 37,38 A gynecological
review found 26 cases of discitis after sacrocolpopexy or REFERENCES
39
rectopexy in a 50-year period. Although this complication 1. Bordeianou L, Hicks CW, Kaiser AM, Alavi K, Sudan R,
is rare it should always be considered in patients complai- Wise PE. Rectal prolapse: an overview of clinical features,
ning of persisting back pain after any type of rectopexy. diagnosis, and patient-specific management strategies.
J Gastrointest Surg 2014;18:1059-1069.
FINANCIAL CONSIDERATIONS 2. Goldstein SD, Maxwell PJ. Rectal prolapse. Clin Colon Rectal
Surg 2011;24:39-45.
An Australian study from 2004 conducted a cost- 3. Shorvon PJ, McHugh S, Diamant NE, Somers S, Stevenson GW.
effectiveness analysis for posterior mesh rectopexy in a Defecography in normal volunteers: results and implications.
randomized setting. When costs for theater time, staff, Gut 1989;30:1737-1749.
laparoscopic equipment and hospital stay were included, 4. Palit S, Bhan C, Lunniss PJ, Boyle DJ, Gladman MA, Knowles CH,
Scott SM. Evacuation proctography: a reappraisal of normal
the laparoscopic operation was less costly than the open variability. Colorectal Dis 2014;16:538-546.
operation. The shorter hospital stay in the laparoscopic 5. Madiba TE, Baig MK, Wexner SD. Surgical management of
group accounted for this saving. 40 rectal prolapse. Arch Surg 2005;140:63-73.
94