Laparoscopic ventral rectopexy and posterior colporraphy – vaginal sacrocolpopexy for rectal prolapse and mechanical outlet obstruction
Laparoscopic ventral rectopexy, posterior colporraphy and vaginal sacrocolpopexy for the treatment of rectal-genital prolapse and mechanical outlet obstruction
Simone Slawik, Ruth Soulsby, Helen Carter* Helena Payne#, AR Dixon
Department of Colorectal Surgery, GI Fluroscopy* & GI Physiology#
North Bristol NHS Trust, Frenchay Hospital, Bristol, UK. www.bristolsurgery.com
Mr Tony Dixon
Consultant Colorectal Surgeon,
Frenchay Hospital, Bristol, BS16 1LE
Introduction. Whilst trans-abdominal fixation +/- resection offers better functional results and lower recurrence than perineal procedures, mesh rectopexy is complicated by constipation. Laparoscopic autonomic nerve-sparing, ventral rectopexy allows correction of the underlying abnormalities of the rectum, vagina, bladder and pelvic floor.
Methods. A prospective database was used to audit our seven-year experience of this technique. The recto-vaginal septum was mobilised anteriorly to the pelvic floor avoiding nerve damage. A prolene mesh was sutured to the ventral rectum, posterior vagina and vaginal fornix and secured to the sacral prominentry. Patients were assessed with questionnaires and Cleveland Clinic scores.
Results. 80 patients, 6 males, median age 59yrs (range 31-90) have undergone laparoscopic prolapse surgery between Jan. 1997 and Dec. 2005: 55% had full thickness prolapse and 46% rectal anal intussusception. Five had solitary rectal ulcer. 58% had undergone previous surgery; hysterectomy 33%, posterior colporraphy 15%, posterior rectopexy 6%, Delorme’s rectal mucosectomy 5% and Birch colposuspension 3%. Half (54%) were incontinent (mean Wexner score 11, range 2-17) and 31% reported symptoms of obstructed defecation; 7 had slow transit constipation and underwent resection.
The median operative time was 125mins (range 50-210) with one conversion. Median time to diet was 12hrs and median length of stay 3 days (1-12). No patient has developed recurrent full thickness prolapse at a median follow-up of 54 months (30-96). Incontinence improved in 39 of 43 patients (91%); median post-operative Wexner score 1 (0-9). Obstructed defecation resolved in 20 of 25 patients (80%). Pelvic pain resolved in all but one. Complications occurred in 21%; faecal impaction 4%, wound infection 2%, bleeding 2%, leak 1%, chest infection 1%, retention 1%. Three developed minor evacuatory difficulties and two, urinary stress incontinence.
Discussion. Laparoscopic ventral rectopexy is safe with relatively low morbidity. In the medium-term it provides good results for prolapse and associated symptoms of incontinence and obstructed defecation.
Key words: ventral rectopexy, posterior colporraphy, rectal-genital prolapse, rectal-anal intussusception.
Berman introduced laparoscopic rectal prolapse repair in 1992[i]. Two randomised trials2,3 have demonstrated a reduced hospital stay and peri-operative morbidity using this approach. Solomon3 also showed reductions in stress response, pain and better cosmesis. More importantly, clinical and functional outcomes were comparable, in both groups and in both trials. Kellokumpu’s case control study showed similar results4. The most common side effect of mesh rectopexy is post-operative constipation. The interest in resection rectopexy is centred on improved functional outcomes and decreased recurrence rates5. The results of resectional rectopexy have been substantiated, in the median term, in the laparoscopic era6.
Full thickness rectal prolapse is an intussusception of the rectum extending beyond the anal canal7. In women, weakness of the pelvic diaphragm and rectovaginal fascia allows descent of the middle compartment and the development of a rectocele, enterocele and/or vaginal/vault prolapse8. The vaginal support system includes apical (level 1) support provided by the cardinal-uterosacral complex and lateral (level 2) support, provided by the pubocervical and rectovaginal fascia9. Apical or vault prolapse also follows hysterectomy or relaxation/severing of the cardinal-uterosacral ligaments seen with childbirth and ageing10. Should prolapse occur and remain untreated, chronic downward pressure leads to loss of lateral attachments and formation of a cystocele and/or rectocele and rectal intussusception. Enteroceles may form in conjunction with vault prolapse when a hysterectomy is performed without precise closure of the vaginal cuff and its supporting anterior (pubo-cervical) and posterior (rectovaginal) fascia11. Vault prolapse usually occurs a few years after a hysterectomy and usually in conjunction with other pelvic floor defects. In many cases, vault prolapse is not diagnosed even though it can make up the majority of the pelvic floor defect. Indeed, most cases of prolapse also involve some degree of vault prolapse that is either overlooked or miss diagnosed as an isolated cystocele or rectocele12.
Many of these patients also have symptomatic anterior mucosal rectal prolapse and when carefully examined, an overt rectal prolapse. Whilst the natural history of incomplete intussusception is variable, it may well lead to an overt rectal prolapse. The principle symptoms are bleeding, mucus discharge, pelvic pain, urgency, obstructed defecation and tenesmus. Symptoms that frequently precipitate a two-week wait cancer referral.
Nicholls and Simson13 treated 14 patients with solitary rectal ulcer without overt rectal prolapse using a combined posterior and ventral rectopexy. There were two failures. Of the 12 who improved, two developed constipation. The heterogeneity of these patients dictates that surgery must be tailored to suit each individual. We would argue that the purpose of any surgery is to correct the prolapse and it’s leading cause, the intussusception and any associated middle compartment descent or prolapse and whilst doing so, avoid autonomic neural damage in addition to maintining rectal compliance and sensitivity.
In light of the Nicholls paper13, our observations of the anomalies of pelvic anatomy seen during laparoscopic sutured rectopexy and open vaginal sacrocolpopexy, the senior author developed a laparoscopic nerve-sparing technique for treating overt and occult rectal prolapse and significant rectal, rectal/anal intussusception with associated symptomatic middle and anterior compartment prolapse in early 1997. A similar approach has also been independently developed by others14. This paper presents the medium term outcome of patients who underwent this new procedure.
Between January 1997 and December 2005, 80 patients have undergone laparoscopic ventral rectopexy; 74 females underwent concurrent posterior coloporraphy and vaginal sacrocolpopexy. Data were obtained from a prospectively collected, institutionally approved electronic database. Faecal incontinence was assessed using the Cleveland Clinic Incontinence Scoring System15. Patients were reviewed at 6, 12, and 26weeks and annually thereafter. All completed post-operative questionares16,17developed and validated for the assessment of bowel and lower urinary tract symptoms in women. This database was analysed to study surgical outcomes. All patients were made aware that the surgery was a departure from traditional open posterior rectopexy and all gave informed consent.
Full ano-rectal physiology was carried out on all patents operated upon the first three years and in selected cases thereafter. Defecating proctograms (with oral and vaginal contrast), barium enemas, transit studies (shapes test), anal ultrasound and urodynamics were again performed in selected patients.
The main selection criteria for consideration of this novel approach were intolerable symptoms and the sigmoidoscopy finding of significant “high take off” rectal intussusception, overt or occult full thickness prolapse. This requires very careful and systematic clinical examination of the pelvic floor (both anterior and middle compartments) with the patient in left lateral. Patients are occasionally examined whilst squatting. In carrying out the sigmoidoscopy it is vital that one goes beyond the recto-sigmoid junction, release the air pressure and ask the patient to strain whilst withdrawing the scope. This may need to be repeated several times.
Informed consent was obtained in all cases. All patients receive pre-operative phosphate enema, thrombo-embolic and antimicrobial prophylaxis. Patients are placed in modified Lloyd-Davies using Allen stirrups allowing hip extension. All are catheterised. The uterus is manipulated using a Velsellum and Sprackman forceps18. Three ports (10mm umbilical, 5 and 12mm right iliac fossa) are sufficient. A 300laparoscope is used throughout. A harmonic scalpel (Ethicon Endosurgery, Bracknel, UK) is used for the dissection.
The rectosigmoid junction is retracted to the left allowing the peritoneum to be incised over the sacral prominentry avoiding the right hypogastric nerve. The incision is extended along the side of the mesorectum then continued in front of the pouch of Douglas. Denonvillier’s fascia is incised and the rectovaginal septum is opened, a process facilitated by the actions of the pneumoperitoneum. No posterior rectal or lateral ligament dissection is carried out. The insertion of an Amielle vaginal trainer (Owen Mumford Ltd) facilitates the vaginal dissection/suturing in post hysterectomy patients. Grasping the pouch of Douglas exerts counter-traction. The dissection is carried out as far as possible, down to the pelvic floor. A 15x15cm polypropylene mesh is trimmed transversely to 3x17cm, the last 7cm tapering to 1cm. The mesh is sutured to the ventral aspect of the seromuscular wall of the rectum using three, interrupted, non-absorbable sutures (Ethibond 0, Ethicon, Johnson & Johnson). The most cranial suture is placed around the level of the pouch of Douglas. The posterior wall of the vagina is then sutured to the ventral aspect of the mesh with three sutures as before. The most cranial is sutured to the posterior vaginal fornix. The tapered end of mesh is fixed to the sacral prominentry using four “Protack” titanium staples, (Tyco Healthcare) without placing any particular traction on the rectum. The edges of incised peritoneum are then closed over the mesh with a running suture.
Concurrent symptomatic cystocele
In post-hysterectomy patients with a symptomatic cystocele and or anterior enterocele, the bladder is carefully mobilised from the anterior vaginal wall for 3-4cms. The polypropylene mesh (as above) is folded double and bi-valved. The shorter anterior limb is sutured to the anterior vaginal wall and covered with the bladder/peritoneum. In none-hysterectomy patients, a tunnel is made through the broad ligament, through which is passed a separate narrower (2cm-wide) piece of mesh. The proximal end is fixed to the promontory on top of the other mesh.
All received oral mechanical bowel prep. Resection begins after completion of the recto-colpopexy (see above) and follows a standard medial to lateral approach with mobilisation of the splenic flexure but without opening up the mesorectum and peritoneum medially above the prominentry. Inferior mesenteric vessels are identified and divided between Hem-o-Lok clips (Teleflex Medical, High Wycombe, UK). The upper 1/3 of the rectum is divided using a linear cutter (Ethicon Endosurgery ATG 45). The umbilical port is extended either side of the umbilicus in the midline to allow delivery of the bowel. The proximal bowel and head of a circular stapling device is returned to the abdominal cavity and the incision is closed around the re-introduced umbilical port. The pneumoperitoneum is recreated and the anastomosis completed.
Between January 1997 and December 2005, 74 females and six males of median age 59yrs (range 31-90) and median BMI 25 (19-36) have undergone novel laparoscopic prolapse surgery for full thickness prolapse and/or mechanical outlet obstruction. Patients were classified ASA I (58%), ASA II (34%), ASA III (8%). Forty-four (55%) patients had a full thickness prolapse. A further 36 (46%) had grade III rectal anal intussusception; 15 amounting to an overt full thickness rectal prolapse whilst five had concurrent solitary rectal ulcers. 58% of the patients had undergone previous pelvic floor surgery; hysterectomy 33%, posterior colporraphy 15%, posterior rectopexy 6%, Delorme’s rectal mucosectomy 5% and Birch colposuspension 3%. Forty-three patients were incontinent pre-operatively (mean Wexner score 11, range 2-17) and 31% had pre-operative symptoms of obstructed defecation; 7 had slow transit constipation.
The median time for surgery was 125mins (range 50-210) with one conversion. When we started offering this surgery we were very cautious and kept our patients on clear fluids for 48 hours and only allowed them home once they had opened their bowels. With increased experience, catheters were removed in theatre and patients were allowed to eat as soon as they had recovered from the anaesthetic and go home the next day. Nether the less, the median time to tolerance of full diet was 12hrs and median length of stay was 3 days (1-12). Minor complications comprised faecal impaction (4%), extraction port site infection (2%), bleeding (2%), chest infection (1%) and urinary retention (1%). Patients were discharged with a week’s supply of senna, glycerine suppositories and two enemas.
The median follow-up was 54 months (20-96). To date no patient has developed recurrent full thickness prolapse. Four have continued with symptomatic post-operative residual hypertrophied rectal mucosal prolapse: all responded to stapled rectal mucosectomy (3) or formal excision. Two female patients developed urinary stress incontinence. Each responded to a TVT sling. One resection rectopexy anastomosis leaked and required a temporary loop ileostomy. No septic sequel followed. The functional result post stoma closure was excellent. Incontinence improved in 39 of 43 patients (91%) with the six-month median post-operative Wexner score falling to 1 (0-9). Obstructed defecation resolved in 20 of 25 (80%). Unfortunately, 3 patients developed minor difficulty with evacuation. These were managed with a combination of senna and enemas. The five solitary rectal ulcers quickly became asymptomatic and healed. Pelvic pain, a common presenting feature resolved in all but one patient,
Rectal prolapse is a profoundly debilitating condition causing pain, bleeding, ulceration, constipation and faecal incontinence. Curative treatment is exclusively surgical and whilst surgical treatment has evolved considerably, the ideal solution has remained elusive. Perineal operations described by Mikulicz (1889), Thiersch (1891) and Delorme (1900)19 were largely abandoned for abdominal approaches that gave better functional results and lower rates of recurrence20. Pemberton and Stalker described the first abdominal suspension operation in 193921. Ripstein’s anterior sling, and Well’s posterior sling became popular during the middle of the last century. Mikulicz’s operation re-gained its popularity following the publication of Altemeier’s series: 106 patients and only 3 recurrences22. The most widely used perineal operation in the UK entails stripping of the mucosa and plication of the muscle layers of the prolapse – Delorme’s operation.
The Association of Coloproctology of Great Britain and Ireland sent out a questionnaire in 199823asking their members what was there usual practice for rectal prolapse, 41% of responding surgeons considered a variant of abdominal rectopexy as their first choice treatment for fit patients. By definition they were accepting a recurrence rate of around 5%; the majority of patients also experience a functional disturbance, usually constipation24. Resection rectopexy is thus recommended for patients with pre-operative constipation. In 1998, 23% preferred a less invasive perineal approach, usually Delorme’s rectal mucosectomy, for elderly and unfit patients with all its inherent side effects of constipation or incontinence, consequent of the reduction in rectal volume and compliance25. The recurrence rate following a perineal procedure is also substantial approaching the order of 30%. In the same questionare, 38% of respondents had no routinely favoured approach.
The PROSPER trial was originally set up with the fundamental aim of evaluating the benefits and risks of abdominal and perineal approaches. The main effect of PROSPER seems to have been a sea change in practice or opinion with 2/3 now electing for a perineal approach and only 20% an abdominal operation23.
A laparoscopic approach to rectal prolapse is gaining popularity and momentum. Laparoscopy combines the advantages of reduced hospital stay26, improved patient comfort and better cosmesis with the low recurrence rate seen with the more traditional abdominal approach. These interventions all utilise the familiar posterior rectal mobilisation outside the mesorectal fascia and posterior fixation of the rectum to the sacrum using either sutures or a sheet of foreign material. Whilst the approach may be new, the actual surgery itself has not changed and continues with its perpetual shortcomings.
In a small series of 14 patients with solitary rectal ulcer without overt rectal prolapse, Nicholls and Simson13 approached the problem using a combined posterior and ventral rectopexy. They had two failures. Of the 12 patients who improved, two developed constipation. The results are interesting given that by definition, this approach will almost certainly diminish rectal capacity, compliance and sensitivity.
Full thickness rectal prolapse is an intussusception of the rectum extending beyond the anal canal, occurring mainly in elderly and parous women7. In women, weakness of the pelvic diaphragm and rectovaginal fascia allows descent of the middle compartment and the development of either a rectocele, enterocele and/or vaginal/vault prolapse8. The vaginal support system includes apical support provided by the cardinal-uterosacral complex and lateral support, provided by the pubocervical and rectovaginal fascia9. Apical or vault prolapse also follows hysterectomy or relaxation of the cardinal-uterosacral ligaments seen with childbirth and ageing10. Should prolapse occur and remain untreated, chronic downward pressure leads to a loss of residual lateral attachments and formation of a cystocele and/or rectocele and rectal intussusception. Enteroceles also form in conjunction with vault prolapse when a hysterectomy is performed without precise closure of the vaginal cuff and its supporting pubo-cervical and rectovaginal fascia11.
Vault prolapse usually occurs a few years after a hysterectomy and usually in conjunction with other pelvic floor defects. However, in many cases it is not even diagnosed even though it can make up the majority of the pelvic floor defect. Indeed, most cases of rectal prolapse also involve some degree of vault prolapse that is either overlooked or miss diagnosed as an isolated cystocele or rectocele12. Many of these patients also have symptomatic anterior mucosal rectal prolapse and when carefully examined, an overt rectal prolapse. Whilst the natural history of incomplete intussusception is variable, it may well lead to an overt rectal prolapse.
In our minds, the principle of prolapse surgery should be to correct all the anatomical defects, prevent any bowel dysfunction and avoid any adverse bladder and sexual sequelae. In theory, laparoscopic ventral mesh rectopexy helps correct pelvic floor descent during defecation by providing vertical support via the perineal body. It also carries distinct advantages for the middle pelvic compartment by supporting and reinforcing the rectovaginal septum and at the same time corrects any associated genital prolapse and rectocele. This could, in part, explain the beneficial effects on symptoms of obstructed defecation. The avoidance of a posterior mobilisation also avoids the risk of autonomic nerve denervation and/or injury. We also hoped that the laparoscopic approach would confer safe, predictable, effective surgery to an ever-increasing elderly population who otherwise would be subjected to a perineal procedure.
D’Hoore and colleagues in Leuven advocted an almost identical approach to ours in 1996, and published their interim results, median follow-up 61 months on 42 patients in late 200414. Their results are remarkably similar to our own in that there were no major postoperative complications and only two late recurrences. These two recurrences were put down to the learning curve. There was a significant improvement in continence in 28 of 31 patients with incontinence and symptoms of obstructed defecation resolved in 16 of 19 patients. New onset mild obstructed defecation was seen in two patients. The Leuven group reported no problems with mesh erosion. The Oxford group27 have confirmed that D’Hoore’s technique is safe, reproducible and effective. 30 patients underwent laparoscopic anterior resection for prolapse and 10 for for obstructed defecation symptoms not responding to pelvic floor retraining. Constipation significantly (>50%) improved in 71% (prolapse), 80% (intussusception). Constipation worsened in one patient.
A comparable nerve sparring, open procedure has been reported28. Using a posterior mesh with bilateral ventrolateral mesh extensions in similar groups of patients with rectoceles, rectal intussusceptions, enterocele or combined genital/rectal prolapse, Silvis et al., found that constipation improved in 14 of 18 patients. Sagar’s group29 reported on a larger series of 29 patients, median follow-up 26months. There were three operative failures (10%) and one mesh erosion. Two further patients required revision surgery because of unsatisfactory results. The remaining patients had good symptomatic improvement for urinary and rectal symptoms. A more complex open approach30 using a Gore Tex perineal sacral suspension has yielded similar high patient satisfaction scores and improvements in obstructed defeactory symptoms and perineal descent.
We have confirmed the reproducibility and efficacy of using laparoscopic ventral rectopexy, posterior colporraphy and vaginal sacrocolpopexy in treating patients with full thickness rectal prolapse, high take-off rectal intussusception with obstructed defecation, solitary rectal ulcer syndrome as well as combined genital prolapse. It also deals with a rectocele. The technique can also be modified to address a concurrent symptomatic anterior vaginal prolapse. Our current patients are now admitted on the day of surgery and in the majority of cases, discharged home within 23 hours of admission. Like D’Hoore14, we believe that resection rectopexy should be limited to highly selected patients and that perineal procedures for prolapse should be reserved for high risk patients unsuitable for a general anaesthetic.
The authors are grateful for the advice of Mr Paul Durdey, Colorectal Surgeon, Mr Fraser McLeod, Consultant O&G and Mr Tim Whittlestone, Urologist in developing the technique.
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