Aldo Infantino1 and Andrea Lauretta1
(1)
Department of General Surgery, Santa Maria dei Battuti Hospital, San Vito al Tagliamento (PN), Italy
Aldo Infantino
Email: ainfantino@libero.it
Abstract
There is general agreement that surgical treatment is essential for complete rectal prolapse (CRP). Rectoanal intussusception (RAI), also known as internal prolapse, is often regarded as a medical condition; it can be found in healthy subjects [1] and the interpretation of radiological images remains controversial [2]. Therefore surgical treatment for symptomatic RAI is still a matter of debate, and bowel retraining (i.e., high-fiber diet, bulk laxatives, avoidance of straining and digitation, and pelvic floor exercises) must be considered as a first approach, leaving surgery as the last option for cases where conservative therapy fails. Fecal incontinence (FI) and obstructed defecation syndrome (ODS) make CRP and RAI very disabling conditions. FI is present in 30–80% of patients with CRP [3], and also in up to 44% [4] of those with RAI. ODS is often characterized by strenuous effort to expel stools, feeling of incomplete evacuation, rectal tenesmus and frequent visits to the toilet, digitation, and the use of enemas and/or suppositories [5]. Furthermore RAI and CRP are often associated with a more complex pelvic floor prolapse. Many patients who complain of a single pelvic compartment prolapse may be affected by prolapse of multiple pelvic compartments [6]. Multiple pelvic defects, variously associated with one another and to different degrees, can be present at the same time: rectocele and rectal occult mucosal or full-thickness prolapse are often associated with enterocele, and uterine, vaginal, and bladder prolapses [7].
19.1 Introduction
There is general agreement that surgical treatment is essential for complete rectal prolapse (CRP). Rectoanal intussusception (RAI), also known as internal prolapse, is often regarded as a medical condition; it can be found in healthy subjects [1] and the interpretation of radiological images remains controversial [2]. Therefore surgical treatment for symptomatic RAI is still a matter of debate, and bowel retraining (i.e., high-fiber diet, bulk laxatives, avoidance of straining and digitation, and pelvic floor exercises) must be considered as a first approach, leaving surgery as the last option for cases where conservative therapy fails. Fecal incontinence (FI) and obstructed defecation syndrome (ODS) make CRP and RAI very disabling conditions. FI is present in 30–80% of patients with CRP [3], and also in up to 44% [4] of those with RAI. ODS is often characterized by strenuous effort to expel stools, feeling of incomplete evacuation, rectal tenesmus and frequent visits to the toilet, digitation, and the use of enemas and/or suppositories [5]. Furthermore RAI and CRP are often associated with a more complex pelvic floor prolapse. Many patients who complain of a single pelvic compartment prolapse may be affected by prolapse of multiple pelvic compartments [6]. Multiple pelvic defects, variously associated with one another and to different degrees, can be present at the same time: rectocele and rectal occult mucosal or full-thickness prolapse are often associated with enterocele, and uterine, vaginal, and bladder prolapses [7]. A unique pathophysiologic theory has been suggested [8]. Furthermore, the central problem is not exclusively mechanic but also, if not mostly, biological. This is confirmed by the involvement of the psyche [9], and also by changes to intestinal motility in the whole gastrointestinal tract, not just the large bowel [10]. Consequently, the management and treatment of CRP and RAI is, to date, far from standardized. Surgical treatments are commonly categorized into abdominal and perineal approaches. Abdominal rectopexy is considered more invasive than the perineal approach, although, with the advent of laparoscopy, this is no longer the case [11, 12]. The benefits of the abdominal approach consist principally of reduced recurrence rates and better functional results. Abdominal procedures share the common surgical aims of rectal mobilization and fixation, but differ in the extent of rectal mobilization and the method of fixation used. There remains significant controversy concerning the most appropriate technique: whether or not to use mesh to fix the rectum to the sacrum; ventral (Ripstein technique) or posterior (Wells’ or Orr-Loygue) technique; rectopexy with or without sigmoid resection; and the type of mesh used (whether it is absorbable or not, or even biological).
19.2 Surgical Techniques
19.2.1 Ripstein Technique
The Ripstein technique consists of complete mobilization of the rectum and securing it to the hollow of the sacrum by using a fascia lata graft. Synthetic mesh has replaced the fascia lata graft and a laparoscopic approach is performed. The results of this procedure have not shown great success: persistence of preoperative constipation was more common than after resection rectopexy (57% vs. 17%; p = 0.03), and new-onset constipation affected 12% of patients after the procedure [13]. Schultz et al. showed that the increased constipation was a particular problem among patients with internal rectal intussusception [14]. This was explained by an increased intestinal transit time after the procedure [15]. The Ripstein procedure has been proven to achieve good anatomic repair of the prolapse, associated with improved continence; however, in the presence of constipation, procedures other than the Ripstein technique should be preferred [13].
19.2.2 Wells’ Technique
In the the Wells’ technique the perirectal peritoneum is opened on both sides, and the rectum is fully mobilized with the mesorectum dissected to the level of the levator plane, avoiding injury of the presacral nerve plexi. A nonabsorbable mesh, 4 ± 6 cm, is fixed to the sacral hollow and the lateral wings of the mesh are fixed to the lateral walls of the rectum [16]. Laparoscopy has also been successfully applied to this technique, with no major intraoperative or postoperative complications. In a report on 77 patients, constipation was improved in 36% of cases; but 18% of the patients complained of new-onset constipation, even though 90% of the patients were satisfied at long-term follow-up [17]. A modification of the technique has been proposed in cases of rectal and vaginal prolapse after hysterectomy: Wells’ rectopexy with the sling extended to anchor the vaginal vault after correction of the enterocele [18].
19.2.3 Orr-Loygue Technique
Orr proposed fixation of the rectum, after complete isolation of the organ, to the sacral promontory using two strips of muscular fascia sutured distally to the lateral sides of the rectum and proximally to the presacral fascia. Loygue [19] modified the technique by the use of a synthetic mesh, 3 cm wide, sutured to the anterolateral side of the lower extraperitoneal rectum, with 4–5 nonabsorbable sutures; to avoid any tension the meshes are sutured to the sacral promontory at a distance of 2–3 cm from each other, using a nerve-sparing technique. A modified Orr-Loygue technique has been used in our surgical unit, with the aim of reducing rectal dissection and improving nerve sparing: a limited posterior and lateral rectal dissection avoiding any lateral ligament division is performed. A polypropylene mesh, trouser-shaped, is fixed to the sacral hollow and sutured to the anterolateral rectal walls. The distal ends of the mesh are sutured to the vaginal fornix or vaginal vault. This procedure has been associated with good functional results in more than 90 patients, and postoperative constipation occurred in only 2 of 99 patients [20]. In a systematic review, the effectiveness of ventral rectopexy surgery for treatment of CPR and RAI has been evaluated [21]. In 12 nonrandomized case series studies with 728 patients, seven studies used the Orr-Loygue procedure (ventral rectopexy with posterior rectal mobilization to the pelvic floor) and five studies used ventral rectopexy without posterior rectal mobilization. Overall weighted mean percentage decreases in fecal incontinence rate and constipation were 45% and 24%, respectively, with a low relapse rate (3.4%). New-onset constipation after surgery was observed with a weighted mean rate of 14.4%. The authors concluded that greater reduction in postoperative constipation is obtained by avoiding posterior rectal mobilization [21]. Even when performed with reduced posterior rectal mobilization, the Orr-Loygue procedure is still associated with new-onset constipation, although to a lesser extent than other rectopexy procedures.
19.2.4 Frykman-Goldberg Procedure
Sigmoidectomy for rectal prolapse has been proposed by Frykman and Goldberg, in an attempt to avoid postoperative constipation [22]. Resection rectopexy (Frykman-Goldberg procedure), in which a rectopexy is combined with a sigmoid resection, mitigates postoperative constipation and has consequently been favored [23]. Encouraging results have been published: outlet obstruction and fecal incontinence resolved in 81% and 72%, respectively, of patients operated for CRP. Postoperatively only two patients complained of a new rectal voiding alteration [24]. Resection does avoid constipation, but it carries risks related to the anastomosis [25, 26]. Compared with the Wells’ procedure, resection rectopexy has lower morbidity, but produces similar functional results and has a similar relapse rate [27].
19.3 Discussion
The lack of prospective randomized trials does not allow us to draw any definitive conclusions for the best surgical treatment for CRP and RAI. Unfortunately, many studies are not comparable because of the different classifications used, the different definitions of success, and the short follow-up times. The definitive treatment for CRP is surgical, while the correct approach for RAI remains a gray area. RAI is difficult to treat and results are often disappointing; the initial approach should be conservative: dietary advice, biofeedback, and rehabilitation of the pelvic floor muscles can help to reduce outlet obstruction and incontinence. Even when stringent patient selection criteria are applied, rectopexy is associated with symptom improvement in only two-thirds of patients affected by RAI [28]. Surgical treatment of rectal prolapse can be undertaken through the abdominal or perineal route, but the recommended route has not yet been defined. The perineal approach has a lower rate of complications and is normally reserved for more fragile patients. However, laparoscopy [29, 30] has more recently reopened the debate on the best approach, because it is less traumatic and it is feasible for all open procedures. In fact laparoscopy has low postoperative morbidity and mortality rates: 4–9% and 0–3%, respectively [31]. It is associated with less postoperative pain, minor analgesic requirement, better cosmetic result, faster recovery time, and less time taken off work [26, 32, 33]. Several studies have confirmed that comparison between the “open” technique and laparoscopy favors the latter [34–36]. In addition, a study on economic impact showed that laparoscopic rectopexy compared with the open procedure, other than giving better clinical results, costs less [37]. Finally, it has been demonstrated that laparoscopy is particularly suitable for elderly or frail patients [38]. Therefore age is not only no longer a limitation for abdominal rectopexy, and it has been shown to have no influence on functional results, since results have been shown to be similar in patients who are older than 70 years compared with those who are younger than 70 years [39]. We can conclude that, once the abdominal route has been chosen, the procedure should be performed laparoscopically even though the current available data do not indicate that one technique is better than the other. Postoperative constipation, mainly due to rectal denervation secondary to sectioning of the lateral ligaments and complete rectal mobilization [40, 41], is the main drawback of abdominal rectopexy. The Orr-Loygue technique should reduce this functional complication, especially when avoiding extensive isolation of the rectum, as proposed by our group; however, no comparative studies have been published to confirm this hypothesis. Results of data reported in the literature indicate that the Ripstein procedure produces the less-favorable results in terms of postoperative function [42]. The Orr-Loygue technique appears to be superior to the Ripstein procedure because the free anterior rectal wall avoids stenosis and results in better rectal motility. Functional results after using the Orr-Loygue procedure are also better than those of the Wells’ technique, but, as mentioned above, no comparative studies have been published to confirm this. Portier et al. [43] indicated that limited dissection of the rectum produced good results in terms of recurrence rate, and constipation and FI improvement. Seventy-three patients underwent Orr-Loygue ventral rectopexy with limited dissection for either CRP or IRA: recurrence rates were 5.9% and 0%, respectively; FI and constipation were resolved in 58.1% and 51.9% of cases of CRP, and in 70.6% and 60% of cases of IRA, with a patient satisfaction of 94.5% [43]. Although it is beyond the scope of this chapter, the growing popularity of ventral rectopexy, as described by D’Hoore, should be addressed [44]. The preservation of lateral ligaments and the absence of posterior dissection reduce the risk of autonomic nerve injury to virtually zero. This technique, and a modification published recently by our group [45], seems to produce a definitive answer to the postoperative constipation issue. Finally, whatever technique is used, the combined repair of central and posterior compartments of the perineum is mandatory, in order to avoid multiple operations with a higher risk of complications [46]. In cases of associated genital prolapsed, uterine fixation to the sacral promontory associated with Orr-Loygue rectopexy has proved to be reliable, with a low complication rate and no recurrence at 20 months of follow-up [47]. In cases of vaginal vault prolapse or enterocele, the use of abdominal colposacropexy with mesh has a cure rate of 90% [48]. Abdominal rectocolpopexy is the recommended procedure for cases of associated middle and posterior compartment defects [44, 45].
19.4 Final Consideration
In conclusion, if sacral rectopexy with mesh is proposed, the modified Orr-Loygue technique is recommended because it is less aggressive and most effective at restoring anatomy and improving FI and ODS. Nerve preservation, limiting isolation and dissection of the posterior rectal wall, and maintaining lateral ligament integrity, is essential to prevent postoperative constipation. Although there is no overwhelming clinical evidence to indicate a preference for one surgical procedure over another, once the surgeon has chosen the abdominal route the a laparoscopic approach seems to be the best option since it offers a greater chance of early recovery, a minor incidence of morbidity, and it is less expensive. There is evidence that any associated central compartment defects should be treated at the same time.
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