Laparoscopic Rectopexy for Rectal Prolapse: Will it be the Gold Standard?

Abstract

A review of the current literature is presented regarding the surgical management of full thickness rectal prolapse, comparing laparoscopic rectopexy with open abdominal operations and perineal procedures. Outcome measures include length of stay, short- and long-term outcomes and financial burdens. Current evidence suggests that laparoscopic rectopexy as treatment for full thickness rectal prolapse is a safe alternative to the other options.

Background

Rectal prolapse, also known as procidentia, is defined as the protrusion of all layers of the rectal wall beyond the anus [1]. Patients find it an extremely distressing condition with the potential of significant morbidity, such as ulceration, pain, bleeding, incontinence, constipation and even gangrene. Whilst the majority occurs in elderly females, the condition can occur in either sex and at any age.

It can be subdivided into two broad categories, occult and non-occult, depending upon the prolapse’s position in relation to the external anal sphincter. Furthermore, the condition can be classified as full or partial thickness in nature. This review will focus on full thickness, external rectal prolapse.

There are a plethora of exacerbants for the condition, including weakness of the pelvic floor musculature, external and internal anal sphincter weakness, high parity and a deep pouch of Douglas [2, 3]. In addition, neurological and connective tissue disorders can result in the condition. As a result of the breadth of causes, no perfect treatment option has been determined.

Surgical intervention was first described by Pemberton in 1939 [4]. He described an abdominal approach whereby the prolapse was suspended and fixed. Whilst techniques have developed over time, the principle remains valid today. The two approaches used can be divided into abdominal and perineal. Historically, either a conservative or perineal approach has been the preferred method in the elderly and frail whereas a laparotomy has been preserved for those with greater physiological reserves due to the latter’s superior rate of recurrence, at less than 10 % [5]. With the development of laparoscopic surgery, the opportunity to utilise the abdominal approach combined with the recovery benefits of laparoscopic surgery have been seized. Few would argue with the short-term benefits of laparoscopic repairs with regards to reduced pain and shorter hospital stays. However, less certainty and consensus surrounds the long-term success rates of these procedures.

Management Options for Rectal Prolapse

The management of rectal prolapse, like most conditions of a surgical nature, can be either conservative or operative. Historically, conservative management is the preserve of the frail and elderly. For those unfit for surgery, management with a combination of bulk laxatives and high fibre diet is recommended. There are a variety of options for operative management that, whilst observing the same basic principles, differ in their execution; the core differences being, the approach and the permutations of resection and fixation, known as rectopexy. The principal methods of repair are:

1. Transabdominal rectopexy/resection/resection rectopexy

   These methods can be either an open or a laparoscopic repair. As their names suggest, they involve fixation or removal of a segment of bowel, or a combination of the two. When rectopexy is incorporated, it may be in the form of a material mesh or simple sutures, and involves the fixation of the rectum to the sacrum. A spectrum of different fixation materials has been used, including Teflon, Gor-Tex, vicryl and nylon. The rectum itself may be fully mobilised by dividing the lateral ligaments, or otherwise these may be left intact and a partial mobilisation achieved. With regards to the attachment of the mesh, the Ripstein or Well’s procedure can be used prior to its fixation to the sacrum [6]. In the former’s case, the rectum is completely encircled, with a sling mesh, whereas in the latter only partial encirclement takes place, typically two thirds of the total circumference, in this case with an Ivalon sponge. The rationale behind the Well’s procedure is that, by sparing a third of the rectum from encirclement, peristalsis is not impaired by fibrosis. The laparoscopic ventral rectopexy (LVR) has been increasingly used as an effective management of rectal prolapse. LVR, popularised by D’Hoore [7], involves dissection in the recto-vaginal space to the pelvic floor, with minimal lateral and posterior dissection of the rectum, following which a synthetic or biologic mesh is sutured to the anterior rectum and the cranial end attached to the sacrum with a fixation device. The rationale behind the procedure is the preservation of the autonomic neurological supply to the rectum to prevent constipation.

2. Perineal resection

   There are two approaches to this treatment option: perineal rectosigmoidectomy (Altemeier’s procedure) and Delorme’s procedure [8]. The former involves resection of the redundant rectum and lower colon with a colo-anal anastomosis. The principle works on the basis of fibrosis preventing recurrence. Delorme’s procedure relies upon mucosal stripping opposed to resection, with subsequent fixation of the muscle layers.

3. Anal encirclement (Thirsch’s Procedure)

   Performed under a local anaesthetic, this approach is a stalwart option for those with significant risk factors for a general anaesthetic or the older cohort of patients. It involves the insertion of an encircling suture, once the defect has been reduced, which is then tightened in the expectation of preventing further prolapse.

   The transabdominal rectopexy with or without resection has long been regarded as the preferred treatment modality for those robust enough to withstand a general anaesthetic. The open approach relies upon a laparotomy, with all of its associated risks, whilst the development of minimally invasive techniques has positively impacted upon recovery times after major surgery. In patients who have been deemed unfit for a major procedure, the perineal approach has been preferred.

Aims

The aim of this literature review is to collate the current evidence base for laparoscopic rectopexy in comparison with open and perineal repairs to ascertain if this should now be considered as the gold standard for treatment. There are a number of indicators to assess the merits of a procedure. It cannot be based upon one aspect alone, but rather the combination of these and the overall risk to benefit ratio. In order to ensure as judged an opinion as possible, the following key indicators have been determined in assessing the laparoscopic rectopexy’s place in surgical practice: length of stay, short term outcomes, long term outcomes and the financial burdens involved.

Method

A literature search was performed through the National Library of Medicine’s PubMed database, NHS Evidence, MEDLINE, EMBASE and The Cochrane Library. The following terms were used: “rectal prolapse”, “rectum prolapse”, “laparoscopy”, “laparoscopic surgery” and “laparoscopic and rectopexy”. The limits to the search were the following: papers published from 1995 onwards, papers published in English and those pertaining to humans. The abstracts were reviewed and those papers not related to this work were excluded. The text reports of potentially relevant papers were reviewed in full. The remaining papers were analysed as well as related articles from reference lists, enabling as comprehensive a search as possible to be performed. The studies incorporated in this review focussed on adults suffering from rectal prolapse and did not consider the juvenile population.

A variety of papers and levels of evidence were reviewed, varying from single centre trials to case series and meta-analyses. This provided a sound breadth of the information presently available regarding the efficacy and feasibility of laparoscopic rectopexy.

Assessment of Outcomes

To establish a preferred method for surgical intervention, a number of criteria need to be considered. These include short-term and long-term outcomes, length of hospital stay and the economic burden on the healthcare sector.

To maintain clarity of thought when evaluating this data, these criteria have been subdivided into three distinct categories, namely core outcomes, clinical end points and financial implications.

Core outcomes encompass:

• i.Recurrence
• ii.Incontinence
• iii.Constipation

Clinical end points encompass:

• i.Postoperative mortality
• ii.Postoperative morbidity
• iii.Length of hospital stay

Financial implications encompass the associated economic costs of a laparoscopic approach compared with an open one in terms of:

• i.Fixed costs
• ii.Variable costs

Results

Core Outcomes

The three greatest long-term negative outcomes are the following: recurrence, postoperative constipation and incontinence. The foremost, by nature of the significant rectal mobilisation and fixation, is a relatively rare complication when rectopexy is performed, with reported rates of 0–7.69 % in laparoscopic rectopexy, compared with 0–13.2 and 5–20 % in open rectopexy and perineal repairs, respectively [5, 9–14]. Constipation however proves to be a potentially common burden for the patient to bear. It has been repeatedly reported that postoperative constipation after posterior mesh rectopexy stands around or even exceeds the 50 % threshold, this being the case when the procedure is performed either via an open or laparoscopic approach [15, 16]. Laparoscopic ventral rectopexy, however, appears to result in less constipation, with reported improvement rates of 72 % [17].

Historically, it has been generally accepted that the patient’s pre-morbid state dictates the operative treatment of choice. Young, fit patients invariably undergo a transabdominal procedure whilst the perineal approach is the reserve of frailer patients. Whilst the former appears to have better functional results, combined with lower recurrence rates, the latter has lower morbidity. Until the recently published PROlapse Surgery, PErineal or Rectopexy (PROSPER) trial [18] (see below), there was only one trial that directly compared abdominal resection rectopexy against perineal rectosigmoidectomy, with results favouring the abdominal approach [5]. Twenty patients were included, with one half undergoing the abdominal procedure and the other half the perineal approach. In terms of recurrence, 10 % of the perineal cohort was reported to have recurred compared with none from the abdominal repair. With regards to postoperative incontinence, there was a 60 % occurrence in the perineal group compared with 10 % in the abdominal group (95 % CI 1.20 to 152.21).

The 2009 original article by de Hoog compared the results in terms of recurrence and functional outcomes when the traditional open method was compared with laparoscopic repair and robot-assisted laparoscopic repair [19]. This study suggested that whilst functional outcomes were improved with all three methods, there was a significantly greater rate of recurrence in the robot-assisted laparoscopic repair (p = 0.027). Furthermore, the recurrence rate with laparoscopic repair had a confidence value of p = 0.059, making its validity equivocal.

Sajid et al’s meta-analysis of a total of 668 patients undergoing either laparoscopic rectopexy or open rectopexy showed no statistical difference in recurrence (p = 0.51), incontinence (p = 0.57) or constipation (p = 0.82) betwixt the two groups [11]. This concurred with the subsequent meta-analysis carried out by Cadeddu et al [20]. Whilst both of these meta-analyses supported the use of laparoscopic rectopexy in providing a safe and effective alternative to the conventional open approach, their endorsement held the caveat that there is a dearth of evidence from large scale randomised control trials to enhance its credibility.

A cohort of 245 consecutive patients was analysed by Formijne Jonkers et al and demonstrated that there was a significant correlation to support the use of laparoscopic surgery (in the form of ventral rectopexy) when considering the complications of constipation and incontinence [21]. Their work argued that there was statistically significant data demonstrating a reduction in constipation (p < 0.001) and incontinence (p < 0.001) in their patient group. D’Hoore et al’s work in the British Journal of Surgery appears to support this, with 28 out of 31 patients with incontinence experiencing a significant improvement in continence and 16 out of 19 patients with constipation stating their symptoms had resolved [7].

A further layer to the analysis of core outcomes concerns the decision as to whether resection should accompany the rectopexy. Two somewhat limited data trials from 1992 examined this topic [22, 23]. The first, by Luukkonen et al, compared mesh rectopexy against resection and suture rectopexy. The second trial, by McKee et al, compared resection and suture rectopexy with suture rectopexy alone. Of the 48 patients recruited in both trials combined, there were no occasions of recurrence. Constipation was found to be significantly less of a postoperative issue in those undergoing resection and rectopexy compared with those who underwent rectopexy alone (2/24 compared with 12/24—a 95 % CI of 0.01–0.44). Whilst reported, faecal incontinence was deemed to be not statistically different in its rate of occurrence between either cohort (8/24 in the resection cohort compared with 5/24 in the rectopexy cohort; a 95 % CI of 0.52–6.99).

The final two factors to consider when evaluating the ideal method for the surgical management of rectal prolapse are:

• i.Should the lateral ligaments be preserved or divided?
• ii.Which method of fixation for transabdominal procedures is preferable?

Taking the aspect of preservation or division of the lateral ligaments first, the limitations of the data set make firm comment somewhat challenging [24, 25]. Broadly, these two trials would appear to suggest that there is a trend for a greater rate of recurrence in patients in whom the lateral ligaments are spared (17–19 % compared with 0 % for those with division of the lateral ligaments) but this is, to a degree, offset by a reduced rate of constipation (95 % CI (−) 1.39 to (−) 0.61).

As aforementioned in the descriptions of transabdominal rectopexy, a variety of methods of fixation can be utilised. These include a plethora of meshes, Ivaon sponge and staple (simple or laparoscopic). Whilst a number of studies have considered this topic, due to the array of comparables, firm conclusions prove difficult to draw. It does appear however, that there is no significant impact on core outcomes whatever method is used [25–28].

The recently published PROlapse Surgery, PErineal or Rectopexy (PROSPER) trial of 293 cases, across 34 centres, conducted by the University of Birmingham, was an RTC aimed at establishing the optimal method of treatment by comparing the merits of the variety of techniques available [18]. Patients with full thickness rectal prolapse were randomised into the following groups:

• i.Abdominal and perineal surgery
• ii.Suture versus resection rectopexy for those receiving abdominal procedures
• iii.Altemeier’s versus Delorme’s for those receiving perineal procedures.

No significant difference was observed between any of the comparison groups in terms of recurrence (although the rates for abdominal repairs of 26 % is considerably higher than reported elsewhere), incontinence rates or quality of life. The study, however, did not specifically examine the impact of performing abdominal procedures laparoscopically.

Clinical End Points

The major end points, from a patient’s and clinician’s perspective, are postoperative morbidity and mortality. For both groups, the duration of hospital stay have, for differing recourse, a significant implication.

The work of Deen et al reported no mortality in either the perineal rectosigmoidectomy or abdominal resection cohorts [5]. However, 1/10 of the rectosigmoidectomy patients encountered postoperative morbidity, with an anastomotic stricture. This was in comparison with 3/10 of the abdominal resection patients developing postoperative morbidity, two cases of ileus and one case of postoperative infection.

In terms of morbidity and mortality, for patients of all ages, several articles have demonstrated no significant impact for open and laparoscopic transabdominal procedures [7, 29]. In Sajid et al’s work, when the 668 patients from 12 studies were meta-analysed, there was no significant difference in mortality (p = 0.60) and morbidity (p = 0.73) between the open and laparoscopic approaches [11]. On a more defined level, Wijffel et al’s Oxford-based study examined mortality and morbidity in a cohort of patients over the age of 80 years undergoing a laparoscopic repair. This work showed no significant difference in mortality, morbidity or duration of hospital admission between the laparoscopic approach compared with historical data for perineal procedures [30]. This appears to be supported by the Japanese retrospective analysis of Kaiwa et al [31], as well as the Helsinki report of Carpelan-Holmstrom [9]. However, in the case of the former, their sample size of 14 patients, 9 of whom were over 70 years, may limit the confidence held within their work.

The PROSPER trial [18] reported no significant difference in morbidity or mortality when comparing perineal with abdominal procedures, and likewise there was no difference when resection rectopexy was compared to rectopexy alone. The laparoscopic approach was not specifically examined.

Laparoscopic surgery has revolutionised surgical practice. Many operations that would have previously resulted in prolonged hospital admissions are managed within either the ‘Short Stay’ or even the ‘Day Case’ units. The impact of shorter lengths of stay has a beneficial effect on both patients’ expectations and allocation of finite healthcare resources. By virtue of its minimally invasive character with the lack of large wounds, recovery times are significantly reduced compared with open procedures. The laparoscopic ventral rectopexy encompasses the additional benefit of negating the need for drains and the low risk of haemorrhage. Its application to rectopexy therefore makes it a realistic option for day case or overnight surgery.

Studies have suggested an average stay of 2–7 days for patients undergoing laparoscopic rectopexy [32–34]. However in an unselected cohort of 120 consecutive patients by Powar et al, 23 % were discharged on the same day as their procedure, with a further 67 % discharged within 23 h of surgery [35]. Of the 90 % of patients discharged in the first 24 h from this study, there was only one readmission and no significant difference in complication rates.

Careful selection of patients is required to ensure that appropriate candidates are co-opted for this enhanced discharge programme. It is ideally suitable for younger patients, in the absence of disabilities.

Financial Implications

Modern healthcare is constrained by the balance between clinical effectiveness and the financial impacts of health technologies. In the UK, the National Institute for Health and Care Excellence (NICE) guidelines aim to address the balance between these competing factors [36]. Advancements in medical practice are stringently evaluated to determine their benefits and these are compared with the economic impact of these methods.

Salkeld et al demonstrated that the mean cost of a laparoscopic rectopexy, once theatre, instrument and hospital stay costs had been incurred, was £2,812; this being £357 cheaper than its mean open equivalent [37]. The key factor in this is the reduction in hospital stay. Broadly, admission costs can be subdivided into fixed and variable. The infrastructural costs remain firm and would not alter whether an open or laparoscopic procedure was performed. The variable costs are however indelibly linked with the duration of hospital admission. Taheri et al have proposed that the variable cost savings account for 30–50 % of the mean daily hospital bed costs [38].

Inevitably, the cost of hospital admissions is not the only factor to impact upon health care expenditure. If the cost of care is merely transferred from the secondary to primary care setting, then the net result of the change in practice may be negated [39]. Examplars of this would include prolonged District or Practice Nurse input and social service packages of care. However, on the basis of the peri-operative outcomes of laparoscopic compared with open repair, this seems unlikely to be the case.

Conclusions

Over the past 20 years, there has been a significant shift change in the management of rectal prolapse. The evolution and refinement of laparoscopic surgery and its application to abdominal rectopexy have positively impacted upon surgical practice.

A number of independent factors need to be considered, both in turn and in conjunction, before reaching a determination as to the benefits and drawbacks of a technique. These have, for the purpose of this review, been broken down into core outcomes, clinical end points and financial implications. Furthermore, the quality of the evidence needs to be assessed. For example, the lack of an extended period of follow up makes assessment of recurrence a more arbitrary judgement. In addition, the lack of blinding for most of the studies makes them vulnerable to the accusation of bias.

Until the recently published PROSPER trial, there was a paucity of level 1 evidence comparing the perineal and transabdominal approaches. However, PROSPER appears potentially flawed in terms of the high recurrence rates reported with abdominal procedures when compared with other series. Furthermore, for the purposes of answering the question pertaining to whether laparoscopic rectopexy should be the gold standard, this approach was not examined.

Overall, the evidence reviewed provides the surgeon with confidence that first and foremost laparoscopic rectopexy is a safe surgical option, with no statistically significant difference in mortality or morbidity compared with its open equivalent. Furthermore, the scope for using the laparoscopic repair in the older cohort of patients, for instance those over the age of 80 years in whom perineal procedures have been historically preferred, is encouraging. The data reviewed lends support to the beneficial core outcomes for patients, although, as aforementioned, this must be taken within the context of a limited duration of prolonged follow up. From a fiscal perspective, the advantages of the laparoscopic approach are generally supportive. In terms of future work, multi-centre randomised controlled clinical trials assessing the use of laparoscopic versus open repairs or perineal procedures would lend credence to the current evidence supporting these findings.

With reference to the method of fixation, the jury is still out. There seems to be no conclusive evidence to rank on material above another for this task and further studies are required [25–28]. The question of division of the lateral ligaments provides a balance between the increased risk of recurrence with preservation compared with higher rates of constipation with division, presumed to be due to the denervation of the rectum through damage to the parasympathetic branches of the inferior hypogastric plexus [24, 25].

In summary, it is the opinion of the authors that laparoscopic rectopexy, with results comparable to its open counterpart and few of the disadvantages, should be deemed the treatment of choice in patients with rectal prolapse on the basis of the available evidence base. There is currently not enough evidence to support which laparoscopic technique should be employed and, although the proponents of laparoscopic ventral rectopexy would argue that it is the superior technique due to reduced rates of postoperative constipation, the recent concerns about mesh erosion point the authors of this review towards preferring a conventional posterior rectopexy with suture or fixation device attachment to the sacrum for the treatment of full thickness rectal prolapse in their clinical practice [40].