Ventral Rectopexy

Abstract

Rectal prolapse is a debilitating condition that often results in impaired quality of life. Posterior compartment defects including rectal prolapse and rectal intussusception are often associated with middle and anterior compartment prolapse and require a multicompartment approach to treatment. In recent years, ventral rectopexy, with or without sacrocolpopexy for combined middle compartment prolapse, has emerged as a safe and effective method of treatment for rectal prolapse. In this article, we aim to review the etiology of rectal prolapse and intussusception, describe the indications and workup for surgery, discuss technical aspects of ventral rectopexy alone and in combination with sacrocolpopexy, review potential surgical complications, and describe the reported outcomes of the surgery.

Rectal prolapse is a debilitating disorder of the pelvic floor that often results in impaired quality of life. It affects women more commonly than men, and often involves more than one compartment of the pelvis. ^{1 2} The prevalence of concomitant pelvic floor disorders is as high as 30% in patients with rectal prolapse and dynamic imaging studies often show coexistent pelvic floor abnormalities in the anterior and middle compartments of the pelvis. ^{3 4} Historically, there has been debate as to the etiology of rectal prolapse. Previous theories have suggested that rectal prolapse may be related to a progressively worsening sliding type of hernia given the common presence of a deep cul-de-sac, redundant sigmoid colon, and widened levator ani musculature. ^{5 6} Alternatively, it has been suggested that the progression of rectoanal intussusception may be the cause. ⁷ Although both theories are plausible, the exact etiology is likely variable between patients and multifactorial.

Surgical repair of rectal prolapse can be performed via a perineal or abdominal approach. Thus far, there has not been convincing evidence to show superiority of one approach over another in terms of recurrence, functional improvement, or quality of life. ⁸ Choice of repair depends on a thorough preoperative evaluation, taking into consideration overall health and presence of concurrent pelvic floor disorders. Ventral rectopexy (VR) has recently gained acceptance as a safe and effective approach in the treatment of rectal intussusception and rectal prolapse. Anatomically, VR addresses rectal intussusception with or without rectal prolapse when the lead point is located anteriorly. In women, this lead point may be associated with a coexisting enterocele and/or rectocele that can be repaired concurrently.

VR was first described over 20 years ago as the Orr-Loygue procedure ⁹ and was further modified by D'Hoore et al to be performed laparoscopically with dissection anteriorly into the rectovaginal septum with limited posterior dissection to preserve rectal innervation. A single mesh is then anchored to the sacral promontory and placed on the distal rectum. ¹⁰ Since the description by D'Hoore et al, VR has been performed both laparoscopically and robotically and has been combined with sacrocolpopexy in patients with coexisting middle compartment prolapse. ^{11 12 13} VR has been used in the treatment of rectal prolapse, rectal intussusception, and large symptomatic anterior rectoceles. ^{10 14 15} In this article, we describe the indications and workup for surgery, discuss technical aspects of VR alone and in combination with sacrocolpopexy, review potential surgical complications, and describe the reported outcomes of the surgery.

Preoperative Evaluation and Patient Selection

Patients with rectal prolapse are best evaluated using a multidisciplinary approach given the prevalence of coexisting urogenital prolapse. A thorough history and physical exam should be done, noting the presence of fecal incontinence, constipation, or incomplete evacuation. Medical comorbidities should be carefully considered; those patients who are appropriate candidates for abdominal surgery may be considered for VR.

Physical exam should focus on the extent of prolapse, presence of a patulous anus, and any findings that may be indicative of pelvic floor dysfunction. History and physical exam findings pointing to urogenital prolapse or dysfunction should also be documented. Colonoscopy should be obtained prior to surgical intervention to evaluate for colonic lesions or the presence of colitis that may direct the clinician toward alternative routes of treatment.

Fluoroscopic or magnetic resonance imaging (MRI) defecography can be obtained as part of a preoperative evaluation for potential middle or anterior compartment defects. Choice of imaging is dependent on availability and experience. However, a meta-analysis comparing fluoroscopic to MRI defecography suggested that fluoroscopic defecography may be better suited at detecting structural abnormalities such as intussusception. ¹⁶ Patients with symptoms suggestive of obstructive defecation can be evaluated further by anorectal manometry. Pelvic dyssynergia as identified through pelvic floor testing can be addressed initially by physical therapy and biofeedback. In patients with concomitant urogenital prolapse or dysfunction, urodynamics and urogynecology evaluation should be pursued.

It has not yet been fully elucidated which patients will benefit most from VR. Studies have reported good functional outcomes in patients who have undergone VR for rectal intussusception, rectal prolapse, and anterior rectocele. ^{14 15} It has been suggested that VR may be better suited as an operation for primary prolapse repair rather than recurrent prolapse. This was studied in a prospective cohort study looking at 108 patients who underwent VR. ¹⁷ Prolapse recurrence rates were reported at 1.4, 6.9, and 9.7% for primary repairs and at 13.9, 25, and 25% for recurrent prolapse procedures at 1, 3, and 5 years, respectively. Time to recurrence was much shorter for those undergoing VR for recurrent prolapse. Another retrospective cohort study looking at risk factors for recurrent prolapse after VR found several factors that may play an important role. ¹⁸ Patients who were older, had higher Cleveland Clinic incontinence scores, and had prolonged pudendal nerve terminal motor latency were found to be at higher risk of recurrence. These findings suggest that patients with a weaker pelvic floor may have suboptimal results with VR. A thorough preoperative evaluation can help identify patients who may be considered for other types of prolapse repair. Further studies are needed to identify preoperative indicators of success for VR.

Preoperative Consultation

Details of the surgery, risks, and recovery period should be discussed thoroughly to inform the patient about possible complications and set clear expectations of the postoperative period. Potential surgical complications include mesh infection/erosion and mesh migration/detachment. An observational cohort study looking at 919 patients who underwent VR showed a mesh complication rate of 4.6%. ¹⁹ Among those patients, 1.3% had mesh erosion into the vagina. Mesh erosion into the rectum has also been reported. ²⁰ Urinary complications of VR include urinary tract infection, urinary retention, and injury to the ureter, bladder or vas deferens. ²¹ Vertebral discitis at the site of proximal mesh attachment is a rare but well-recognized risk. ²²

Postoperatively, patients should be advised to avoid lifting more than 10 pounds, avoid sexual intercourse, and use laxatives such as MiraLAX for at least 6 weeks following surgery. Although there have been favorable results reported regarding improvement in constipation and incontinence, patients should be advised these conditions may not fully resolve. Patients who have preoperative symptoms of obstructive defecation or incontinence may continue to benefit from pelvic floor physical therapy after VR.

Operative Technique

A previous article has described a laparoscopic approach to VR. ²³ If available, a robotic platform provides excellent visualization deep in the pelvis along with wristed instruments that aid in suturing the mesh. The following text describes our approach to VR using the da Vinci Surgical System (Intuitive Surgical Inc, Sunnyvale, CA). The patient is positioned supine with both arms padded and tucked alongside the body in modified lithotomy. Abdomen, vagina (as needed), and perineum are prepped and draped. Access to the rectum and vagina should be maintained throughout the procedure. Depending on the preference of the surgeon and skill of the assistant, a three- or four-arm robotic setup can be used. After insufflation and port placement, the abdominal cavity is surveilled laparoscopically. The patient is placed in steep Trendelenburg position and the robotic arms are docked. Hysteropexy or a uterine manipulator may be used for additional exposure if necessary.

To facilitate access to the perineum, we dock via a left-hip approach. The rectosigmoid junction is grasped and retracted cephalad and anteriorly exposing the right pararectal fossa. We begin by using a 30-degree down-orientation of the scope that allows for better visualization of posterior structures. The right ureter is visible in most patients through the lining of pelvic peritoneum. Its course should be noted and visualized throughout the procedure. Monopolar scissors are used to divide the right lateral aspect of the peritoneum starting at the level of the sacral promontory and advancing distally along the rectum. The location of right common iliac artery and vein should be noted, and the plane of the peritoneal incision made medial to it. The extent of dissection along the right pararectal fossa should remain superficial and limited to 2 to 3 cm in width—just enough to admit a strip of mesh. We do not recommend extensive posterior mobilization of the rectum. The lateral rectal stalks should be preserved to minimize the risk of rectal dysfunction and constipation. Dissection continues distally toward the pelvic floor and curves anteriorly at the level of the cul-de-sac in the shape of a letter “J.” At this point in the procedure, we switch the scope to a 30-degree up-orientation. The remainder of the dissection is performed in an anterior plane between the vagina and rectum. A vaginal manipulator (Hoyte Sacro Tip or similar) is essential in identifying the vagina and establishing a correct plane of dissection. The vaginal manipulator should be advanced rather firmly cephalad and slightly anteriorly to provide optimal exposure of the rectovaginal septum. Rectal manipulators (such as EEA sizers) can be used as necessary for additional exposure and to help with identification of the rectum within the surgical field.

The surgeon can expect increased thickness and vascularity of tissues—a result of recurrent intussusception and prolapse. This can make identification of structures somewhat challenging. Additionally, tissues can be distorted in the case of prior hysterectomy. The dissection within the rectovaginal plane should be performed sharply with scissors and with judicious use of energy. The goal of the dissection is to develop the plane as far distally as the pelvic floor, identify lateral aspects of the distal rectum, and develop areas of exposed levator muscle on both sides of the distal rectum. The exposed levator “windows” on both sides of the rectum serve as landing sites for the distal corners of the mesh to be anchored directly to the pelvic floor ( Fig. 1 ). The distal extent of the dissection is confirmed with digital rectal examination and should be as low as 3 cm from the anal verge.

Fig. 1.

Intraoperative photo of the exposed levator muscle on both sides. Sutures have been placed to anchor the corner of the mesh to the levator muscle on both sides.

We use a lightweight polypropylene surgical mesh. Because a lightweight mesh contains less material, a less pronounced foreign body reaction is expected, resulting in better tissue incorporation. ²⁴ The mesh is fashioned with a distal width of 4 cm tapering to a proximal width of 2 cm to resemble a spatula ( Fig. 2A ) or an “L” shaped form ( Fig. 2B ). The proximal end of the mesh should not be trimmed until all the sutures are placed intracorporeally.

Fig. 2.

( A ) Graphic representation of synthetic mesh cut with a wide distal zone and with ( B ) an L-shaped configuration.

The mesh is introduced into the abdominal cavity and positioned with the wide end toward the distal rectum. First, two sutures are placed to anchor the mesh to the pelvic floor. We use Ethibond or similar nonabsorbable suture to secure the mesh to the levator muscles. The mesh is then tacked to the anterior surface of the rectum using several rows of simple interrupted 3–0 Vicryl or similar absorbable sutures using shallow bites into the muscularis to avoid full-thickness bites. Although technically more demanding, some surgeons recommend anchoring the proximal aspect of the wide part of the mesh to the posterior vaginal wall to provide a measure of support and suspension to obliterate the cul-de-sac.

The tapered proximal end is secured to the sacral promontory with two or more nonabsorbable sutures (Ethibond, GORE-TEX or similar). Overlying the sacral promontory at the landing site are typically one or two veins that can result in bleeding or hematoma if injured during suturing. We recommend coagulating these veins preemptively with bipolar coagulation. The anchoring sutures should be placed into the anterior longitudinal ligament using shallow skiving bites to avoid driving the needle into an intervertebral disk. The mesh tension is set just snug enough, but not too tight. After the mesh is secured, the excess is trimmed with robotic scissors.

Flexible or rigid sigmoidoscopy is performed to confirm there were no transmural sutures placed and the rectal lumen is patent. We recommend using CO ₂ insufflation while occluding the sigmoid colon with a bowel grasper. If transmural sutures are noted, they should be removed trans-abdominally using robotic scissors. Mesh is covered with peritoneum by closing the peritoneal defect with running absorbable 3–0 Vicryl or similar suture.

Patients with symptomatic vaginal prolapse and rectal prolapse can be approached with a combined procedure involving a colorectal and urogynecology team. We perform the posterior dissection and anchor the mesh to the pelvic floor and the rectum. The urogynecology team may perform a supracervical hysterectomy if needed. A separate piece of mesh or a single Y-shaped mesh can then be used to perform a sacrocolpopexy. The proximal ends are then sutured to the sacral promontory ( Fig. 3 ).

Fig. 3.

Graphic representation of a Y-shaped mesh placed and secured in the pelvis. The posterior limb of the mesh is placed on the anterior rectum. The crotch of the Y-shaped mesh and anterior limb is secured to the vagina. The tail of the mesh is secured to the sacral promontory. (Reprinted with permission from The Cleveland Clinic Center for Medical Art and Photography.)

Choice of Mesh

There continues to be debate regarding use of biologic versus synthetic mesh. To date, there has not been a randomized controlled study looking at this question. A systematic review looking at complication rates and recurrence has shown there is not a significant difference in mesh erosion or recurrence rates. ²⁵ A more recent systematic review looking at mesh erosion found there was a significantly lower incidence of mesh erosion in the biologic mesh group (0.22%) when compared with the synthetic mesh group (1.87%). ²⁶ However, there was variability in the included studies regarding study type, length of follow-up, and type of mesh used. Further studies are needed to determine which type of mesh is safer and is associated with lower recurrence rates.

Mesh-Related Complications

Mesh-related complications have been reported following VR. In an observational study looking at 919 consecutive patients following laparoscopic VR, 18 patients developed mesh-related complications. ¹⁹ Of these, seven developed mesh erosion into the vagina. Treatment consisted of debridement of the mesh and closure of the vagina over the defect. One patient required a restorative resection with coloanal anastomosis. Nine patients had mesh slippage from the sacral promontory leading to recurrence of rectal prolapse. Refixation of the mesh addressed this issue. Most mesh-related complications can be treated successfully and surgical treatment has been shown to improve overall function and quality of life. ²⁷ A recent study has also shown the use of absorbable suture when compared with nonabsorbable suture leads to less synthetic mesh-related complications. ²⁸ We, therefore, recommend the use of absorbable sutures to anchor the mesh to the rectum.

Discitis

Lumbosacral discitis has been reported infrequently in the literature. ^{19 29} Although rare, this can be a serious complication leading to chronic pain and infection. A case report has implicated the use of titanium screws as one cause of discitis. ²⁹ Given this possibility, we recommend avoiding screw tacks and instead routinely use permanent suture placed into the anterior longitudinal ligament. A high index of suspicion is essential if patients present with signs of infection or back pain postoperatively. Intravenous antibiotics should be the initial treatment with possible mesh removal and orthopaedic consultation.

Recurrence

Despite excellent results reported in the literature, recurrences will still occur. In a study looking at risk factors for recurrence, the most common findings during reoperation were detachment of the mesh from the sacral promontory, and inadequate adherence of the mesh to the mid-rectal body. ¹⁸ Patients who present with recurrence should undergo repeat evaluation with defecography to help identify potential etiology of recurrence. In addition, patients should wait at least 6 months prior to reoperation. Although a recent study showed VR may not be ideal for recurrent rectal prolapse, ¹⁷ we believe the decision to repeat a ventral approach depends on preoperative workup and intraoperative findings. Factors to consider include level of rectal prolapse lead point, presence of technical issues leading to recurrence, and presence of concomitant pelvic organ prolapse not addressed during the initial operation.

Outcomes

Excellent outcomes have been reported in the literature for VR. In a recent systematic review,17 studies with a total of 1,242 patients were evaluated. ²¹ Within this group of studies, there were three randomized clinical trials and one prospective trial. The cumulative rate of recurrence across all studies was 4.1% for full-thickness rectal prolapse and 2.7% for mucosal prolapse. Significant predictors of recurrence were male sex and length of mesh. Mesh length of 20 cm was found to have a significantly lower risk of recurrence when compared with a mesh length of 15 to 17 cm. The overall complication rate was 14%; urinary complications were seen most frequently. Mesh-related complications were 0.96%. The weighted mean improvements in fecal incontinence and constipation were 79.3 and 71%, respectively.

Recurrence rate and functional outcomes in robot-assisted VR have also been studied. A single-center retrospective study from the Netherlands reported outcomes similar to laparoscopic VR. ³⁰ A total of 258 patients were included in the study. Complications related to robot-assisted VR within 30 days of surgery were reported at 1.9% for major complications and 7% for minor complications. Late major and minor complications were 3.5 and 7.1%, respectively. Major complications were defined as Clavien-Dindo ≥ 3 and minor complications were defined as Clavien-Dindo 1 or 2. Urinary complications were seen most commonly. One case of spondylodiscitis was noted and treated successfully with antibiotics. A case of mesh erosion into the vagina was treated conservatively with estrogen cream. Recurrence rate was 12.9% for external rectal prolapse after 3 and 5 years. In terms of functional results, 78.6% of patients had improvement in obstructive defecation symptoms and 63.7% of patients had improvement in fecal incontinence. A more recent retrospective study from France looking at 96 patients over a 10-year period reported similar recurrence and functional improvement rates. ³¹

Several recent studies have reported functional results as well as recurrence rates in patients who underwent combined VR and sacrocolpopexy. ^{12 13 32} Recurrence rates for rectal prolapse ranged from 0 to 13%. Significant improvement in quality of life indicators, anatomy, and pelvic floor symptoms was seen in all studies. Combined procedures have been done both laparoscopically and robotically.

Conclusion

VR is a useful approach in selected patients with rectal intussusception, rectal prolapse, and rectocele. In the presence of multicompartment pelvic organ prolapse, VR can be combined with sacrocolpopexy. There is growing data that VR alone and in combination with sacrocolpopexy provides excellent anatomic and functional results. Additional prospective studies are needed to determine which patients are best suited for this surgical approach.