Open Approaches for Rectal Prolapse John Hartley Academic Surgical Unit

Open Approaches for Rectal
Prolapse
John Hartley
Academic Surgical Unit
University of Hull
Open procedures for rectal prolapse
Open operations for rectal prolapse
• Perineal operations inferior to abdominal
procedures, but definite role
• Delorme’s procedure – simple but high recurrence
rate, can be repeated
• Perineal rectosigmoidectomy – more complex but
lower recurrence rate
• “If the patient is fit enough and life expectancy >
5yrs abdominal approach preferred”
Keighley and Williams 2nd Edition 2001
Open operations for rectal prolapse
Major colorectal procedures –
Consultant and higher trainees
Procedures for prolapse
Perineal
Abdominal
JH 2002-2004
281
10
1
HST yr 6
198
6
4
HST yr 6
191
8
1
HST yr 4
87
3
1
The realities – Yorkshire colon and rectal surgery
Open operations for rectal prolapse
A range of possibilities:
• Exclusion procedures
• Pelvic floor repair
• Anterior or posterior rectopexy
• Resection – alone or with rectopexy
Open operations for rectal prolapse
Sigmoid exclusion procedure (Lahaut’s
operation)
• Rectum fully mobilised in pelvis
• Rectosigmoid sutured to posterior rectus
sheath
• Sigmoid extra-peritonealised behind rectus
muscle
Open operations for rectal prolapse
Lahaut’s operation
• 33 pts
• 1 death (3%)
• No recurrences
• 11 of 12 pts improved continence
• One faecal fistula (?ischaemic)
• One obstruction
Mortensen et al Ann R Coll Surg Engl 1984:66:17
18
Open operations for rectal prolapse
Pelvic floor repair via the abdomen
• Full anterior and posterior mobilisation of the
rectum
• Repair of pelvic floor posterior (originally ant and
post) to rectum
• Difficult access
• Pelvic floor thin and attenuated
• Largely replaced by rectopexy
Pelvic floor repair for prolapse
Results of abdominal pelvic floor repair for prolapse
Authors
Procedure
N
Mortality
Recurrence
(%)
Snellman 1961 Ant. repair
42
0
4 (10)
Porter 1962
Ant. Repair
46
0
23 (50)
Kupfer and
Goligher 1970
Post. Repair
63
1
5 (8)
Klaaborg et al
1985
Post. repair
23
0
3 (13)
Hughes and
Gleadell 1962
Ant and post.
Repair
84
1
5 (6)
From Keighley and Williams 2001
Comments
Mucosal
recurrence
Open procedures for rectal prolapse
Rectopexy
• Probably the operation of choice
• Recurrence rates approx. 2%
• Continence restored in 60-80% with rectopexy
alone
• How should rectum be fixed?
• When should resection be added?
Open operations for rectal prolapse
Anterior rectopexy (Ripstein procedure)
• Full mobilisation of rectum
• Fixation to sacral promontary by sling
(polypropylene, teflon or fascia)
• Principle complication – fibrous stricture
Anterior rectopexy
Anterior rectopexy
N
Mortality
(%)
Recurrence
(%)
Comments
Gordon and
Hoexter 1978
1111
4 (0.3)
26 (2)
Impaction 14, stricture
20 (1.8%)
Morgan 1980
64
2 (1.6)
2 (3)
Stenosis
Launer 1982
54
0
4 (7)
Stricture 9 (17%)
Holmstrom 1986
108
3 (2.8)
5 (4)
Stricture 4
Tjandra 1993
142
1 (0.1)
10 (8)
1/3 recurrences >10 yrs
post op
From Keighley and Williams 2001
Open operations for rectal prolapse
Posterior rectopexy
• Posterior aspect of fully mobilised rectum
attached to sacrum
• Lateral peritoneum divided, posterior
mobilisation to tip of coccyx, division of
lateral ligaments
• No anterior restriction, distensible rectum
• Mesh to sacrum and lateral aspects rectum
Posterior rectopexy
Posterior rectopexy
Method of fixation
• Teflon
• Polypropylene (marlex)
• Polyvinyl alcohol sponge (Well’s procedure)
- infection (recurrence)
• Vicryl
• Gore-Tex
• SIMPLE SUTURES
Sutured posterior rectopexy
Posterior rectopexy (suture only)
N
Mortality (%)
Recurrence (%)
Loygue 1971
146
2 (1.3)
5 (3)
Carter 1983
32
0
0
Goligher 1984
52
0
1 (2)
Graham 1984
23
1 (4.3)
0
Blatchford 1989
42
0
2 (5)
Sayfan 1997
19
0
0
From Keighley and Williams 2001
Prosthetic vs suture posterior rectopexy (no
resection)
Ivalon sponge (n=31)
Sutures alone (n=32)
Hospital stay (days)
14 (8-52)
14 (8-50)
Mortality
0
0
Complications
6 (19%)
3 (9%)
Recurrent prolapse
1 (3%)
1 (3%)
Late postop incontinence 6/10
2/10
Postop constipation
10 (31%)
15 (48%)
Novell et al. Br J Surg 1994;81:904-906.
Division of lateral ligaments in mesh posterior
rectopexy
Lateral ligaments divided
(n=14)
Lateral ligaments preserved
(n=12)
Preop
Postop
Preop
Postop
3
2
4
2
Time
54
straining (%)
54
12
56
No.
constipated
3
10
6
7
Rectal
prolapse
14
0
12
6
Continence
score
Speakman et al. Br J Surg 1991;78:1431-1433
Open operations for rectal prolapse
Resection alone
• Sigmoid or partial rectal resection (n=113)
• Incontinence:
- Improved 23 (20%)
- Same 13 (11%)
- Worse 10 (9%)
• Sepsis morbidity: 52% after “low” and 19% after high
anastomosis
• Recurrence at 10 yrs 14% after “high” and 9% after “low”
resections
Schlinkert et al Dis Colon Rectum 1985:28:409-412
Resection Rectopexy
Resection Rectopexy
• Aims to achieve low recurrence rates and avoid
long term constipation
University of Minnesota series
• 138 pts
• Anastomotic leaks in 5 (4%)
• Recurrent prolapse in 2 (1.4%)
• Continence improved in all but 1 pt
• Constipation improved in 56% same in 35% worse
in 9%
Watts et al. Dis Colon Rectum 1985;28:96-102.
Rectopexy +/- Resection
Preop status and outcome
Marlex rectopexy
(n=16)
Rectopexy and
sigmoidectomy (n=13)
Incontinent preop
12
9
Unchanged or worse 3
3
Continence restored 9
6
Constipated preop
3
5
Unchanged or worse 3
1
Constipation improved 0
4
Normal bowel habit preop
13
8
Unchanged 9
8
Became constipated 4
0
Sayfan et al. Br J Surg 1990;77:143-145.
Rectopexy +/- Resection
Constipation (%)
Incontinence (%)
Preop
Postop
Preop
Postop
Rectopexy
(n=129)
47 (36)
42 (33)
48 (37)
25 (19)
Resection
rectopexy
(n=18)
12 (67)
2 (11)
5 (28)
3 (17)
Tjandra et al. Dis Colon Rectum 1993:36;501-507
Open Approaches for Rectal Prolapse
Summary
• Lower recurrence rates but higher morbidity
than perineal procedures
• Fixation superior to pelvic floor repair, or
resection alone
• Posterior fixation superior results
• Sutures alone comparable to mesh fixation
• Less constipation with concomitant
resection
Open Approaches for Rectal Prolapse
Conclusions
Sigmoid resection with sutured rectopexy
offers:
• Low risk of recurrence
• The long term avoidance of constipation
• PROCEDURE OF CHOICE
• (why not laparoscopically?)