Rectopexie ventrale pour prolapsus rectal

Rectal prolapse is a full-thickness intussusception of the rectum. It an be still retained within the anal canal (internal rectal prolapse) or can protrude through the anal ring (overt,total rectal prolapse).Untreated it will lead to structural damage to the anal sphincter complex and cause fecal incontinence. Surgery for rectal prolapse intends to restore the anatomy and to improve function (preservation of anal contience, and improved rectal voiding) while avoiding surgery related morbidity and functional sequallae (constipation).
Laparoscopic ventral rectopexy is a reproducible and safe technique. This ‘nerve-sparing’ technique will avoid postoperative constipation. The unique position of the mesh allows not only to correct the recal intussusception but also descent from the
middle pelvic compartment.

From January 1999 to December 2008, 405 patients (94% female) underwent LVR. Most patients suffered from total rectal prolapsed (42%, n=170). Other indications were rectal intussusceptions (internal rectal prolapsed, 27%, n=109) and rectocele or enterocele (31%, n=126). Seventy eight patients had LVR combined with perineotomy to perform a complete mesh reinforcement of the rectovaginal septum in order to correct a more complex rectocoele.
Median age was 55 years (range, 16-86). Conversion to laparotomy was necessary in 2%.There was no postoperative mortality. Median hospital stay was 4.5 days (range 1-21). At final follow-up (at a mean of 25 months) recurrence was objectified in 19 patients (4.6%). Most often a detachement of the mesh at the sacral promontory occurred. In none of the patients treated for total rectal prolapsed mesh erosion occurred. Overal mesh erosion rate is 2.2% (9 patients), all treated for rectocele.

Functional outcome
Functional outcome was study in a consecutive cohort of patients with total rectal prolapse (n=42 patients). Faecal incontinence was present in 76% of patients (median Wexner score 13, range 2-20). All but 3 patients regained continence within 62 mo of follow-up. Patients with faecal incontinence need a complete work-out including defaecography to exclude internal rectal prolapsed. Internal intussception is a major cause of faecal incontinence that should be treated with prolapsed repair.
At preoperative evaluation also 56% of patients suffered from constipation. In contrast to more classical rectopexy techniques LVR resulted in a significant decrease of postoperative constipation (26%). LVR corrects obstructed defaecation and only had a minor impact on slow transit constipation. De novo constipation occurred only in 5% of patients. These results have been confirmed in three other case series. Those results explain result interest in LVR to treat patients with internal rectal prolapsed and OD. More clinical research is needed to assess indications for LVR in perspective to STARR and tranSTAR procedures to treat OD.
Recently this first cohort of patients were reassessed to obtain long-term follow-up data. At a median follow-up of 13 years 29 patients returned questionnaires (29/36, 69%). None of the patients reported recurrent prolapsed. Mean Wexner score slightly increased from 3.0 (range 0-19) to 4.9 (range 0-20). Three patients developed significant incontinence over time. Symptoms of obstructed defaecation resolved in 76% of patients at 5-year follow-up and remained unchanged over time. Mean overall satisfaction score (scale 0-10) was 8.5.

These data support long-term efficacy of LVR and the beneficial functional outcome. Different randomized trials are started to validate those results.

References

  • D’Hoore A, Cadoni R, Penninckx F. Long-term outcome of laparoscopic ventral rectopexy for total rectal
    prolapse. Br J Surg 2004; 91:1500-1505.
  • D’Hoore A, Penninckx F. Laparoscopic ventral recto(colpo)pexy for rectal prolapse: surgical technique and
    outcome for 109 patients. Surg Endosc 2006; 20: 1919-1923.
  • D’Hoore A, Vanbeckevoort D, Penninckx F. Clinical, physiological and radiological assessment of rectovaginal
    septum reinforcement with mesh for compex rectocele. Br J Surg 2008; 95: 1264-1272