Laparoscopic Approach

Professor Roger Motson, Colchester

There are probably more operations for rectal prolapse than any other colorectal disease. If you believe that abdominal rectopexy has any place in the treatment of rectal prolapse then it surely has to be performed laparoscopically. The internal part of the operative procedure is identical to that performed at open surgery but the incision and wound-related pain and complications are avoided. It is not suited to those patients who are unfit for general anaesthesia or who cannot tolerate a steep head-down position fort he duration of the procedure. In practice this excludes fewer than 10|% of patients.

Umbilical, left and right iliac fossa ports are inserted. Occasionally a fourth port suprapubically may be necessary for additional retraction of the sigmoid colon if very redundant. Head-down tilt will displace the small intestine from the pelvis but it is sometimes necessary to divide terminal ileal and caecal adhesion at the pelvic brim to maintain the view. Dissection is best performed with the harmonic scalpel and starts over the sacral promontory to right of the mesorectum. Hypogastric nerves are identified and preserved and dissection carried down to the pelvic floor. Dissection must contiue until the perianal part of the levators is visualised. The great majority of the dissection is done from the right leaving only peritoneum to be divided on the left. Both ureters must be identified during the course of the dissection. I personally do not use mesh and fix the mesorectum to the sacral promontory with interrupted non-absorbable sutures.

Alternative techniques include the addition of recto-sigmoid resection, which to my mind increases risk and has no difference in functional result, the insertion of mesh for fixation to the sacrum (which occurs anyway) and a new procedure with encouraging results using mesh strips attached to the anterior distal rectal wall and the sacral promontory much like colposuspension.

Conversion, all for technical reasons has been necessary in only 3 of 45 cases. Operating time averages 90 minutes and hospital stay is in the order of 3 days if social service issues do not delay discharge.