Open Abdominal Options

John Hartley

Powerpoint File

The management of rectal prolapse is exclusively surgical with the procedure being performed via either a trans-abdominal or perineal approach. The large number of surgical procedures which have been described for rectal prolapse says much for the lack of consistent success of any single operation.

In broad terms the advantages of an abdominal approach over a perineal procedure are a consistently lower recurrence rate, a tendency towards greater improvements in continence, and the preservation of a rectal reservoir. However, abdominal approaches are clearly more invasive and carry all of the attendant risks of conventional pelvic surgery without forgetting the risk of pelvic autonomic nerve injury with resulting bladder and/or sexual dysfunction.

The principles of abdominal procedures involve fixation of the rectum to the sacrum alone or in combination with resection of the rectum. Fixation of the rectum or "rectopexy" can be accomplished with foreign material or simple sutures. Anterior rectopexy (the ripstein procedure) comprises a complete mobilisation of the rectum posteriorly following which a loose non absorbable (e.g. marlex) is slung around the anterior rectum and fixed to the sacrum. Reported recurrence rates are around 10% but the sling has been reported to cause complications in around 15% with 4% requiring corrective surgery. The posterior sling rectopexy (or Wells procedure) involves an identical mobilisation following which the mesh is fixed to the sacrum and then attached to the lateral aspects of the hitched up rectum leaving the anterior wall free of foreign material. The recurrence rate following this procedure is said to be comparable to that of the ripstein repair although the posterior mesh is said to cause less narrowing of the rectum and hence less constipation.

Simple anterior resection of the rectum without fixation has been purported to produce the same effect as rectopexy, in that the fully mobilised rectum is thought to fix to the sacral hollow by secondary scarring. The procedure has potential advantages in the avoidance of prosthetic material, and also the resection of redundant colon might be expected to relieve associated constipation (said to be present in perhaps 50% of patients with prolapse). However, the procedure risks morbidity and indeed mortality from the colorectal anastomosis, and the loss of the rectal reservoir may be associated with deterioration of continence in a further 10-20% of patients whose pelvic floor is of poor quality in the first place.

Resection and rectopexy in combination, in which redundant sigmoid and rectosigmoid is excised and the rectal remnant is fixed to the sacrum, has been associated with broadly similar recurrence rates, but is said to provide greater improvement in bowel symptoms than other methods. This holds true especially for less constipation. There is debate as to whether the lateral ligaments should be divided in mobilisation of the rectum during this procedure. Division of the ligaments, and therefore a more complete mobilisation, results in lower recurrence rates but higher rates of constipation than if the ligaments re preserved. The latter observation is presumably explained by division of the pelvic autonomics during this manoeuvre.

Simple suture rectopexy is the least complex of all abdominal approaches (and is readily performed laparoscopically), and has reported recurrence rates of 2-5%. Leaving redundant sigmoid in situ is said to predispose to constipation post fixation.

In summary the choice of procedure for rectal prolapse is controversial with established colon and rectal surgeons often not reaching consensus on any given case. The reality of prolapse surgery in the UK is that many of the sufferers are so frail that perineal approaches continue to be required. The evidence base in prolapse surgery is poor with no study demonstrating superiority for a single technique. The PROSPER study through the Association of Coloproctology will continue recruiting to 2007 and may add to our understanding of this disabling condition.

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