Transcript Open approaches for rectal prolapse

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?)