1. Abdominal approach for Rectal prolapse Leung Yu Wing TKOH

2. Complete rectal prolapse Circumferential protrusion through the anus of all layers of the rectal wall 2009 Nucleus Medical Media, Inc.

3. Epidemiology True incidence unknown Annual incidence in Finland quoted to be 2.5/100, 000 Male to female 1:6 More common in the elderly Kairaluoma MV, Kellokumpu IH. Epidemiologic aspects of complete rectal prolapse. Scand J Surg. 2005;94(3):207-10

4. Predisposing factors Chronic constipation Multiple vaginal delivery Previous surgery, e.g. hysterectomy Connective tissue disorder

5. Associated anatomic features Karulf RE, Madoff RD, Goldberg SM. Rectal Prolapse. Curr Probl Surg 2001;38:757-832.

6. Symptoms Protruding rectum Faecal incontinence 50-75% Constipation 25-50% Pain variable Ulceration 10-25% Bleeding Incarceration, gangrene rare

7. World J Gastroenterol. 2010 June 7; 16(21): 2689-2691. http://emedicine.medscape. com/article/2026460- overview ACS Surgery Section 5 Chapter 36

8. Workup Barium enema / Colonoscopy – Exclude other colonic lesions – Barium enema better demonstrate redundancy – Biopsy for rectal ulcer to exclude other pathology Video defaecography

9. Workup Anorectal manometry – Decrease in resting pressure in internal sphincter – Absence of anorectal inhibitory reflex Sitz marker study – Measure colonic transit to determine need for colonic resection Pudendal nerve terminal motor latency (PNTML) – Neurologic injury / dysfunction

10. Management Fibre and stool softener may alleviate constipation Surgery is the mainstay for treatment No study directly compare surgical and conservative management Tou S, Brown SR, Malik AI, Nelson RL. Surgery for complete rectal prolapse in adults. Cochrane Database Syst Rev. 2008: CD001758.

11. Management A number of procedures have been described Perineal approach for elderly frail patients Abdominal approach for fit patients Brown AJ, Anderson JH, McKee RF, Finlay IG. Strategy for selection of type of operation for rectal prolapse based on clinical criteria. Dis Colon Rectum 2004; 47: 103–107 Deen KI, Grant E, Billingham C, Keighley MRB. Abdominal resection rectopexy with pelvic floor repair versus perianal rectosigmoidectomy and pelvic floor repair for full-thickness rectal prolapse. British Journal of Surgery 1994;81(2):302–4.

12. Management Abdominal approach – division of lateral ligament vs no division – suture vs prosthesis for rectopexy – rectopexy vs resection + rectopexy – open vs laparoscopic

13. Division of lateral ligament 18 patients had posterior rectopexy, of whom 10 had division of lateral ligament No recurrence No significant difference detected in constipation score Mollen RM, Kuijpers JH, van Hoek F. Effect of rectal mobilisation and lateral sphincter division on colonic and anorectal function. Diseases of the Colon and Rectum 2000; 43:1283–7.

14. Division of lateral ligament A prospective randomized study of rectopexy with (n=14) or without (n=12) division of lateral ligaments Recurrence in the group with division vs without 0% vs 33% In the division group, constipation increased from 21.4% to 71.4% (pre-op to post-op) Speakman CTM, Madden MV, Nicholls RJ, Kamm MA. Lateral ligament division during rectopexy causes constipation but prevents recurrence: results of a prospective randomized study. British Journal of Surgery 1991;78(12):1431–3.

15. Suture rectopexy Recurrence rates 3-9% May produce new onset (15%) or worsened (50%) constipation Carter AE. Rectosacral suture fixation for complete rectal prolapse in the elderly, the frail and the demented. Br J Surg. 1983;70:522–523. Aitola PT, Hiltunen KM, Matikainen MJ. Functional results of operative treatment of rectal prolapse over an 11-year period: emphasis on transabdominal approach. Dis Colon Rectum. 1999;42:655– 660.

16. Mesh rectopexy Wells procedure Fixation of rectum using an Ivalon sponge and transection of lateral ligaments Wells C. New operation for rectal prolapse. Proc R Soc Med. 1959;52:602– 603. Karulf RE, Madoff RD, Goldberg SM. Rectal Prolapse. Curr Probl Surg 2001;38:757-832.

17. Suture vs mesh A randomized trial of 31 Ivalon sponge rectopexy vs 32 suture rectopexy One recurrence in each group Novell JR, Osborne MJ, Winslet MC, Lewis AA. Prospective randomized trial of Ivalon sponge versus sutured rectopexy for full-thickness rectal prolapse. British Journal of Surgery1994;81(6):904–6. Ivalon spongeSuture Post-op complications19%9% Faecal incontinence29%16% Post-op constipation48%31%

18. Ripstein procedure Recurrence 2.3-5% Morbidities 20% Incontinence 28.3% Constipation 45.7% Schultz I, Mellgren A, Dolk A, Johansson C, Holmstrom B. Long-term results and functional outcome after Ripstein rectopexy. Dis Colon Rectum. 2000;43:35–43. McMahan JD, Ripstein CB. Rectal prolapse: an update on the rectal sling procedure. Am Surg. 1987;53:37–40.

19. Ventral mesh A systematic review of 728 patients Recurrence rate 3.4% A decrease in constipation rate 23%. However, new onset of constipation was 14.4% Samaranayake CB, Luo C, Plank AW, Merrie AE, Plank LD, Bissett IP. Systematic review on ventral rectopexy for rectal prolapse and intussusception. Colorectal Dis. 2010;12:504–512.

20. Resection A randomized study on resection + suture rectopexy vs mesh rectopexy No recurrence Similar improvement in incontinence 33% in rectopexy alone became severely constipated post-op 3 complications in resection group (1 in rectopexy alone group) Luukkonen P, Mikkonen U, Jarvinen H. Abdominal rectopexy with sigmoidectomy versus rectopexy alone for rectal prolapse: A prospective, randomized study. Internal Journal of Colorectal Disease 1992;7(4):219–22.

21. Resection A case series of 16 patients had marlex mesh rectopexy vs 13 patients had sigmoidectomy with sutured rectopexy Sayfan J, Pinho M, Alexander-Williams J, Keighley MR. Sutured posterior abdominal rectopexy with sigmoidectomy compared with Marlex rectopexy for rectal prolapse. Br J Surg. 1990;77:143–145. Rectopexy alone Rectopexy + resection Continence75%66.7% Persisted constipation100%20% New constipation30.8%0% Complications1 small bowel obstruction

22. Laparoscopic rectopexy A case control study of 111 patients underwent laparoscopic rectopexy, 86 patients underwent open repair Kariv Y, Delaney CP, Casillas S, et al. Long-term outcome after laparoscopic and open surgery for rectal prolapse: a case-control study. Surg Endosc. 2006;20:35– 42. Laparoscopic repairOpen repair Recurrence3.9%4.7% Post-op incontinence 30%33% Constipation35%53% Hospital stay3.96.0

23. Laparoscopic rectopexy 40 patients randomized to laparoscopic vs open group Laparoscopy group: – less pain and narcotic requirement – better mobility – shorter hospital stay – Estimated saving of 357 pounds per patient Salkeld G, Bagia M, Solomon M. Economic impact of laparoscopic versus open abdominal rectopexy. British Journal of Surgery 2004;91(9):1188–91. Solomon MJ, Young CJ, Eyers AA, Roberts RA. Randomized clinical trial of laparoscopic versus open abdominal rectopexy for rectal prolapse. British Journal of Surgery 2002;89(1):35–9.

24. Robotic Moorthy K, Kudchadkar R, et al. Robotic assisted rectopexy. Am J Surg. 2004;187:88 –92.

25. Robotic 14 robot assisted laparoscopic rectopexy vs 19 conventional laparoscopic rectopexy Similar conversion rates 3-5% Similar constipation, continence Mean operating time 39min longer Costs US$745.09 higher Heemskerk J, de Hoog DE, van Gemert WG, Baeten CG, Greve JW, Bouvy ND. Robot- assisted vs conventional laparoscopic rectopexy for rectal prolapse: a comparative study on costs and time. Dis Colon Rectum. 2007;50:1825–1830..

26. Conclusion Abdominal approach – Division of lateral ligament vs no division Division of lateral ligament may have less recurrence, but more constipation – Suture vs prosthesis for rectopexy Prosthesis may have more complications, more constipation

27. Conclusion Abdominal approach – Rectopexy vs resection + rectopexy With resection, there is less constipation, but slightly more complications – Open vs laparoscopic Laparoscopic approach has comparable results Laparoscopic approach decreases hospital stay and costs

29. PROSPER trial 293 patients from 2/2001 to 4/2008 were randomised between – (a) abdominal and perineal and – (b) suture vs resection rectopexy for those receiving abdominal procedure or – (c) Altemeier’s vs Delorme’s for those receiving perineal procedures Primary outcome were defaecatory performance and QOL, secondary outcome were operative mortality / morbidity and recurrence http://www.birmingham.ac.uk/research/activity/mds/trials/bctu/trials/coloproctolo gy/prosper/index.aspx

30. Q&A

34. Workup In 26 patients of rectal prolapse, EMG and pudendal nerve terminal motor latency were performed before Ripstein rectopexy Anal continence was improved, but was not predicted by pre-op EMG / PNTML Schultz I, Mellgren A, Nilsson BY, Dolk A, Holmstrom B. Preoperative electrophysiologic assessment cannot predict continence after rectopexy. Dis Colon Rectum. 1998;41:1392–1398.

35. Workup 45 patients underwent anal manometry and PNTML before rectal prolapse repair Pre-op squeeze pressure >60mmHg vs lower Better post-op fecal continence 10% vs 54% PNTML was not predictive of post-op continence Glasgow SC, Birnbaum EH, Kodner IJ, Fleshman JW, Dietz DW. Preoperative Anal Manometry Predicts Continence After Perineal Proctectomy for Rectal Prolapse. Dis Colon Rectum. 2006;49:1052-1058.

36. Division of lateral ligament 20 patients randomized, 11 underwent marlex rectopexy with division of lateral ligament, 9 patients without. Continence improved in both groups, post-op symptoms improved significantly in those without division compared with those with division. Selvaggi F, Scotto di Carlo E, Silvestri L, Festa L, Piegari V. Surgical treatment of rectal prolapse: a randomised study (Abstract). British Journal of Surgery 1993;80:S89.

37. No rectopexy vs rectopexy Multicentre randomized controlled trial of 251 patients 116 no rectopexy compared with 136 rectopexy, sigmoidectomy added if constipation No sig difference in complication Significant difference in 5 year recurrence 8.6% vs 1.5% Karas JR, Uranues S, Altomare DF, et al. No rectopexy versus rectopexy following rectal mobilization for full-thickness rectal prolapse: a randomized controlled trial. Dis Colon Rectum. 2011 Jan;54(1):29-34

38. Alternative mesh materials 2 trials comparing polyglycolic acid mesh (n=37) vs polyglactin (n=30) / polypropylene (n=17) mesh 1 recurrence in polyglycolic acid mesh Residual incontinence – 20% for polyglycolic acid mesh – 35% for polyglactin mesh Winde G, Reers B, Nottberg H, Berns T, Meyer J, Bunte H. Clinical and functional results of abdominal rectopexy with absorbable mesh-graft for treatment of complete rectal prolapse. European Journal of Surgery 1993;59(5):301–5. Galili Y, Rabau M. Comparison of polyglycolic acid and polypropylene mesh for rectopexy in the treatment of rectal prolapse. European Journal of Surgery 1997;163(6):445–8.

39. Marlex mesh rectopexy

40. Resection 18 patients randomized to rectopexy alone or with sigmoidectomy 77.8% in rectopexy alone group, 22.2% in sigmoidectomy group complained of severe constipation Mckee RF, Lauder JC, Poon FW, Aitchison MA, Finlay IG. A prospective randomized study of abdominal rectopexy with and without sigmoidectomy in rectal prolapse. Surgery, Gynecology and Obstretics 1992;174(2):145–8.

41. Resection 12 patients with no preexisting constipation had laparoscopic rectopexy without resection No complications No recurrence Only 1 patient previously had irritable bowel syndrome developed significant constipation Hsu A, Brand MI, Saclarides TJ. Laparoscopic rectopexy without resection: a worthwhile treatment for rectal prolapse in patients without prior constipation. Am Surg. 2007;73:858–861.

42. Laparoscopic rectopexy Retrospective study of 13 by open technique and 8 by laparoscopic approach Incontinence sig. improved in both groups Post-op stay was shorter in laparoscopic group Boccasanta P, Rosati R, Venturi M, Montorsi M, Cioffi U, De Simone M, et al.Comparison of laparoscopic rectopexy with open technique in the treatment of complete rectal prolapse: clinical and functional results. Surgical Laparoscopy and Endoscopy 1998;8(6):460–5.

43. Laparoscopic rectopexy A case series of 109 patients had laparoscopic ventral rectopexy for rectal prolapse Conversion 3.7% Recurrence 3.7% No mortality, minor morbidity 7% Mean hospital stay 5.14 days 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. DHoore A, Cadoni R, Penninckx F (2004) Long-term outcome of laparoscopic ventral rectopexy for total rectal prolapse. Br J Surg 91: 1500–1505

44. Laparoscopic rectopexy 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.

45. Laparoscopic rectopexy 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.

46. Laparoscopic rectopexy 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.

47. Anterior resection In a review of 113 patients Operative morbidity 29%, including 3 anastomotic leakage Recurrence rate at 2, 5, 10 years were 3%, 6%, 12% Also a low pelvic anastomosis in those with borderline continence may cause complete loss of control Cirocco WC, Brown AC. Anterior resection for the treatment of rectal prolapse: a 20- year experience. Am Surg. 1993;59:265–269. Schlinkert RT, Beart RW Jr, Wolff BG, Pemberton JH. Anterior resection for complete rectal prolapse. Dis Colon Rectum. 1985;28:409–412.

48. Robotic 2 mesh rectopexy, 4 sutured rectopexy + sigmoidectomy were performed No mortality 1 conversion 1 rectal tear with temporary colostomy No recurrence Ayav A, Bresler L, Hubert J, Brunaud L, Boissel P. Robotic-assisted pelvic organ prolapse surgery. Surg Endosc. 2005;19:1200–1203.

49. Robotic 6 cases of robotic assisted rectopexy No conversion No mortality or major complications No recurrence No reports of constipation Mean operative time 127min Moorthy K, Kudchadkar R, et al. Robotic assisted rectopexy. Am J Surg. 2004;187:88 –92.

50. Quality of life 54 patients underwent laparoscopic rectopexy No mortality, morbidity 5.5% 7.4% recurrence 20.3% constipation Continence improved in 72.4% QOL rated satisfactory in 96% Auguste T, Dubreuil A, Bost R, Bonaz B, Faucheron JL. Technical and functional results after laparoscopic rectopexy to the promontory for complete rectal prolapse. Prospective study in 54 consecutive patients. Gastroenterol Clin Biol. 2006 May;30(5):659-63.

51. Anal encirclement

52. Altemeier’s procedure

53. Delorme’s procedure

54. Treatment algorithm