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Review
, 31 (2), 188-197

Surgical Options for Full-Thickness Rectal Prolapse: Current Status and Institutional Choice

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Review

Surgical Options for Full-Thickness Rectal Prolapse: Current Status and Institutional Choice

Tomohide Hori et al. Ann Gastroenterol.

Abstract

Full-thickness rectal prolapse (FTRP) is generally believed to result from a sliding hernia through a pelvic fascial defect, or from rectal intussusception. The currently accepted cause is a pelvic floor disorder. Surgery is the only definitive treatment, although the ideal therapeutic option for FTRP has not been determined. Auffret reported the first FTRP surgery using a perineal approach in 1882, and rectopexy using conventional laparotomy was first described by Sudeck in 1922. Laparoscopy was first used by Bermann in 1992, and laparoscopic surgery is now used worldwide; robotic surgery was first described by Munz in 2004. Postoperative morbidity, mortality, and recurrence rates with FTRP surgery are an active research area and in this article we review previously documented surgeries and discuss the best approach for FTRP. We also introduce our institution's laparoscopic surgical technique for FTRP (laparoscopic rectopexy with posterior wrap and peritoneal closure). Therapeutic decisions must be individualized to each patient, while the surgeon's experience must also be considered.

Keywords: Rectal prolapse; laparoscopic surgery; mesh; peritoneal closure; posterior wrap; rectopexy.

Conflict of interest statement

Conflict of Interest: None

Figures

Figure 1
Figure 1
(A) General anesthesia with concurrent epidural anesthesia is performed with the patient in the lithotomy position. Anal tone is routinely checked beforehand. (B) A deep Douglas’ pouch is often observed. (C, D) The rectum and mesentery are completely mobilized from the sacral promontory. The superficial dissectable/transectable layer (solid arrow), and not the deep dissectable/transectable layer (dotted arrow), should be traced to preserve the nerves
Figure 2
Figure 2
(A) The hiatal ligament bleeds easily (arrow). (B) Veins of the coccygeal periosteum also bleed easily (arrow). (C-F) The left lateral ligament is transected (dotted arrows) while the pelvic nerves and neurovascular bundle are preserved. The levator muscle is exposed under sufficient countertraction (blue arrow)
Figure 3
Figure 3
(A) The levator muscle is well exposed bilaterally under sufficient countertraction (blue arrow). (B) The exposed area is assessed using forceps. (C) The anterior rectal wall is mobilized sufficiently from its peritoneal reflection (red arrow) under sufficient countertraction (blue arrow). (D) The mobilized area is assessed using forceps. Anterior rectal dissection is completed to 2 cm below the peritoneal reflection (red arrow)
Figure 4
Figure 4
(A) The hypogastric plexus is preserved bilaterally. (B) Pelvic nerves are also preserved. (C) The preserved hypogastric plexus is confirmed (arrow). (D) The area of mesh fixation is estimated without injuring the nerves and vessels (dotted area)
Figure 5
Figure 5
(A) Optimal points for mesh fixation on the presacral fascia are marked without injury to the nerves (dotted line) and vessels. (B) After the mobilized rectum has been elevated cranially to the promontorium (blue arrow), the optimal points for mesh fixation of the rectum are marked. The anterior wall is elevated (red arrow). (C) Mesh is inserted through the port. Nerves (dotted lines) and vessels on the sacrococcyx should be visible through the mesh to prevent tack injuries. (D) Mesh is fixed to the pre-sacrococcygeal fascia using absorbable tacks
Figure 6
Figure 6
(A) Mesh is fixed to the pre-sacrococcygeal fascia (arrows) using absorbable tacks. (B, C) The mobilized rectum is lifted cranially to the promontorium (blue arrow). Pelvic nerves (dotted lines) are preserved. (D-F) The seromuscular layer of the rectal wall is sutured to the mesh using a small number of interrupted non-absorbable polypropylene sutures. Pelvic nerves (dotted lines) are preserved. The anterior wall is elevated (red arrows)
Figure 7
Figure 7
(A) The peritoneum (dotted lines) is closed bilaterally to prevent mesh exposure, and the anterior wall is elevated (red arrows). (B) The peritoneum is closed bilaterally (yellow arrows) to prevent mesh exposure. (C) A suture is placed for peritoneal closure (yellow arrows) to prevent mesh exposure. The anterior wall is well elevated (red arrows). (D) Staples can be used to close the peritoneum. The peritoneum should be closed bilaterally (yellow arrows) to prevent mesh exposure. The anterior wall is well elevated (red arrows)
Figure 8
Figure 8
(A) The redundant sigmoid colon and mobilized rectosigmoid are visible. (B) The mesentery of the mobilized rectosigmoid is elevated (blue arrow) and the cul-de-sac of the pelvic floor can be observed (red arrow). Obliterating the cul-de-sac is necessary to prevent unexpected postoperative complications after surgery. (C) The mesentery of the redundant sigmoid colon is elevated (blue arrow) and the cranial cul-de-sac is visible (red arrow). Obliterating the cul-de-sac is necessary to prevent unexpected postoperative complications after surgery. (D) The full-thickness rectal prolapse is resolved, and a normalized anus can be seen

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