Comparison between Laparoscopic Ventral and Posterior Mesh Rectopexy for Rectal Prolapse
1–4Department of General Surgery, Faculty of Medicine, Assiut University, Assiut, Egypt
Corresponding Author: Ibrahim M Abdelaal, Department of General Surgery, Faculty of Medicine, Assiut University, Assiut, Egypt, Phone: +201140024448, e-mail: firstname.lastname@example.org
How to cite this article: Sayed MM, Reyad HA, Korany M, et al. Comparison between Laparoscopic Ventral and Posterior Mesh Rectopexy for Rectal Prolapse. World J Lap Surg 2022;15(3):239–245.
Source of support: This study was approved by Assiut University Protocol ID: AssiutU4988 and registered at ClinicalTrials.gov ClinicalTrials ID: NCT03026738
Conflict of interest: None
Received on: 01 September 2021; Accepted on: 06 September 2022; Published on: 07 December 2022
Aim: Recently, laparoscopic techniques are widely used for treatment of rectal prolapse. Therefore, the present work aims to compare the results between laparoscopic ventral mesh rectopexy (LVMR) and laparoscopic posterior mesh rectopexy (LPMR) for patients suffering from rectal prolapse.
Materials and methods: This prospective study included forty-four patients with rectal prolapse admitted and managed at the Assiut University Hospitals (Assiut, Egypt) in the period between November 2016 and 31 December 2020. They were divided into two groups (22 patients in each group). Operative parameters, complications, length of hospital stay, postoperative improvement of constipation and fecal incontinence, as well as recurrence were investigated. Clinical symptoms were followed up after surgery with the mean period of 23.73 ± 14.817 months.
Results: In the presented study, the mean patient age was 42.43 ± 14.05 years. There were 14 males (6 in the LPMR group vs 8 in the LVMR group) and 30 females (16 for LPMR vs 14 for LVMR) without a significant difference in-between. Operative time was shorter in LPMR (114.09 ± 12.690 minutes) compared with LVMR (181.82 ± 15.395 minutes). No postoperative complications were observed in 81.82% of patients who underwent LPMR and 90.91% of patients who underwent LVMR. Patients who underwent LVMR showed no impotence. Wexner’s constipation score was postoperatively lower in LVMR than in LPMR (6.71 ± 3.29 vs 10.78 ± 2.80; respectively) indicating the significant improvement of constipation in LVMR compared with LPMR. A significant improvement of the symptoms of obstructed defecation syndrome was observed in both groups (p-value = 0.0001). Gastrointestinal quality-of-life score was highly increased from 66.09 ± 9.59 to 114.23 ± 8.64 after LVMR.
Conclusion: Our study proves that LVMR is superior to LPMR in prevention of impotence, improvement of constipation as well enhancement of the quality of life. Thus, LVMR offers a safer and more effective approach for patients of all ages.
Keywords: Laparoscopic posterior mesh rectopexy, Laparoscopic ventral mesh rectopexy, Rectal prolapse.
Rectal prolapse is more common in females and increases with age.1 Rectal prolapse is either external or internal. External rectal prolapse is a circumferential protrusion of all layers of the rectum over the anal sphincter.2 Internal rectal prolapse, as well denoted to as rectal intussusception or occult rectal prolapse, appears to be a pioneer of external rectal prolapse.1 Many patients with rectal prolapse suffer from symptoms of constipation and fecal incontinence, leading to a significant negative impact on quality of life.3
Two approaches are probable. The perineal approach is related to a high recurrence rate. So, it is preferred for patients who are not candidates for an abdominal operation. Currently, the abdominal procedures convey a lower recurrence rate and improved functional outcome and they are favored over the perineal procedures.4
The objectives of the surgical management are to correct the anatomical abnormality and to remedy the accompanying symptoms of incontinence, pain, and constipation, with the lowest rate of complications and a reasonable recurrence rate.4
Laparoscopic procedures for the management of rectal prolapse have been applied in patients of all ages. Laparoscopic rectopexy is safe and effective in patients of all ages and offers a lower rate of postoperative surgical site infection and length of hospital stay.3
Laparoscopic ventral mesh rectopexy is widely used, especially in Europe. In 2004, this procedure was first described by Lundby and Laurberg.5 The technique relies on correcting the descent of the posterior and middle pelvic compartments coupled with reinforcement of the vaginal septum and elevation of the pelvic floor.6
Hence, the objective of this study is to compare the results between LVMR and LPMR for patients admitted to Assiut University Hospital (Assiut, Egypt) with rectal prolapse, including recurrence, improvement of incontinence and constipation, operative time, and to assess the complications of both techniques.
MATERIALS AND METHODS
This is a prospective study of forty-four cases of patients with rectal prolapse admitted and managed at the Assiut University Hospitals in the period between November 2016 and 31 December 2020.
Patients were divided into two groups (22 patients per group):
Group A had LPMR.
Group B had LVMR.
All patients with rectal prolapse, either external or internal prolapse.
Patients with comorbidities and patients with previous complicated abdominal surgery.
All patients listed for operation underwent bowel preparation for 3 days before surgery in the form of low-fiber diet, followed by clear fluid intake and 2–3 enemata at the day before surgery.
Low-molecular-weight heparin (LMWH) 12 hours before surgery for prophylaxis against deep venous thrombosis (DVT). This was in addition to the elastic compression stockings worn by patients before induction of anesthesia,
Written consents were taken from patients explaining the details of surgery, the merits of minimally invasive surgery, and illustrating the possible complications of surgery and the probability of change to open surgery.
Type of Anesthesia
The patients were placed in the Lloyd–Davies position. A 30° laparoscope was placed through an umbilical Hassan port. One 10-mm operating port was put in the right iliac fossa and other 5-mm port was inserted 5 cm lateral to the umbilical port to the right side. A third assisted port was implanted in the left iliac fossa. An additional port might be inserted in the suprapubic region (Fig. 1).
A superficial peritoneal window was performed over the right part of the sacral promontory and extended caudally over the right outer border of the mesorectum down to the right side of the pouch of Douglas. In females, the vagina was retracted anteriorly, and a careful dissection of the rectovaginal septum was made down to the pelvic floor (Fig. 2).
Its distal extent was confirmed by digital rectal and vaginal examination. In males, careful dissection of the rectovesical septum was done down to the perineal body. The performed dissection in this technique spared the hypogastric nerves and parasympathetic nerves from the lateral stalks and avoided the mesorectum mobilization. A strip of polypropylene (3 × 20-cm) mesh was inserted and sutured as distally as possible on the anterior rectal wall/perineal body with three, interrupted non-absorbable sutures (Fig. 3).
The posterior wall of the vagina was fixed to the mesh by nonabsorbable sutures. Then, the mesh was secured tension-free to the sacral promontory via three nonabsorbable sutures. The mesh was peritonealized by suturing the free edges of the previously divided peritoneum over the mesh to afford additional ventral elevation of the enterocele and evade small bowel adhesions to the mesh.1
Laparoscopic posterior mesh rectopexy was done through mobilization of the mesorectum posteriorly from the sacral promontory to the pelvic floor. Lateral stalks were not divided. Bowel resection and circumferential division of the peritoneum were not performed in this study. A T-shaped polypropylene mesh was located with the vertical “leg” laying flush with the anterior surface of the sacrum and held to the promontory of sacrum with three nonabsorbable sutures. The mesh “wings” were closed to the lateral sides of the rectum with two absorbable sutures on each side.2
Deep venous thrombosis prophylaxis via LMWH was continued during the hospital stay.
Intravenous (I.V.) fluids and antibiotics (in the form of 3rd-generation cephalosporins plus metronidazole) were administered.
Oral ﬂuids were begun once intestinal peristalsis was recovered with progress to a normal diet as tolerated.
The patients were discharged once they tolerate solid meals and passage of ﬂatus or stool.
Intraoperative complications, early postoperative morbidity, operative time, blood loss, postoperative hospital stay, and hospital readmission were documented. All patients were reviewed in the outpatient clinic at 3-months intervals postoperatively within the first year and then annually, and evaluated for recurrence and morbidity.
There were primary and secondary outcomes. Regarding primary outcome measures, disappearance of prolapse, recurrence, and its improvement were observed. Moreover, operative time, complications, length of hospital stay, functional outcome (constipation and continence), as well as quality of life were the secondary outcome parameters. The clinical changes after surgery were evaluated by Wexner constipation score (WCS), Browning and Parks’ scale (BPS), obstructed defecation syndrome score (ODSS), as well gastrointestinal quality of life scale (GIQOL).
Statistical Product and Service Solutions (SPSS) v26.0 Inc., Chicago, IL, USA. was utilized for data analysis. Medians, means, minimum, and maximum were the calculated quantitative data that were compared by Mann–Whitney U test. Qualitative data were denoted as numbers and percentages (%) and were compared by Chi-square test or Fisher’s exact test when suitable. One-way ANOVA test was applied to investigate the differences in preoperative and postoperative scores within the same group. A significance level of p-value less than 0.05 was used in all statistical tests.
Gender and Age
Of 22 patients who underwent LPMR, 6 (27.27%) were males and 16 (72.73%) were females. On the other hand, of 22 patients who underwent LVMR, there were 8 (36.36%) males and 14 (63.64%) females with no significant difference between both groups (p = 0.747). The patients’ ages ranged from 11 to 63 years old with the mean age 42.43 ± 14.05 years and 40.5 years as a median. About 36.36% of patients were below 40-years old in group A, while about 40.91% of patients in group B with no significant difference between groups as shown in Table 1.
|Variable||Group A (LPMR)||Group B (LVMR)||Total||p-value|
|<40||8 (36.36%)||9 (40.91%)||17|
|40–50||4 (18.18%)||6 (27.27%)||10||0.209|
|50–60||6 (27.27%)||7 (31.82%)||13|
|>60||4 (18.18%)||0 (0%)||4|
Complete rectal prolapse, constipation, fecal incontinence, bleeding per rectum, obstructed defecation, and internal rectal prolapse were the common symptoms in both groups. Clinical presentation of rectal prolapse was distributed as presented in Table 2. It was noted that complete rectal prolapse (grade V) and constipation were the main clinical symptoms in group A. While, internal rectal prolapse (grades II and III), constipation, and obstructed defecation in addition to bleeding per rectum were the prominent symptoms in group B.
|Clinical presentation||Group A (LPMR)||Group B (LVMR)||Total|
|Bleeding per rectum||9||11||20|
|Complete rectal prolapse||14||10||24|
|Internal rectal prolapse||8||12||20|
The mean operative time of both LPMR and LVMR groups was calculated. In group A, 114.09 ± 12.690 minutes were the mean operative time ± standard deviation. While 181.82 ± 15.395 minutes were that of group B. Laparoscopic posterior mesh rectopexy operation time was shorter than that of LVMR with a significant difference between operative times of both groups (p = 0.001).
Estimated Blood Loss
The blood loss was measured for patients who underwent either LPMR or LVMR. No significant difference between the volume of the lost blood of both groups (p = 0.598) was observed. The results are summarized in Table 3 and represented as a bar chart in Figure 4.
|Volume of blood lost (mL)||Group A (LPMR)||Group B (LVMR)||Total||p-value|
|50||6 (27.27%)||3 (13.64%)||9|
|100||7 (31.82%)||6 (27.27%)||13|
|150||5 (22.73%)||8 (36.36%)||13||0.598|
|200||4 (18.18%)||5 (22.73%)||9|
Length of Hospital Stay
Regarding Table 4, there was no significant difference in hospital stay between both groups after surgery was found.
|Hospital stay (days)||Group A (LPMR)||Group B (LVMR)||Total||p-value|
|Three||9 (40.91%)||9 (40.91%)||18|
|Four||9 (40.91%)||11 (50%)||20||0.648|
|Five||4 (18.18%)||2 (9.09%)||6|
Eighteen patients (81.82%) in group A and twenty patients (90.91%) in group B who underwent laparoscopic posterior and ventral mesh rectopexy, respectively, had no complications after surgery. However, recurrence, impotence, and discitis were recorded as postoperative complications in both groups.
It was found that three patients (13.64%) in group A versus one patient (4.54%) in group B presented with recurrence. On the other hand, impotence was observed in one patient (4.54%) of group A. No impotence was recorded for group B in contrast with group A. Moreover, one patient (4.54%) in group B had discitis. Unlike group B, discitis was not reported as a postoperative complication in group A. As a result, there were no significant differences in postoperative complications between the two groups (p = 0.142). The results of postoperative complications are summarized in Table 5.
|Postoperative complications||Group A (LPMR)||Group B (LVMR)||Total||p-value|
|No complication||18 (81.82%)||20 (90.91%)||38|
|Recurrence||3 (13.64%)||1 (4.54%)||4||0.142|
|Impotence||1 (4.54%)||0 (0%)||1|
|Discitis||0 (0%)||1 (4.54%)||1|
The four patients in both groups who suffered from recurrence were classified according to recurrence grade and recurrence-free time (Table 6). After applying the Oxford Rectal Prolapse Grading System, it was found that three patients in group A suffered from preoperative prolapse of grade V. While, the preoperative prolapse in the patient of group B was of grade IV. Three patients in group A had a recurrence-free time for 4 and 6 months, respectively. While, the patient in group B was free from rectal prolapse for 6 months.
|Variables||Group A (LPMR)n = 3||Group B (LVMR)n = 1|
|Patient #1||Patient #2||Patient #3||Patient #1|
|Grade V||Grade V||Grade V||Grade IV|
|Postoperative||Grade V||Grade III||Grade IV||Grade III|
|Recurrence-free time (months)||4||6||6||6|
We ordered MRI defecography once symptoms that suggest the possibility of rectal prolapse recurrence appeared. As shown in Table 6, the postoperative recurrence of one of the patients who underwent LPMR was of grade V after 4 months. The rest of patients in both groups who did not clinically improve, were followed up after 6 months by MRI defecography. It was found that the postoperative recurrence of the two patients underwent LPMR became grades III and IV. However, the patient who underwent LVMR suffered from grade III postoperative recurrence.
Clinical Changes after Surgery
Constipation, obstructed defecation syndrome, and incontinence were the main clinical symptoms that were followed up for 6–50 months after surgery with the mean period of 23.73 ± 14.817 months. As shown in Table 7, improvement of constipation was higher in group B in comparison with group A.
|Clinical symptoms||Group A (LPMR)||Group B (LVMR)||Total|
|Obstructed defecation syndrome|
Furthermore, one patient of group B did not improve from incontinence. Also, two patients in group B complained persistence of obstructed defecation even with correct dieting and training for proper defecation habits. Those two patients had no prolapse recurrence as shown by defecography done 3 months after presenting of symptoms. However, one patient in group A suffered from obstructed defecation syndrome that appeared 4 months after the operation. He had a prolapse recurrence on MRI defecography.
The clinical changes after surgery were evaluated by WCS, BPS, ODSS, as well as GIQOL. One-way ANOVA test was used for comparing the changes in the functional results within each group (Table 8).
|Scoring test||Group A (LPMR)||Group B (LVMR)|
|Preoperative (Mean ± SD)||Follow-up (Mean ± SD)||p-value||Preoperative (Mean ± SD)||Follow-up (Mean ± SD)||p-value|
|WCS||14.28 ± 2.08||10.78 ± 2.80||0.0001||15.53 ± 2.24||6.71 ± 3.29||0.0001|
|BPS||3.50 ± 0.58||1.50 ± 0.58||0.003||3.60 ± 0.55||1.80 ± 0.84||0.004|
|ODSS||18.20 ± 1.99||6.00 ± 5.42||0.0001||18.92 ± 1.68||6.75 ± 5.06||0.0001|
|GIQOL||61.00 ± 8.01||105.45 ± 7.54||0.0001||66.09 ± 9.59||114.23 ± 8.64||0.0001|
Regarding WCS, it was postoperatively lower in LVMR than LPMR (6.71 ± 3.29 vs 10.78 ± 2.80, respectively). These results indicate the significant improvement of constipation in group B compared with group A. The postoperative decrease in BPS values proves the improvement of incontinence in both groups. The change was statistically significant (p-value = 0.003 and 0.004 for groups A and B, respectively). After applying ODSS, there was no difference between the results of both groups. They showed an improvement of the symptoms of obstructed defecation syndrome (p-value = 0.0001).
In group A, GIQOL score was increased from 61.00 ± 8.01 to 105.45 ± 7.54 after surgery. While the score increased from 66.09 ± 9.59 to 114.23 ± 8.64 after LVMR. The improvement is more in LVMR group and the difference is clinically significant.
Laparoscopic rectopexy has been verified to be as effective as open rectopexy in complete rectal prolapse treatment with a low recurrence rate. Signiﬁcant reductions in postoperative pain, hospital length of stay, recovery time, and complications compared with open abdominal rectopexy were encountered. The present study compared two laparoscopic rectopexy procedures: LPMR and LVMR. The comparison involved operative parameters, complications, hospital length of stay, postoperative improvement in fecal incontinence and constipation, as well as recurrence. Between November 2016 and 31 December 2020, forty-four patients were eligible for this study with 22 patients undergoing LPMR and 22 patients undergoing LVMR.
In the present work, the mean patients’ age was 42.43 ± 14.05 years. There were 14 males (6 in the LPMR group vs 8 in the LVMR group) and 30 females (16 for LPMR vs 14 for LVMR) with no significant difference in-between. In this study, the rectal prolapse incidence was higher in females. Our findings agree with those reported by Mik et al. and Madbouly and Youssef.7,8
It is well-known that rectal prolapse can occur as a result of many factors such as, chronic constipation or diarrhea long-term history of straining during bowel movements, the weakness of muscles, especially anal sphincter and ligaments in the rectum with age. Also, nerve damage that was caused by pregnancy, difficulty in childbirth, and anal sphincter paralysis leads to rectal prolapse.7
The duration of surgery is affected by numerous factors such as surgical technique, sex of the patient, intraoperative complications, surgeon’s experience, and the operating team.
As regards to the operative time, it was shorter in LPMR (114.09 ± 12.690 minutes) compared with LVMR (181.82 ± 15.395 minutes) with a significant difference between the operative times of both groups (p = 0.001). These results can be explained by many reasons. In LVMR, dissection of rectovaginal septum to expose the whole anterior surface of the rectum in females and dissection in the rectovesical pouch that was held to the apex of the prostate in males spent long operative time. While mobilization of the rectum from the sacrum in LPMR was easy. Also, fixation of the mesh in LPMR was easier than that of LVMR.
Regarding postoperative complications, no complications have been observed in 81.82% of patients who underwent LPMR and 90.91% of patients who underwent LVMR. However, recurrence, impotence, and discitis were recorded as postoperative complications in both groups. Recurrence was found in 13.64% of patients who underwent LPMR vs 4.54% of patients who underwent LVMR. The previous studies recorded 0–21% of recurrent full-thickness rectal prolapse after LVMR.3,9–15
MRI defecography was done for the patients in both groups of our study who did not clinically improve. It was found that the postoperative recurrence of the three patients who underwent LPMR became grades III, IV, and V. However, the patient who underwent LVMR suffered from grade III postoperative recurrence. The recurrence might occur in elderly patients and multipara women due to weak pelvic floor muscle.
Moreover, one patient (4.54%) who underwent LVMR had discitis. Unlike LVMR, discitis was not reported as a postoperative complication in LPMR. As a result, there were no significant differences in postoperative complications between the two groups (p = 0.142). Our findings agree with those reported by Samaranayake et al. who observed discitis in two cases who underwent LVMR.16
Impotence occurred in one patient (4.54%) who underwent LPMR. No impotence was recorded for patients who underwent LVMR. Like our findings, no cases of impotence have been reported for LVMR according to Owais et al.17 The risk of pelvic sympathetic and parasympathetic nerve damage after LPMR is considered the main cause of sexual dysfunction in men.18,19 As reported, the risk of nerve injury should be less than 1–2% during the selection of repair procedures, especially in men.18 Hence, our results assured that LVMR is better than LPMR in avoiding the pelvic nerve damage and impotence.
Mesh erosion into the rectum or vagina is a reported complication after laparoscopic rectopexy. The reported mesh-erosion rate ranged between 1 and 5%.20 Infection, pervious pelvic irradiation, undiscovered vaginal injury, and large-size mesh that folds after fixation are the common causes of mesh erosion.21 However, mesh erosion did not occur in the presented study, this may be due to the absence of long-term follow-up after surgery.
Concerning clinical changes after surgery, constipation, obstructed defecation syndrome, and incontinence were followed up for 6–50 months after surgery. In this study, improvement of constipation was higher in LVMR (82.35% improved) in comparison with LPMR (22.22% improved). Our results agreed with other reported studies stating that LVMR was superior to LPMR because of the lower risk of nerve damage and postoperative constipation.16,22
We found that 82.35% of patients were improved from constipation after LVMR near other reported percentages (86%, 97%, 81%, and 89%).3,10–12
Regarding WCS, it was postoperatively lower in LVMR than LPMR (6.71 ± 3.29 vs 10.78 ± 2.80, respectively). These results indicate the significant improvement of constipation in LVMR compared with LPMR. The postoperative constipation mechanisms might be due to: the leave of a redundant sigmoid colon that might link to yield a mechanical obstruction or due to interruption of the autonomic sympathetic innervation of the rectum, leading to a hindgut denervation inertia and distal slow transit or due to division of the lateral ligaments. Furthermore, the denervation inertia inconsistently dominates any mechanical improvement from fixation of the intussuscepting prolapse. This explained why LPMR sometimes improves and other times worsens constipation9 Moreover, the basis of the postoperative constipation improvement in LVMR is the restriction of the mobilization to anterior rectum that leads to rectal intussusception and prevention of posterior and lateral rectal mobilization as well as denervation inertia. Our results are similar to a previous study that reported the improvement of constipation (WCS fallen from 9 to 6) after LVMR.9
Furthermore, one patient of group B was not improved from incontinence. The postoperative decrease in BPS values in LPMR and LVMR proved the improvement of incontinence. The change in both groups was statistically significant (p-value = 0.003 and 0.004 for groups A and B; respectively).
In a previous study, 27–90% of patients have shown an improvement of fecal incontinence that improved after LVMR.23 Also, Dyrberg et al. have confirmed a complete improvement of incontinence in 74.4% of patients followed up 60 days after LVMR and in 86.3% improved after LPMR.2 In conclusion, the restitution mechanism could be assisted by the improvement in rectal compliance and anorectal sensation. Also, restoration of internal anal sphincter function and postoperative constipation were important reasons for restitution.24,25
After applying ODSS, there was no difference between the results of both groups. A significant improvement of the symptoms of obstructed defecation syndrome was observed in both groups (p-value = 0.0001). These results agree with other reported studies3,14,26 that stated that obstructed defecation syndrome deteriorated in 12 patients (75%) which was higher than our result (2 patients, 16.67% not improved). Defective rectal filling sensation, functional and mechanical outlet obstruction, the consumption of force at straining, and severe rectal intussusception in addition to rectocele can lead to obstructed defecation.
Additionally, GIQOL was applied. In LPMR, Gastrointestinal Quality of Life score was increased from 61.00 ± 8.01 to 105.45 ± 7.54 after surgery. While the score changed from 66.09 ± 9.59 to 114.23 ± 8.64 after LVMR. The improvement is more in the LVMR group, and the difference is clinically significant (p = 0.0001). About 77.78% of patients who underwent LPMR did not improve from constipation versus 17.65% of patients who underwent LVMR. This might be the reason for the worsened life quality in LPMR compared with LVMR.
To summarize, laparoscopic rectopexy has been proved to be as effective as open rectopexy in rectal prolapse treatment with a low recurrence rate. Laparoscopic rectopexy is preferable than open abdominal rectopexy in the reduction of postoperative pain, hospital length of stay, recovery time, and postoperative complications. Also, our study proves that LVMR is superior to LPMR in prevention of impotence, improvement of constipation, as well as enhancement of the quality of life. Thus, laparoscopic rectopexy especially LVMR, offers an effective and safe approach for patients of all ages. However, more studies with a large number of cases and long duration of follow-up are required to evaluate long-term consequences.
The authors would like to thank Dr Noha M Hosny (lecturer of pharmaceutical analytical chemistry at Faculty of Pharmacy, Assiut University, Assiut, Egypt) for her valuable contribution to performing the statistical analysis of this study and editing–reviewing this paper.
Ibrahim M Abdelaal https://orcid.org/0000-0002-8942-8016
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