30 consecutive patients with constipation were operated due to rectal prolapse between January 2010 and December 2020 at the Clinic for General and Visceral Surgery at the Kepler University Hospital Linz. 14 by laparoscopic anterior resection rectopexy (LARR), 8 by laparoscopic posterior resection rectopexy (LPRR) and 8 by laparoscopic suture resection rectopexy (LSRR). 23 of them were suffering from external and 7 from internal rectal prolapse. 6 patients also reported symptoms of fecal incontinence. Concomitant findings by defecography were rectocele in four patients, enterocele in two patients and an elongated sigmoid colon in five patients. Additionally, six patients were suffering from diverticular disease. Retrospectively, the clinical and demographic data of the study participants were taken from the hospital information system and all patients were contacted again by telephone. 25 of them were reached and validated Cleveland Clinic Constipation Score (CCCS) and Gastrointestinal Quality of life score (GIQLI) were used to ask them about their preoperative condition and postoperative outcome after resection rectopexy. The GIQLI was divided into five subgroups including gastrointestinal symptoms, emotions, physical status, social dysfunction and effects of medical treatment. Furthermore, patients were asked about prior surgeries in the abdominal and pelvic area and females about vaginal deliveries. Exclusion criteria for admission to the study were other indications for surgery than constipation and an incomplete follow-up protocol. The study was conducted after approval from the ethics committee and Institutional Review Board.
All patients were evaluated preoperatively by thorough medical history, physical examination, colonoscopy and radiological assessment (defecography, CT scan with gastrografin preparation and colonic transit time). A detailed assessment was performed of their general condition, comorbidities and risk factors. Gynecologists, urologists, radiologists and pelvic floor physical therapists were also included in discussions as needed.
All variables were analysed at baseline (preoperative values) and included gender, age, BMI, ASA class, type of surgery, operative time, complications and length of stay. Complications were defined as minor in cases where no surgical reintervention was necessary (Clavien Dindo grade 1 or 2) and as major when patients had to undergo surgical reexploration (Clavien Dindo grade 3 or higher). Operation time was defined as the beginning of the skin incision to completion of the surgical dressing. CCCS and GIQLI were used to evaluate constipation and quality of life. The responses— scored using a numerical rating scale were documented before surgery, and at time of the phone survey. The period for recording perioperative results started at the time of surgery and ended with the discharge of the patient. Candidates were evaluated median 68.0 ± 42.8 months after surgery during a phone interview which included filling out the standardised questionnaires. All data concerning the operations and changes resulting from it were reported. Informed consent was obtained from all of the patients.
Statistical analysis was performed using the open-source R statistical software package, version 3.6.1 (The R Foundation for Statistical Computing, Vienna, Austria). The type I error was not adjusted for multiple testing. Therefore, the results of inferential statistics are descriptive only. An intention to treat approach as well as a per-protocol approach has been taken. All data of continuous variables were checked for normal distribution (test of normality: Kolmogorov-Smirnov with Lilliefors significance correction, type I error = 10%) and for heteroscedasticity (Levene test, type I error = 5%). Comparisons (LARR vs. LPRR vs. LNRRP) of variables with normally distributed data without different variances were performed by a parametric analysis of variance (ANOVA; due to the results, there was no need for multiple comparisons). For comparisons of all other continuous variables and of variables measured on ordinal scales a non-parametric analysis of variance (Kruskal Wallis test, followed by Nemenyi's multiple comparisons) was used. Data of categorical variables were compared by the exact chi-square test (with provision of adjusted residuals). Pre-post-comparisons of continuous variables with normally distributed data were performed by the paired t-test; otherwise and for comparisons of variables measured on ordinal scales the exact Wilcoxon test was used. Multiple regression analyses (including stepwise approaches) were used to investigate the influence of the following variables on improvement of CCCR and on improvement of GIQLI: type of resection rectopexy, age, BMI, follow up, CCCR, GIQLI, ASA, gender and pre-operations.
In all patients standardized operation techniques were used and all procedures were performed laparoscopically in Lloyd-Davies position under general anesthesia by the same surgical team. All patients had preoperative mechanical bowel preparation and oral antibiotics, as well as perioperative parenteral antibiotics. Pneumoperitoneum was created via the umbilical port (11 mm), with peritoneal insufflation with CO2 gas to the pressure of 12 mm Hg. After insertion of the laparoscope (Storz, Germany), three additional ports were placed under direct vision—one in the right lumbar (11 mm) and right iliac region (11 mm), and one suprapubic (5mm). After exploration of the abdomen and pelvic area dissection was started in the area of the promontory after releasing adhesions to the sigmoid rectum and towards the uterus. The peritoneum was incised, and the superior rectal artery exposed. The left ureter was visualized, then the mesorectal sheath was opened with electrosurgical scissors, the left and right hypogastric plexus were visualized and spared. Dissection corresponding to a TME up to the pelvic floor was performed, whereby heat was not applied to the nerve bundles and only the scissors were used for cutting. The peritoneum was opened at the fold and the rectum was mobilized up to the pelvic floor. Subsequently, a window was created at the upper edge of the superior rectal artery. Mesosigmoideum was dissected in the area of the expected resection border up to the colon with the LigaSure Atlas™ (Medtronic, USA) and then the intestine was skeletonized tubularly up to the lower distal resection border in the transition to the upper middle third of the rectum. Finally, the intestine was set down in one stroke by a linear stapler (iDrive®, Medtronic, USA). Pfannenstiel incision was performed and Alexis® wound protector/retractor was inserted and the measured colon resected. The colorectal anastomosis was performed using a circular stapler (Touchstone, 29 mm; Dach Medical Group, Bürmoos, Austria). A pneumatic test was performed to verify the absence of any primary leakage.
For LARRP a folded TiO2 Mesh™ (10x15cm, MFP111, AFS medical, Austria) was inserted and placed on the anterior wall of the rectum down to the pelvic floor and fixed with 0-Prolene® (Ethicon; Somerville, NJ, USA) simple interrupted stitches at a distance of 2 cm from the anterior wall. The upper end is pulled in the direction of the promontory and sutured here directly to the promontory with two simple interrupted stitches. This technique was first described by D`Hoore in 2004 in order to allow preservation of the autonomic nerves by mobilizing the rectum in the anterior plan only .
LPRPP was performed by cutting a TiMESH® in the shape of a cross with the two transverse legs approximately 3 cm long and 2 cm wide. The mesh is held in the correct position on the os sacrum by ProTack™ Fixation Device. The rectum was fixed with 0-Prolene® (Ethicon; Somerville, NJ, USA) simple interrupted stitches below the anastomosis on the left and right side of the mesh wings.
For LSRR a continuous suture was made to each side between the peritoneum or lateral os sacrum and the rectum using V-Loc suture without compromising the vascular perfusion, so that the entire intestine is nicely stretched but the anastomosis was naturally free of tension.