Ventral rectopexy


Ventral rectopexy is a surgical procedure for external rectal prolapse, internal rectal prolapse, and sometimes other conditions such as rectocele, obstructed defecation syndrome, or solitary rectal ulcer syndrome. The rectum is fixed into the desired position, usually using a biological or synthetic mesh which is attached to the sacral promontory. The effect of the procedure is correction of the abnormal descended position of the posterior compartment of the pelvis, reinforcement of the anterior surface of the rectum, and elevation of the pelvic floor. In females, the rectal-vaginal septum is reinforced, and there may be an opportunity to simultaneously correct any prolapse of the middle compartment. In such cases, ventral rectopexy may be combined with sacrocolpopexy. The surgery is usually performed laparoscopically.

Background

There are over 300 different variations of surgical procedures described for rectal prolapse, and this area has seen rapid development. However, there is no clear consensus regarding the best method. Surgical treatment for rectal prolapse may be via the perineal or abdominal approach. Generally speaking, perineal procedures have less complications but higher rates of recurrence compared to abdominal procedures. Ventral rectopexy falls into the abdominal procedure category, and can be considered as a type of abdominal rectopexy.
Abdominal rectopexy encompasses several procedures which involve mobilization and fixation of the rectum, with or without resection, via an abdominal surgical approach. Some of types of abdominal rectopexy are now rarely or never performed. For example, the Ripstein rectopexy and the Wells procedure are not longer performed. Risks associated with abdominal rectopexy procedures include post-operative problems with defecation such as new or worsened constipation, obstructed defecation or fecal incontinence. In males, mobilization of the rectum may risk the development of erectile dysfunction. New or worsened constipation does not seem to be a significant problem with ventral rectopexy, which represents the most recent development of abdominal rectopexy.
Another way of categorizing surgery for prolapse of pelvic organs is into suspensive or resective classifications. Ventral rectopexy alone is a suspensive type surgery, a category which also includes colposacropexy. Resection rectopexy additionally involves removal of a section of the sigmoid colon. It is thought to have decreased post operative problems of constipation, because the redundant colon is removed and therefore cannot "kink". However, there is no evidence that this improves the outcomes, and the necessary creation of an anastomosis increases the risk of severe complications.

Orr-Loygue procedure (lateral mesh rectopexy)

Ventral rectopexy with an autologous graft, and then with a synthetic mesh for external rectal prolapse was first reported in 1971. The Orr-Loygue procedure was described in 1984. The Orr-Loygue procedure involved anterior and posterior mobilization of the rectum to the level of the levator ani muscle and removal of the pouch of Douglas. Mesh was sutured to the lateral surfaces of the rectum.

Ventral rectopexy

Ventral rectopexy was developed as a modification of the Orr-Loygue procedure by D'Hoore in 2004. In ventral rectopexy, there is no posterior dissection and mobilization of the rectum apart from to expose the sacral promontory. With no posterior or lateral dissection, damage to the autonomic nerves is minimized. As a result, there are less problems with post-operative constipation. According to one source, there is no excision of the pouch of Douglas, but another source states that ventral mesh rectopexy results in elimination of the pouch of Douglas. The mesh is placed directly onto the anterior surface of the rectum. This procedure aims to suspend the middle and lower sections of the rectum. This modified procedure is now known as the anterior rectopexy or ventral rectopexy. D'Hoore also used a laparoscopic approach.
After 2002, the minimally invasive trans-anal approach known as stapled trans-anal rectal resection became popular for treating obstructed defecation syndrome. However, over time, there has been a general trend away from STARR towards abdominal rectopexy for surgical treatment of obstructed defecation syndrome.
Ventral mesh rectopexy has become one of the most popular options for rectal prolapse. Ventral rectopexy also provides the opportunity to simultaneously correct any prolapse of the middle compartment of the pelvis, and is sometimes combined with sacrocolpopexy. Some have called for caution with regards to the rapid rise in popularity of ventral mesh rectopexy, citing lack of high quality evidence and concerns about long term efficacy and possible mesh related complications. One author described laparoscopic ventral mesh rectopexy as a possible "bandwagon" phenomenon because there has been overwhelming acceptance of the procedure, despite it being a relatively unproven idea which may eventually be proven valid, or may be abandoned in future.

Controversy regarding use of mesh

There has been some controversy connected with transvaginal placement of mesh in the treatment of pelvic organ prolapse and stress urinary incontinence. This is because there is a risk of erosion and sepsis. In 2008 and 2016 the US Food and Drug Administration published guidance about potential serious complications caused by such meshes and upgraded their risk classification of such meshes from Class II to Class III. Procedures involving transvaginal mesh have since decreased by 40–60% in the USA. In 2011, manufacturers of permanent transvaginal meshes withdrew the products from the market. In Europe, the Scientific Committee on Emerging and Newly Identified Health Risks stated in 2015 that implantation of any mesh via the vaginal route should be done only in complicated cases where a primary repair has failed. A Cochrane review in 2016 stated that the risks were higher with such meshes compared to native tissue repair. Transvaginal meshes have higher risk of repeat surgery, injury to the bladder, and stress urinary incontinence which appears after the surgery. They concluded that transvaginal meshes have limited benefit in the primary surgical management of pelvic organ prolapse and stress urinary incontinence. The review was updated in 2024 with the same conclusions but based on newly available evidence.
In response to the controversy connected with transvaginal meshes, the Pelvic Floor Society on behalf of the Association of Coloproctology of Great Britain and Ireland issued a position statement regarding the use of mesh in ventral rectopexy in 2020. They stated that meshes in ventral rectopexy are not the same because the mesh is inserted between the rectum and the vagina and not directly into the vagina as with transvaginal meshes. They also stated that according to current evidence ventral mesh rectopexy is the best available treatment to restore normal rectal function, and that the estimated overall risk of complications is about 2.5% based on the worst-case scenario.

Indications

The definitive indication for ventral rectopexy is:
  • External rectal prolapse in a patient who is fit enough for general anesthesia. In this category of patients, it has been recommended that age and gender are not valid reasons to not perform the procedure. External rectal prolapse may give symptoms of obstructed defecation syndrome, fecal incontinence, or both, Other symptoms are bloody or mucous rectal discharge.
Relative indications are:
Absolute contraindications are:
Relative contraindications are:
  • Male gender. Internal rectal prolapse is uncommon in men. The procedure is more difficult in men, and there may be higher risks for this group.
  • Morbid obesity. Pelvic dissection is more difficult in such patients. There may also be a higher risk of recurrence.
  • High-grade endometriosis.
  • Previous pelvic radiotherapy directed at the pelvis.
  • Previous sigmoid peridiverticulitis.
  • Only minimally symptomatic bowel dysfunction, even if high-grade internal rectal prolapse can be detected. When defecography is performed on healthy volunteers, internal rectal prolapse is detected in about 50-60% of cases. Therefore, symptom severity and the impact on quality of life for the individual are more important factors for surgeons when they are considering this type of surgery.

    Procedure

Approach

There are 3 options for surgical approach: open abdominal surgery, laparoscopic approach or robotic surgery. The laparoscopic approach is safer than open surgery, and there is less risk of complications after the procedure. There is also less blood loss, less pain after the procedure, shorter average length of stay in hospital and faster recovery. Rarely, the procedure must be converted into an open abdominal surgery.
The procedure is still almost always carried out via laparoscopic approach. However, increasingly some surgeons use robotic surgery to conduct the procedure. Some surgeons claim that the use of robotic surgery makes ventral rectopexy less technically demanding, because it requires careful dissection and suture placement in a tight, narrow space. This is especially true in patients with a narrow pelvis. Laparoscopic ventral rectopexy is also difficult in patients who are obese.
Robotic approach has the benefit of three-dimensional visualization, precise dissection and the possibility of refined, articulated movements suitable for a narrow conical space such as the pelvis. There is less trauma to the tissues and less blood loss compared to conventional laparoscopy. In the case of ventral rectopexy, which is considered a difficult procedure requiring a lot of training, robotic surgery is reported to speed up the learning curve for surgeons. Longer operation times are usually reported with robotic surgery, but operation time is less With surgeons who are experienced in using the robotic technique. The laparoscopic approach is cheaper than robotic surgery, but when considering the reduced hospital stay, robotic surgery may be cheaper overall.