Laparoscopic Ventral Rectopexy

Laparoscopic Ventral Rectopexy for Fecal Incontinence Associated with High-grade Internal Rectal ProlapseOxford Pelvic Floor CentreDepartment of Colorectal SurgeryOxford, UK

Fecal incontinence Debilitating25% of institutionalized populationFactorsSphincterNeurologicalCNSStool consistencyDrossman et al. US householder survey of functional gastrointestinal disorders: prevalence, sociodemography and health impact. Dig Dis Sci. 1993;38:1569-1580

Rectal prolapse & IncontinenceComplex interactionAnal resting pressureStretching of internal sphincterRectoanal inhibitory reflex (RAIR) disturbance Incomplete emptyingFarouk, Duthie. Rectal prolapse and rectal invagination. Eur J Surg. 1998;164:323-332

Corrective proceduresMultiple over 50 yearsHigh morbidityVariable resultsLaparoscopic ventral rectopexy? (LVR)Asman HB. Internal procidentia of the rectum South Med J 1957;50:641-645

MethodsAug 2009 July 2011180 subjects with fecal incontinencefailed maximal medical treatment74 LVRWorkupDefecating proctogramAnorectal physiologyEndoanal USEUAOxford Prolapse Grade

Oxford Prolapse Grade

QuestionnairesBefore & 1 year after surgeryRockwood Fecal Incontinence Severity IndexIncontinence

Agachan-Wexner Constipation Score (1-5)obstruction

FISI score decrease

StatisticsMean, median with SDWilcoxon signed rank testComparing improvement>50% FISI = successPatient group comparisonChi-square, Fisher exact testContinuous variables Mann Whitney testPearson correlation- FISI:pre-op squeeze increment

Results74 LVR72 completed duration of study52 (72%) proctogramRemainder EUAComplications in 9 patients (13%)Urinary retention 7Port site infection 1Mesh erosion @5 mths - 1

Results @1 yearMedian FISI score 31 15EUA grp: 38 16Proctogram grp: 30 12Similar improvementsOxford III and IVSimilar FISI scores

Results21 patients completedly continent (29%)53 patients FISI improved >25%40 patients improved >50% (56%)4 patients no change (6%)8 patients worse off (11%)

Additional intervention14 patients additional surgical procedure12 patients sacral neuromodulation2 patients repeat LVR for residual posterior prolapse

Results Wexner scoreSignificantly reduced (median score)13 vs 8 (p< 0.001)6 patients (8%) minor deterioration Mean increase 1.3

Results: Prediction of outcome***Preop squeeze increment is an independent predictive factor of LVR success

DiscussionComparing Functional OutcomeFISIWexnerMore than half showed procedural success1/3 cured

DiscussionFecal incontinent 27% has prolapseAsymptomatic prolapse at menopause 23%

Why correction of prolapse in the symptomatic population actually improves symptoms?Lazorthes et al. Is rectal intussusception a cause of idiopathic incontinence? Dis Colon Rectum. 1998;41:602-605Goei & Baeten. Rectal intussusception and rectal prolapse: Detection and postoperative evaluation with defecography. Radiology. 1990;174:124-126

Available dataBristol group91%Int & externalIhre & Seligson77%internalDelemarre62% internalPortier39/4098%Orr-Loygue rectopexy

Samaranayake 45%int & external(systematic review of 12 case series, 728 patients)

Why LVR works?Delemarre et al:Anorectal physiology in 9 patientsBefore & after rectopexy

Significant increase in maximal squeeze increment in patients regained continencePartial restoration of pelvic floorMore effective active and reflexive anal sphincter action

Why LVR worksAbolition of high rectal pressure wavesRecovery of internal anal sphincter electromyographic activityImprovement in anorectal sensationIncrease in anal resting pressure

LimitationLack of anorectal manometry dataPost-rectopexy pelvic floor imaging

CommentsLVR has a roleWhere does LVR stand in the treatment algorithm?Compared to sacral neurostimulationEqual?Better?

New questions to be answeredPatients with fecal incontinence associated with high grade internal rectal prolapseLVR+/- Neurostimulation

***considering complications eg. mesh erosion***general anaesthesia vs DC (neurostim.)

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