1. Laparoscopic Rectopexy;
Is It Useful for
Persistent Rectal Prolapse
in Children?
Dr. Aditya Ghatnekar
Resident
Dept. of General Surgery
Under the Guidance of
Dr. BD Dhaigude
Professor
Dept of General Surgery
Medhat M. Ibrahim1*, Mohammed Abd El Razik1, Ahmed M. Abdelkader2
1Pediatric Surgery Unit, Faculty of Medicine, Al-Azhar University, Nasr City, Cairo, Egypt
2General Surgery Unite RCMC, Yanbu Industrial City, KSA
Email: *dr_medhat_ibrahem@yahoo.com
Received 6 February 2014; revised 5 March 2014; accepted 13 March 2014
2. INTRODUCTION
• Rectal prolapse is a relatively common, usually self-limiting
illness in children. Peak incidence is between 1 and 3 years
[1] [2].
• It can be partial (protrusion of only mucosa from anal verge)
or complete (full thickness of rectum is involved). The
intervention is required for the Persistent Rectal Prolapse
(PRP).
• Laparoscopic Rectopexy (LRP) is in vogue for adults;
however, only scanty experience is available with this
technique in children.
• In this article the authors have presented their experience with
LRP for PRP at the pediatric surgery unit at the Al-Azhar
University hospital, Nasr City, Cairo, Egypt.
3. Figure 50.1. Fascial attachments of the rectum.
Rectum
The rectum extends from the level of the promontory of the sacrum to the level of the levator ani muscle and varies in length from
12 to 15 cm. The rectum differs from the colon in that the outer layer is covered circumferentially by longitudinal muscle rather
than the three taeniae bands. The rectum has two or three lateral curves that form submucosal folds in the lumen, known as the
valves of Houston. The posterior part of the rectum is devoid of peritoneum and is covered with the endopelvic fascia. The
presacral fascia is a strong, endopelvic fascia that covers the entire anterior surface of the sacrum and also the underlying
vessels and nerves. At about the level of S-4, the presacral fascia runs forward and downward and attaches to the rectum (1).
This portion is referred to as the rectosacral fascia (Fig. 50-1). It is necessary to cut this fascia for full mobilization of the rectum,
as in abdominoperineal resection or low anterior resection. Peritoneum covers the upper two thirds of the rectum anteriorly, and
the upper one third of the rectum is covered by peritoneum laterally. The lower third of the rectum is entirely devoid of peritoneum.
In general, the anterior peritoneal reflection is about 6 to 8 cm from the anal verge. The extraperitoneal portion of the rectum is
covered by the endopelvic fascia, which, on the anterior surface, is called Denonvilliers' fascia. The lateral endopelvic fascia,
which is thicker, is referred to as the lateral rectal stalks, which must also be divided for full mobilization of the rectum.
4. Figure 50.2. Arrangement of the external sphincter
muscles.
Anal Canal
The anal canal, about 4 cm in length, is the terminal portion of the large bowel that passes through the levator ani
muscle and opens to the anal verge. The muscular wall of the anal canal, as a continuation of the circular muscular
layer of the rectum, is thickened and forms the internal sphincter. The anal canal is wrapped by the external sphincter
muscle and the puborectal muscle, which are arranged in three U-shaped loops (2). The top loop is formed by the
puborectal muscle, which originates from the pubis. The intermediate loop is the superficial external sphincter muscle; the origin of this
loop, at the tip of the coccyx, is known as the anococcygeal ligament. The basal loop is composed of the subcutaneous portion of the
external sphincter muscle (Fig. 50-2). The upper portion of the anal canal, where the internal sphincter muscle becomes thickened and
the puborectal muscle wraps around (felt on digital examination of the lateral and posterior quadrants), is called the anorectal ring. From
the level of the anorectal ring distally and between the internal and external sphincter muscles, the longitudinal muscle
coat of the rectum is joined by fibers of the levator ani and puborectal muscles to form the conjoined longitudinal muscle (Fig. 50-3).
These muscle fibers, which may traverse the lower portion of the distal external sphincter to insert in the perianal skin and cause
wrinkling of the anal verge, are referred to as the corrugator cutis ani.
5. Figure 50.3. Anatomy of the anal canal.
At about the midpoint of the anal canal, 2 cm from the anal verge, is an undulating demarcation called the dentate or
pectinate line. Longitudinal folds of the mucosa above the dentate line are known as the columns of Morgagni. For a
distance of about 1 cm above the dentate line, the epithelial lining may be columnar, transitional, or stratified
squamous epithelium; this area is referred to as the transitional or cloacogenic zone. The area above the transitional
zone is lined by columnar epithelium, and the area below the dentate line is lined by squamous epithelium (Fig. 50-3).
This is also the area where the internal hemorrhoidal plexus lies.
6. Figure 50.4. Muscles of the pelvic floor.
Pelvic Floor Muscles
The pelvic floor muscles consist of the levator ani and the iliococcygeal muscle. The levator ani is a broad, thin muscle that forms the floor of the pelvic
cavity and is innervated by the fourth sacral nerve. This muscle has traditionally been considered to consist of three muscles—iliococcygeal,
pubococcygeal, and puborectal. Studies suggest that it consists only of the iliococcygeal and pubococcygeal muscles, and that the puborectal muscle is
actually a part of the deep portion of the external sphincter (3,4). The iliococcygeal muscle arises from the ischial spine and posterior part of the obturator
fascia; it passes downward, backward, and medially and inserts on the last two segments of the sacrum and the anococcygeal raphe (Fig. 50-4). The
pubococcygeal muscle arises from the anterior half of the obturator fascia and the back of the pubis. The fibers of the pubococcygeal muscle are directed
backward, downward, and medially, where they decussate with fibers of the opposite side. The line of decussation is called the anococcygeal raphe (Fig.
50-4). Some fibers that lie more posteriorly are attached directly to the tip of the coccyx and the last segment of the sacrum. This muscle also contributes
fibers to the conjoined longitudinal muscle. The puborectal and levator ani muscles have reciprocal actions; as one contracts, the other relaxes. During
defecation, puborectal relaxation is accompanied by levator ani contraction, which widens the hiatus and elevates the lower rectum and anal canal. When
a person is in an upright position, the levator ani muscle supports the viscera..
7. Perianal and Perirectal Spaces
Surrounding the anorectum are several potential spaces that are normally filled with areolar tissues or fat. These
spaces are clinically important because they are sites where abscesses can form. The perianal space immediately
surrounds the anus. Laterally, the perianal space is contiguous with the subcutaneous fat of the buttocks. Medially, it is
b ound by the anoderm to the level of the dentate line. The ischioanal space is a triangular region below the
levator ani muscle, bound medially by the external sphincter muscle, laterally by the ischium, and inferiorly by the
transverse septum of the ischiorectal fossa (Fig. 50-5). The ischioanal space on each side is filled with fat and contains
the inferior rectal vessels and lymphatics. The deep postanal space connects the ischioanal space on each side
posteriorly and lies between the levator ani muscle above and the anococcygeal ligament below (Fig. 50-6). The deep
postanal space is an important pathway in the formation of abscess; spread from one ischiorectal fossa to the other
may result in a so-called horseshoe abscess. The intersphincteric space lies between the internal and external
sphincter muscles. It is continuous with the perianal space below and extends above into the wall of the rectum. The
supralevator spaces are situated on each side of the rectum above the levator ani (Fig. 50-5). The supralevator spaces
communicate posteriorly and may allow spread of infection cephalad into the retroperitoneum (Fig. 50-6).
Figure 50.5. Anatomy of the perianorectal spaces
(anteroposterior view). Figure 50.6. Anatomy of the perianorectal spaces (lateral
view).
8. Port Placement
Pneumoperitoneum is created using Co2 insufflation of about 100-200ml..Smiling incision taken along
inferior crease of umbilicus. Veress needle is inserted for primary port at elevation angle of 45 degrees
between instrument and body of patient and distal end of veress needle pointed at anus. Thereafter
sites for working ports should be selected appropriately by using transillumination with illuminated
telescope tip to locate avascular area to avoid injury of subcutaneous vessels
9. Rectal Prolapse
• Complete rectal prolapse( procidentia ) :
Full -thickness protrusion of rectum
1st Degree: internal
2nd Degree: visible at anal verge on straining
3rd Degree: external
• Incomplete (Mucosal)
Protrusion of mucosa only, with muscular
layers of rectum remaining in place
15. •This is a prospective clinical study of 14 children managed with LRP (mesh and suture techniques) for PRP
from April 2008 to September 2012.
•The conservative management of nutritional support, bowel habit regulation,and dietary manipulation for
managing the prolapse had failed in all cases hence these cases were referred for surgical intervention.
•12 of the 14 patients were managed with sclerotherapy using ethanolamine oliate injected submucosally in
three to four sittings before being referred to laparoscope rectopexy. Cases with rectal prolapse who did not
respond to conservative management over 1 to 2 years were defined as PRP and were subjected to LRP.
•The decision to operate was based on the age of patient, duration of conservative management (>12
months) and frequency of recurrent prolapse (two or more episodes requiring manual reduction with or
without sedation per month), along with symptoms of pain, rectal bleeding, edema, ulceration, difficult
reduction and recurrent prolapse.
•The record of age, sex, weight, and initial presentation, duration of symptoms, precipitating events and
co-morbidities was maintained. Preoperative evaluation included physical examination, routine laboratory
investigation, plain X-Ray anterior-posterior & lateral view, defecography and proctoscopy in all patients.
The ethical committee approved the technique. Written consent was obtained from the family after full
information about the surgery and the post-operative sequela.
•All children were given enemas on the morning of the surgery. Prophylactic antibiotics were given at the
time of induction of anesthesia.
• All were operated under general anesthesia with endotracheal intubation. After full anesthesia and under
complete sterilization catheter inserted to evacuate the urinary bladder.
Materials and Methods
16. •Supra umbilical transverse skin incision was done for ENDOPATH XCEL port with 5-mm 0˚ scope introduction to the
peritoneum under vision on the laparoscope monitor, then CO2 insufflation to peritoneum up to 12 mmHg intra-abdominal
pressure was operated with hemodynamic and respiratory monitoring by anesthesia.
•Introduction of 5-mm, 30˚ scope at umbilicus port and two 5-mm working ports in mid-clavicular line followed this over the
line joining mid-inguinal point and both costal margins.
•The position of the working ports varied with the child height and abdominal cavity size, ensuring acceptable ergonomics
according to the child body built.
•Trendelenburg position helped in moving away the small bowel from the operative field.
•The rectosigmoid was grasped and mobilized after dividing the right side peritoneal fold starting from the
sacral promontory (Figure 1) and circumferential dissection was made to create a cave between the sacrum and the
rectum with out opening the left peritoneal fold (Figure 2).
•Both the ureters were identified and safe guarded.Rectum was mobilized from the sacral promontory to the lateral
ligaments, and until the surface of the sacrumwas clearly felt with an instrument and continue dissection down to the anal
sphincter (Figure 3).
•The mesh was inserted between the rectum and the sacral surface (Figure 4).
•Rectum was then pulled up and fixed with the presacral fascia. Mesh was fixed on either side of sacral promontory with
two to three (2 cm between each suture in the rectum) seromuscular sutures of PDS size 3/0 using intra-corporeal knotting
(Figure 5).
•Closure of the right peritoneal window with interrupted 3/0 absorbable suture was done to cover the mesh and
close the cavity (Figure 6).
•Patients were kept nil orally till the return of bowel sounds. Postoperatively, stool softeners were routinely prescribed
for at least 4 weeks.
17. Figure 1. Dividing the right side peritoneal fold
starting from the sacral promontory.
Figure 2. Circumferential dissection to create a cave between
the sacrum and the rectum.
18. Figure 3. Dissection continued down to the
anal sphincter.
Figure 4. Mesh was inserted between the
rectum and the sacral surface.
19. Figure 5. Rectum fixed with the pre sacral
fascia, mesh and the bone of sacral promontory of
the sacrum.
Figure 6. Closure of the right peritoneum
reflection.
20.
21. Discussion
• The exact etiology of rectal prolapse in children is unknown. Persistent
Rectal prolapse is thought to be related to several anatomic considerations
such as the vertical configuration of the sacrum, greater mobility of the
sigmoid colon, and aloosely attached rectal mucosa to the underlying
muscularis, and the absence of Houston’s valves in approximately 75% of
infants younger than 1 year of age [1].
• Patients with rectal prolapse have lowered basal and squeeze pressures
with anorectal manometry than normal control subjects [3] [4].
• Rectal prolapse usually presents as a self-limiting disorder in children
younger than 4 years of age [5] [6]. In the pediatric population, the
condition is usually diagnosed by the age of 3 years, with an equal sex
distribution [7].
• Male preponderance has been noted by Shalaby et al. [8] and this study
reaffirmed a male preponderance with 70% of patients being males. Mostly
conservative treatment is successful [6]; however, the prolapse may persist
indefinitely in some children, requiring surgical intervention.
• The percentage of children requiring surgical intervention, eventually, after
failure of conservative management varies from 14% to 20% [9]. Surgery is
indicated in rare cases with intractable rectal prolapse and may be
considered in patients who are not spontaneously cured in 12 - 18 months
of follow-up [9].
22. Discussion (Contd)
• The mean period of conservative management in this study could actually be ascertained as
this study was conducted at a tertiary care hospital, whereas the patients were managed from
the start. However, a trial of at least 12 months of conservative management was given before
the patients were referred to laparoscopic rectopexy.
• Literature is replete with various procedures for this condition, which is a testimony to the lack
of consensus
• over an ideal procedure. Broadly, the operative procedures can be classified as abdominal
[10] or perineal [11]- [15]. Less invasive procedures include injection sclerotherapy [6] [16] [17]
and encircling of the anus [18], with reported success rate of nearly 90% in different series.
• In this study all the above procedures were tried except anal-encircling procedure, which
make our procedure an effective valuable method for management of the persistent rectal
prolapse in children. Abdominal rectopexy is advocated for the recurrent or PRP in children.
• In adults, in a recent meta-analysis comparing outcomes using the laparoscopic technique
with an open procedure, no differences in operative morbidity and recurrence rates were
found [19].
• As experience is being gained in the pediatric cases with the laparoscopic approach, it has
been shown to have good results [9] [20] [21]
23. Discussion (Contd)
• Laparoscopic surgery has the advantages of good accessibility, better visualization of
the narrow pelvic space anatomy during surgery, less post-operative pain, shorter
hospital stay and early recovery, as compared with laparotomy. Apart from these
advantages, the results are similar to those with the open procedures irrespective of
the method used (suture, resection or posterior mesh). Therefore, where expertise is
available, this approach may be preferred [7].
• Koivusalo et al. reported a median operation time of 80 minutes (range 62 - 90
minutes) for LSRP and a median
• hospital time of 6 days (range 3 - 8 days) [9].
• Shalaby et al., in their study, reported the mean duration of surgery as 40 minutes
(range 30 - 55 minutes).
• The mean hospitalization time was 3 days [8]. Experience withLRP in this study
further reinforces these findings; also continuous laparoscopic use will improve the
operative procedure, operative time, and make the hospital stay shorter. The mean
duration of surgery was 30 minutes (range 20 - 60 minutes. No intraoperative
complications were reported. Mean postoperative hospitalization was6 days (range 4
- 10 days).
24. Discussion (Contd)
• The recurrence rates reported for PRP are as much as 6.9% at 5 years and 10.8% at 10 years [8]. Recurrent
• cases can be treated by laparoscopic resection rectopexy with or without mesh [17] [21].
• However, Rintala and Pakarinen prefer laparoscopic suspension of the rectum to anterior sacrum without mesh
and they claimed that this approach is successful in several patients [9]. In this study, after a mean follow-up of 6
months, we had no
• recurrence because the sutures will fix the rectum strongly in the sacral promontory that acted as a dock, while
• the mesh is going to create a port for the rectum to seal over it.
• Koivusalo [9] reported two patients with postoperative constipation. They added that constipation is the only
postoperative problem and is frequently worsened. Shalaby et al. reported only one case of postoperative
constipation out of 52 cases operated with laparoscopic mesh rectopexy [8]. In this study just one case of
postoperative constipation was reported which could be managed conservatively in spite of the longer use of the
post-operative laxative and diet manipulation to prevent the constipation. This stands in stark contrast to high rate
(35%) of postoperative constipation reported earlier by Kariv et al.
• All 14 children were bowel continent at the time of presentation and none of them had any continence issues in
the postoperative setting. Although this is a single center experience without a control group, the results are
satisfactory. Whereas larger randomized control studies are required to secure conclusive evidence for the
superiority of LRP over the conventional open procedure, paucity of PRP cases in a single center remains the
limiting factor. We conclude that LRP is an effective and safe minimal invasive procedure alternative to the open
procedures with similar success rates and no additional complications
25. Results
•Of the 14 children, 10 (71.42%) were males and 4 (28.57%) were females. Male to female ratio
was 2:1. The mean age of presentation was 5 years (range 3 - 8 years).
•The presenting complaints were mass descending per rectum along with bleeding per rectum
lasting from 1 to 3 years. All had rectal prolapse of 5 - 7 cm in length.
•Two children were under neuro-psychiatric treatment and one had walking problem. The two
children under neuro-psychatric treatment were males and weighted 17.4 kg and 18.2 kg at
ages 7 years and 9 years, respectively.
•The child with walking problem was a female aged 6 years and weighted 13.8 kg, which was
below the 5th centile as per NCHS weight for age charts. The remaining 11 out of 14 children
were normal in weight and fell between the 20th and 50th centile by NCHS standards.
•The mean duration of surgery was 30 minutes (range 20 - 60 minutes). No intraoperative
complications were reported. Redundancy of recto-sigmoid was noticed in all patients except
the two with neuropsychiatric problem. Pelvic floor laxity was found in those two cases.
•No intraoperative problems were encountered and no case required conversion. Mean
postoperative hospitalization was 3 days (range 2 - 5 days).
•All were followed up for an average of 10 months (range 4 - 12 months), with no recurrence
reported in any caseduring the follow-up period. One child complained of postoperative
constipation, which improved with dietary manipulation and stool softeners. Also there was no
urinary or fecal control problems in all cases at the follow-up period.
26. References
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28. MERITS
• Laparoscopic surgery has the advantages of good accessibility, better visualization of the narrow pelvic space
anatomy during surgery, less post-operative pain, shorter hospital stay and early recovery, as compared with
laparotomy
• The mean duration of surgery is 30 minutes (range 20 - 60 minutes).
• The mean hospitalization time is 3 days.
• Continuous laparoscopic use improves the operative procedure, operative time, and make the hospital stay
shorter.
• No intraoperative complications have been reported.
• Mean postoperative hospitalization is 6 days (range 4 - 10 days).
• The recurrence rates reported for PRP are as much as 6.9% at 5 years and 10.8% at 10 years.
• Recurrent cases treated by laparoscopic resection rectopexy with or without mesh had no recurrence because the
sutures fixed the rectum strongly in the sacral promontory that acted as a dock, while the mesh created a port for
the rectum to seal over it.
• All 14 children were bowel continent at the time of presentation and none of them had any continence issues in
the postoperative setting.
• In perineal method it is done under local anaesthesia.
• In perineal delorme method, advantages are that it can be done under local/regional anaesthesia. Has lower
morbidity, i.e it avoids laparotomy, & avoid full thickness anastomosis.
• In perineal Altemeier method, advantages are that it can be done under regional anaesthesia and it also avoids
laparotomy.
• In transabdominal rectopexy, it has low recurrence rates of less than 3% post. And less than 10% ant.. It also has
improved incontinence.
• In transabdominal approach by anterior resection, it is a familiar procedure, low recurrence(,10%). No foreign body
• In transabdominal resection rectopexy (Goldberg-Frykman), it has low recurrence 0-5%. Reduces constipation i.e
there is no increase in morbidity with sigmoid resection v/s rectopexy alone.
• In Laparoscopic rectopexy, its advantages are decresed LOS, improved pain control, similar functional outcomes,
and reduced overall costs.
29. Demerits
• This is a single center study without a control group
• Larger randomized control studies are required to secure conclusive evidence for the superiority of Laparoscopic
RectoPexy over the conventional open procedure.
• Paucity of Persistent Rectal Prolapse cases in a single center remains the limiting factor
• In perineal method (Thiersch) it does not correct the underlying problem. Has high recurrence ranging from 7-59%
& complication rate. Also there is breakage of wire, erosion into rectum, sloughing of overlying skin, perineal
sepsis, fecal impaction.
• In perinelal method(Delorme, the disadvantages are that it requires tedious dissection. Has high recurrence of 12-
38%. Reduced improvement in incontinence (25-67%). It also has complications such as mucosal bleeding;
mucosal anastomosis breakdown, mucosal stricture. It is not indicated in children but in elderly with comorbidities.
• In perineal (Altemier method, there is risk of complications such as mesenteric injury, anastomotic leak, & sepsis,
& anastomotic stricture., more importantly it is indicated in elderly/ with comorbidities, young males & in
emergenncy operations.
• In trans abdominal rectopexy, the disadvantages are that it requires laparotomy, so it carries with it the risk of
slower recovery and risk of nerve injury. Its complications are presacral bleeding; fecal impaction from constriction
of lumen. Also carries risk of mesh/sponge infection / erosion into bowel wall leading to pelvic abscesses and
fistulas. More importantly it is indicated in healthy patients with no h/o constipation.
• In transabdominal anterior resection, it has high morbidity with 50% low rectal anastomosis.. It also has a slower
recovery period as well as risk to nerve injury.
• In transabdominal resection rectopexy (Goldberg-Frykman) it requires laparotomy thereby causing slower recovery
& risk of nerve injury. Moreover, there are risk of compllications of presacral bleeding, anastomic leak, pelvic nerve
injury & stricturte. Indicated in healthy patients with constiipation.
• In Laparoscopic Rectopexy only disadvatage is that it’s a longer procedure & requires expertise buyt this can be
overcome easily by shifting the patient in a tertiary care centre.
![INTRODUCTION
• Rectal prolapse is a relatively common, usually self-limiting
illness in children. Peak incidence is between 1 and 3 years
[1] [2].
• It can be partial (protrusion of only mucosa from anal verge)
or complete (full thickness of rectum is involved). The
intervention is required for the Persistent Rectal Prolapse
(PRP).
• Laparoscopic Rectopexy (LRP) is in vogue for adults;
however, only scanty experience is available with this
technique in children.
• In this article the authors have presented their experience with
LRP for PRP at the pediatric surgery unit at the Al-Azhar
University hospital, Nasr City, Cairo, Egypt.](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)