Abdominal procedures vary with respect to the extent of rectal mobilization, method of rectal fixation, and inclusion or exclusion of bowel resection. During abdominal rectopexy, the mesorectal plane is developed and the rectum mobilized down to the pelvic ﬂoor posteriorly, with care taken to identify and preserve the hypogastric nerves. Division of the lateral ligaments may or may not be performed. The concern is that division of the lateral ligaments will lead to rectal denervation and increased postoperative constipation. If performing a suture rectopexy, the fascia propria of the rectum is secured to the sacral periosteum from S-1 to S-3 (226). If performing a sigmoid resection with the rectopexy (Frykman-Goldberg resection rectopexy), the bowel resection is performed after mobilization and before suturing (227). The theoretical advantages of a rectosigmoid resection are creation of a dense area of fibrosis between the anastomotic suture line and the sacrum; removal of abundant rectosigmoid, avoiding torsion or volvulus; additional fixation through straightening of the left colon and decreased mobility from the phrenocolic ligament; and relief of constipation in select patients. It is typically reserved for patients with a long redundant sigmoid colon, although specific criteria have not been proposed. Mesh rectopexies are usually avoided because of concern for increased complications and infections associated with placement of a foreign body at the time of bowel resection. There are two basic types of mesh rectopexy: posterior mesh rectopexy and anterior sling rectopexy (Rip-stein procedure) (228,229). A variety of materials have been used for this procedure, including absorbable and permanent mesh. The assumption is that placement of this material will provide increased support through increased fibrous tissue formation. During the Ripstein procedure, an anterior sling of fascia lata or synthetic mesh is placed in front of the rectum and sutured to the sacrum. Most surgeons avoid this procedure because of fear of obstructed defecation. Modifications using a posterolateral wrap have been developed to resolve this problem.
In a series of more than 10 patients, there were five open series and five laparoscopic reports for suture rectopexy (230). The recurrence rates ranged between 0% and 9%. Most reports showed an improvement in fecal incontinence symptoms, but the results for constipation were variable. There were no mortalities noted and no difference between laparoscopic and open results. For posterior mesh rectopexy, there were 14 open series and five laparoscopic reports. The recurrence rates ranged between 0% and 6%. As with suture rectopexy, there was general improvement in fecal incontinence, mixed results for constipation, and no differences between laparoscopic and open outcomes. The mortality rate was between 0% and 3%, with increased rates of infection if resection rectopexy was performed. For anterior sling rectopexy (Ripstein procedure), there were eight studies with a recurrence rate between 0% and 12%. Again, there was a trend toward improvement of fecal incontinence and mixed response for constipation. Mortality ranged from 0% to 3%. For resection rectopexy (Frykman-Goldberg procedure), there were nine open series and three laparoscopic reports. Recurrence ranged between 0% and 5%. There was general improvement in continence as well as an overall reduction in constipation observed in most studies. Mortality rate was 0% for all studies but one, in which it was 6.7% (231). This study was a small, randomized trial comparing 15 patients undergoing resection rectopexy to 15 patients undergoing absorbable mesh rectopexy. The patient who died was in the resection group and had a myocardial infarction. The authors concluded that sigmoid resection did not seem to increase operative morbidity but tended to diminish postoperative constipation, possibly by causing less outlet obstruction. The study was underpowered to detect a difference in morbidity or mortality.