The laparoscopic series demonstrated similar safety and efficacy to the open techniques, and the effect on continence and constipation tended to mirror the type of rectopexy performed.
In a small, randomized trial, there were significant short-term benefits with laparoscopic rectopexy compared with open rectopexy, including earlier ambulation, more rapid return to normal diet, shorter hospital stay, and lower morbidity (232). Most surgeons believe that there are no differences in recurrence rates between suture and mesh rectopexy. Consequently, the role of mesh in these procedures is suspect. The role of division of the lateral ligaments is somewhat controversial. A Cochrane review performed in 2008 concluded that division of the lateral ligaments was associated with less recurrent prolapse but more postoperative constipation (233). The authors acknowledged the limitations of their review, which consisted of very few trials with small sample sizes and methodological weakness. A review of seven open and four laparoscopic series involving division of the lateral ligaments revealed a general improvement in fecal incontinence and either no change or worsening of constipation (230). Conversely, there were 15 open and 4 laparoscopic series with preservation of the ligaments that displayed improved continence and a trend toward reduced constipation. This study suggests that preservation of the lateral ligaments is associated with an improvement in fecal incontinence and constipation symptoms.
Perineal procedures are more easily tolerated because they avoid laparotomy. Thus, they are ideal for patients at high risk for perioperative and postoperative morbidity and mortality. There are basically two perineal procedures: the Delorme procedure and perineal rectosigmoidectomy (Altemeier operation). Perianal encirclement procedures such as the Thiersch procedure are not recommended because of poor success rates, high recurrence rates, and fecal impaction.
The Delorme procedure was first described in 1900 and involves separation of the rectal mucosa from the sphincter and muscularis propria, followed by resection of the rectal mucosa and plication of the distal rectal wall (muscularis propria) (234) (Fig. 28.9). A review of 10 series found a recurrence rate ranging between 4% and 38% and mortality rates of 0% to 4% (230).The low mortality rates are impressive considering the higher-risk population; however, the recurrence rates make it a less desirable procedure among healthy patients. There was a general improvement in fecal incontinence and constipation. Fecal incontinence (presumably indicating anal sphincter disruption or denervation), chronic diarrhea, and severe perineal descent are associated with failure of this procedure (235). The Delorme operation may be preferred in cases when the prolapsing segment is shorter than 3 to 4 cm or there is no circumferential full-thickness prolapse, making perineal rectosigmoidectomy difficult to perform (230,236).
Figure 28.9 Delorme’s procedure. After mucosal stripping to the full extent of the prolapse, the circular smooth muscle or the rectum is plicated. A mucosa-to-mucosa anastomosis is then performed.