Laparoscopic ventral rectopexy

Over the past decade, laparoscopic ventral rectopexy (LVR) has gained a significant following among colorectal surgeons managing functional anorectal disorders. The minimally invasive nature of laparoscopic surgery reduces perioperative morbidity and length of hospital stay. It is therefore thought useful for elderly and frail patients who might otherwise not have the operation they need. Anterior mobilization of the rectum down to the pelvic floor can readily be performed using the laparoscopic approach. Arguably, LVR provides superior visualization over conventional laparotomy, especially in the deep pelvis. This anterior mobilization also avoids potential autonomic nerve injury associated with posterior rectal mobilization and reduces the risk of postoperative constipation. The use of a mesh in the pelvis to anchor the rectovaginal septum (the rectovesical septum in men) to the sacral promontory provides a form of middle and posterior compartment pelvic floor suspension not available with other techniques of rectopexy. When D’Hoore et al. [1] published their article on LVR in 2004, they reported that in addition to resolution of rectal prolapse, symptoms of obstructed defaecation syndrome (ODS) resolved in 16 of 19 patients. Subsequent to this, more centres have reported successful application of LVR to treat various dyssynergic defaecation presentations, including rectocoele, rectal intussusception and solitary rectal ulcer syndrome (SRUS). Therefore, LVR became a single treatment option for multiple different dyssynergic defaecation problems, except faecal incontinence. Surgeons only needed to master a single technique in order to bring relief to a varied presentation from patients. The results from subsequent reports on LVR have been extremely encouraging. However, LVR for external rectal prolapse alone has equivalent results compared with other laparoscopic techniques for rectal prolapse. In this issue, four different groups of authors have reported their experiences in different aspects of LVR. Formijne Jonkers et al. [2] looked at whether the functional improvement from LVR could be objectively quantified. They used the validated Cleveland Clinic Incontinence Score (CCIS) and Cleveland Clinic Constipation Score (CCCS) to assess patient outcome after LVR for both rectal prolapse and rectocoele. Two-hundred and thirty-three consecutive patients who had undergone LVR for external rectal prolapse, internal rectal prolapse or rectocoele were sent a questionnaire containing both the CCIS and the CCCS questionnaires. Unfortunately, only 150 (64%) patients responded and there was no record of pre-operative CCIS or CCCS data being obtained. Whilst they reported that the number of patients with postoperative constipation or incontinence was significantly reduced, the lack of pre-operative objective scores meant that no meaningful interpretation of the postoperative CCIS and CCCS data could be made. On their own, these results are not of great value. Future studies that compare different surgical techniques in functional anorectal disorders should incorporate preand postoperative objective scores of continence/constipation to allow for more robust interpretation of any results obtained. Powar et al. [3] looked at whether the advantages of laparoscopy could be maximized by assessing the feasibility of same-day discharge after LVR. The authors postulated that these patients would be ideal for a daycase procedure as no rectal resection was performed and surgery was completed laparoscopically with very small wounds. In their experience of 120 patients operated on for rectocoele, internal rectal prolapse and external rectal prolapse, they achieved same-day discharge in 23% of patients, with a mean length of hospital stay of 1.5 days overall. This premise is very enticing and may have a great impact on healthcare delivery as it reduces the bed-occupancy load in overworked hospitals. The challenge will be for other surgeons to replicate this impressive report. Unfortunately, 21% of the patients underwent further procedures, the majority for recurrent symptoms, which appeared rather high. One of the concerns of many surgeons regarding LVR has been the potential complications of using synthetic mesh in the pelvis. Biological meshes are postulated to have a lower risk of erosion or infection and have been used for LVR with some success. Smart et al. [4] performed a systematic review comparing the results of synthetic and biological meshes in LVR. They identified 11 studies involving 767 patients in whom synthetic mesh was used and two studies involving 99 patients in whom biologic mesh was used. By pooling the data from the two groups of patients, they found that the rates of recurrence and of complications caused by the mesh were similar for synthetic and biological meshes. However, it is important to note that the follow up for studies using biological mesh was only 12 months and hence recurrence rates may differ with longer periods of follow up. Whilst no difference for mesh infection was found between synthetic and biological meshes, it is important to note that although there was no infection of biological mesh, there were five out