Laparoscopic posterior mesh rectopexy vs laparoscopic suture rectopexy for complete rectal prolapse;

An analysis of outcome measures. A randomized control trial.

Dr Zia Ullah1, Prof Dr Muhammad Zarin 2, Dr Muhammad Imran Khan.3

1. Postgraduate resident surgery Surgical C Ward KTH.(Co-corresponding author)

Email: [email protected] Contact: 03009399344.
2. Professor of surgery Surgical C ward KTH.
Contact: 03339414477
3. Assistant professor Surgery Surgical C Ward KTH.(Corresponding author)
Email: [email protected] Contact: 03339889959
Laparoscopic posterior mesh rectopexy vs laparoscopic suture rectopexy for complete rectal prolapse;
An analysis of outcome measures. A randomized control trial.

Introduction:

Rectal prolapse describes a condition in which the entire layer of the rectal wall protrudes through the
anal canal. It is more commonly found in elderly women. Rectal prolapse is classified into two types:
complete or full-thickness prolapse and incomplete or partial thickness prolapse. Complete prolapse
represents a protrusion of the entire layer of the rectum to the outside of the anus and, thus, shows
concentric folds. Incomplete prolapse is defined as a condition in which the protruding rectal wall is
limited to the inside of the anal canal, which is also referred to as occult rectal prolapse or internal rectal
intussusception. In clinical practice, mucosal prolapse is readily confused with rectal prolapse. Mucosal
prolapse is not a protrusion of the whole layer of the rectal wall, but a portion of the rectal wall or only
the anal mucosa. It should be differentiated because surgical treatment for both is different. 1

The exact etiology is unknown however some predisposing factors are identified which are: deep
rectoviganal pouch in female, rectal intussusception, perineal nerve injury, relaxation of the lateral
ligaments and the inertia of the pelvic floor. 2,3

The most frequent symptoms are protrusion, hemorrhage, frequent bowel movement, and tenesmus. In
the early phase, the protrusion is shown only during defecation, and with time, the protrusion becomes
more frequent and severe. Symptoms, such as coughing or sneezing, are induced during increased
abdominal pressure. Other common symptoms are fecal incontinence and mucous discharge through
the anus. In most patients, decreased resting rectal pressure and relaxation of the anal sphincter cause
the mucous discharge. Hemorrhage occurs frequently in cases in which the prolapsed rectum is left
unreduced. If severe hemorrhage or strangulation is detected, emergency treatments should be
administered. If rectal prolapse is persistent for a long time, urological impairments, such as bladder
stones or urethral stricture, may be associated. Disorders of the pelvic floor, such as bladder prolapse or
uterine prolapse, may also be combined. 4

Number of trans abdominal and perineal surgical techniques have been described for the treatment of
FRP and the choice of treatment varies substantially between countries. 5,6 Trans abdominal procedures
are performed through laparotomy or laparoscopy and often include rectal mesh fixation. These
procedures were thought to provide more effective repairs with lower recurrence rates than perineal
approaches, but recent data suggest that recurrence rates are much higher than previously thought. 7
Perineal approaches can be done in regional or local anesthesia and have been reserved for frail patients
and patients with intussusception and small FRP to lower the risks inherent to laparotomy and general
anesthesia. Recurrence after perineal procedures varies between 0 and 44% (3–5). Improvement in
incontinence and constipation may be higher in patients undergoing abdominal procedures. 8,9

The two most widely adopted abdominal techniques are laparoscopic posterior sutured rectopexy
(LPSR) and laparoscopic ventral mesh rectopexy (LVMR). LVMR was introduced by D’Hoore et al. to
improve functional outcome with low risk of recurrence, but concerns over mesh complications have
prompted alternative methods, such as LPSR, to be used. The main differences between the two
procedures are the method of rectal mobilization and fixation. Unlike LPSR, there is no posterior
dissection in LVMR, in addition, the anterior wall of the rectum is fixed to the sacral promontory with a
mesh.10 Laparoscopic posterior rectopexy (LPR) for the treatment of FRP was introduced in the early
1990s. More recently, anterior laparoscopic rectopexy has gained increasing interest. But there still
consciences among surgeons.11

Rationale of our study:

Our study aim to determine the efficacy of lap posterior mesh rectopexy vs lap posterior suture
rectopexy, as there are limited studies available on comparison of suture rectopexy with lap posterior
mesh rectopexy. Moreover posterior rectopexy is not commonly performed procedure in majority of
centers. There are few national studies with limited sample size.

Objectives:

To determine efficacy of laparoscopic posterior mesh rectopexy vs laparoscopic suture rectopexy for
complete rectal prolapse.

Research question:

What is the success rate of Laparoscopic posterior mesh rectopexy and laparoscopic suture rectopexy
for rectal prolapse?

Hypothesis:

It is hypothesized that laparoscopic posterior mesh rectopexy is more effective then laparoscopic
posterior suture rectopexy.
Variables of interest:

Age, Gender, lap posterior mesh rectopexy, lap posterior suture rectopexy.

Operational definition:

 Rectal prolapse: it is a condition in which the entire layer of the rectal wall protrudes through
the anal canal.
 Lap posterior mesh rectopexy: A procedure use for the treatment rectal prolapse in which
surgeon fix posterior wall of rectum with sacral promontory through proline mesh using
laparoscope.
 Lap posterior suture rectopexy: A procedure in which surgeon fix posterior wall of rectum to
sacral promontory through nylon suture using laparoscopic technique.

Materials and methods:

Study design:

Randomized control trial.

Sittings:

Department of General Surgery, Khyber Teaching Hospital, Peshawar.

Study Duration:

From January 2019 to January 2022

Sample size:

 Sample size was calculated with open epi.

 Confidence level 90%.
 Margin error = 10%
 Power = 70% using success rate of procedure 20% with mesh rectopexy and 10% suture
rectopexy. Estimated sample size is n= 142.

Sampling technique:

Non probability convenience based sampling.

Inclusion criteria:

 Age 20 to 70
 Both gender.
 Patient with full thickness rectal prolapse.
 ASA grade I and II.
 Undergoing laparoscopic rectopexy.

Exclusion criteria:

 Non consenting individuals.

 Pregnant females.
 ASA grade II, IV.
 Lap converted open procedure.
 Hepatitis B , C positive patients with CLD, patients with coagulation disorders, and cardiac
problems rendering them unfit for GA.

Data collection procedure

This study aimed to investigating the long-term follow-up of the RCT that compared functional outcomes
after LPMR versus LPSR in patients with full-thickness rectal prolapse. Patients will be recruited from
Khyber Teaching hospital. The trial methodology, including details relating to the surgical techniques,
will be reported. Patients will be diagnosed based on medical history, clinical examination (including
squatting with valsula manure and DRE for sphincter tone) and relevant investigations including CT scan
abdomen and pelvis and colonoscopy if needed. Demographic data, medical history, and surgical and
follow-up details of the patients will be recorded. Patients will be first evaluated 2 weeks
postoperatively and then will be followed-up for the evaluation of postoperative sequelae and
complications including constipation and recurrence, at 1, 3, 6, and 12 months in the postoperative
period. All those patient who met our inclusion criteria will be divided into two equal groups to undergo
LPMR or LPSR.. Both procedures will be performed according to standard protocols. Data will be
collected on properma specially designed for study

Data analysis:
Data will be analyze on statistical analysis software IBM SPSS 25.Mean ±SD will be presented for
qualitative variables like age and duration of procedure. Frequency and percentage will be computed for
qualitative variables like gender and success rate of procedure. Chi-square will be applied to compare
success rate of lap posterior mesh rectopexy and lap posterior suture rectopexy. P value of ≤ 0.05 will be
consider significant.

Ethical considerations:

Written informed consent will be taken from participants after explaining the procedure . data will be
collected in specially designed proparma .There is no personal identifier included in our data collection
tool. Confidentiality of the data would be maintained. Permission of the head of the department would
be sought before data collection. Data will be kept in password protected computer. 

Conflict of Interest: None.

Funding source: None.

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