Laparoscopic ventral rectopexy, posterior colporrhaphy and vaginal sacrocolpopexy for the treatment of recto-genital prolapse and mechanical outlet obstruction.

OBJECTIVE: Whilst trans-abdominal fixation +/- resection offers better functional results and lower recurrence than perineal procedures, mesh rectopexy is complicated by constipation. Laparoscopic autonomic nerve-sparing, ventral rectopexy allows correction of the underlying abnormalities of the rectum, vagina, bladder and pelvic floor.

METHOD: A prospective database was used to audit our 7-year experience of this technique. The recto-vaginal septum was mobilized anteriorly to the pelvic floor avoiding nerve damage. A prolene mesh was sutured to the ventral rectum, posterior vagina and vaginal fornix and secured to the sacral promontory. Patients were assessed with questionnaires and Cleveland Clinic scores.

RESULTS: Eighty patients, six males, median age 59 years (range 31-90) underwent laparoscopic prolapse surgery between Jan 1997 and Dec 2005; 55% had full thickness prolapse and 46% rectal anal intussusception. Five had a solitary rectal ulcer. A total of 58% had undergone previous surgery; hysterectomy 33%, posterior colporrhaphy 15%, posterior rectopexy 6%, Delorme's rectal mucosectomy 5% and Birch colposuspension 3%. Half (54%) were incontinent (mean Wexner score 11, range 2-17) and 31% reported symptoms of obstructed defecation; seven had slow transit constipation and underwent resection. The median operative time was 125 min (range 50-210) with one conversion. Median time to diet was 12 h and median length of stay 3 days (1-12). No patient has developed recurrent full thickness prolapse at a median follow-up of 54 months (30-96). Incontinence improved in 39 of 43 patients (91%); median post-operative Wexner score 1 (0-9). Obstructed defecation resolved in 20 of 25 patients (80%). Pelvic pain resolved in all but one. Complications occurred in 21%; faecal impaction 4%, wound infection 2%, bleeding 2%, leak 1%, chest infection 1%, retention 1%. Three developed minor evacuatory difficulties and two, urinary stress incontinence.

CONCLUSION: Laparoscopic ventral rectopexy is safe with relatively low morbidity. In the medium-term, it provides good results for prolapse and associated symptoms of incontinence and obstructed defecation.