# Rectopexy

Rectopexy is a surgical procedure in which the rectum is fixed into the desired position. It is a surgical treatment for rectal prolapse.

## History

Surgical treatment for rectal prolapse may be via perineal or abdominal approach.
Ventral rectopexy was first described in 1984 and was termed the Orr-Loygue procedure. This procedure was modified by D'Hoore in 2004.
Ventral mesh rectopexy has become the most popular option.
An older procedure called posterior mesh rectopexy in which the posterior and lateral surfaces of the rectum were dissected away from... caused autonomic nerve injury, causing further dysfunction and impairment of defecation and rectal motility.

## Indications

* External rectal prolapse which may give symptoms of obstructed defecation syndrome, fecal incontinence or both, Other symptoms are bloody or mucous rectal discharge.
* Internal rectal prolapse (rectal intussusception), if it causes symptoms.
* Anterior rectocele, if large and causing symptoms.

### Posterior sling rectopexy

First described by Wells in 1959. Transabdominal approach is used. The rectum is mobilized posteriorly (at the back) down to the level of levator ani. The anterior (front) surface of the rectum is also dissected, while the lateral (side) stalks (tissue attachments) of the rectum are preserved. This preserves the nerves and reduces problems with constipation as a side effect of the operation. Once the rectum has been mobilized in this manner, a new space between the rectum and the sacrum has been created. A mesh is placed against the inner surface of the sacrum (covered by presacral fascia), behind the rectum. The mesh is secured in the middle by suturing to the presacral fascia. The rectum is stretched cephalad (towards the patient's head), and the lateral edges of the mesh and wrapped around the sides of the rectum. This leaves the mesh in the shape of an incomplete cylinder, and it is fixed to the anterior (front) surface of the rectum. Originally a polyvinyl alcohol sponge was used instead of surgical mesh. A peritoneal fold is then sutured over the mesh, in order to separate it from the abdominal cavity where it would act as a foreign body.

### Resection rectopexy

This procedure is also termed Frykman-Goldberg procedure. The mesorectum is dissected anteriorly (at the front) and posteriorly (at the back) to the level of the pelvic floor, at the level of the upper edge of the external anal sphincter. The lateral ligaments are preserved. The sigmoid colon is removed (sigmoidectomy), and the free ends of the colon are anastomosed (surgically reconnected). The pouch of Douglas (in females) / rectovesical space (in males) is reconstructed by suturing the peritoneum on the right and left of the rectum. The rectum is fixed in place by suturing to the anterior surface of the rectum to the peritoneum (presacral fascia).

## Procedure

There are several variations of surgery which aims to mobilize and fix the rectum back into the desired position.
The approach may be transabdominal, perineal (cochrane review )
Differences include the surgical approach to the prolapsed bowel (transabdominal, open versus laparoscopic, perineal), the method of fixation during the rectopexy (suture or mesh), and the performance of a bowel resection (removal of a portion of the intestine). The choice of synthetic material used to perform the rectopexy may also vary and can include nylon, Teflon, Marlex, Ivalon, Gore‐Tex, Vicryl or Dexon.
The procedure may be carried out via laparoscopic approach or by robotic approach. Laparoscopic approach may be challenging because there is not a lot of space, especially in patients with a narrow pelvis. However, the laparoscopic approach is cheaper. Robotic approach has the benefit of three-dimensional visualization, precise dissection and the possibility of refined, articulated movements suitable for a narrow conical space such as the pelvis.

## Effectiveness
### Mesh Rectopexy versus Resection Rectopexy
### Ventral mesh rectopexy
#### Robotic approach versus laparoscopic approach

One systematic review comparing laparoscopic ventral mesh rectopexy and robotic ventral mesh rectopexy concluded that robotic approach resulted in a longer operation time. However, this may be related to lack of operator experience with the robotic platform, and it has been suggested that a surgeon who is experienced with the robotic approach can perform the operation as fast or faster than a surgeon who is experienced with the laparoscopic approach. The robotic approach resulted in a shorter stay in hospital for patients, which balanced the increased cost of the robotic surgery itself. This may be because robotic surgery is more precise and leads to less bleeding and pain after the procedure. One study showed lower scores for obstructed defecation after robotic approach. In general, both approaches showed improvement in function and quality of life, but some studies reported robotic approach as giving slightly more improvement in quality of life. Both approaches resulted in similar long term outcome and recurrence rates. The review authors concluded that robotic ventral mesh rectopexy is safe and results in at least the same outcomes as laparoscopic approach.