Ventral rectopexy

Ventral rectopexy is a surgical procedure for external rectal prolapse, internal rectal prolapse (rectal intussusception), and sometimes other conditions such as rectocele, obstructed defecation syndrome, or solitary rectal ulcer syndrome. The rectum is fixed into the desired position, usually using a biological or synthetic mesh which is attached to the sacral promontory. The effect of the procedure is correction of the abnormal descended position of the posterior compartment of the pelvis (i.e., the rectum), reinforcement of the anterior (front) surface of the rectum, and elevation of the pelvic floor. In females, the rectal-vaginal septum is reinforced, and there may be an opportunity to simultaneously correct any prolapse of the middle compartment (i.e., the uterus). In such cases, ventral rectopexy may be combined with sacrocolpopexy. The surgery is usually performed laparoscopically (via small openings made in the abdomen).

There are over 300 different variations of surgical procedures described for rectal prolapse, and this area has seen rapid development. However, there is no clear consensus regarding the best method. Surgical treatment for rectal prolapse may be via the perineal or abdominal (transabdominal/peritoneal) approach. Generally speaking, perineal procedures have less complications but higher rates of recurrence compared to abdominal procedures. Ventral rectopexy falls into the abdominal procedure category, and can be considered as a type of abdominal rectopexy.

Abdominal rectopexy encompasses several procedures which involve mobilization and fixation of the rectum, with or without resection, via an abdominal surgical approach. Some of types of abdominal rectopexy are now rarely or never performed. For example, the Ripstein rectopexy (anterior fixation of mesh below the sacral promontory) and the Wells procedure (involving detachment of the lateral ligaments of the rectum) are not longer performed. Risks associated with abdominal rectopexy procedures include post-operative problems with defecation such as new or worsened constipation, obstructed defecation or fecal incontinence. In males, mobilization of the rectum may risk the development of erectile dysfunction. New or worsened constipation does not seem to be a significant problem with ventral rectopexy, which represents the most recent development of abdominal rectopexy.

Another way of categorizing surgery for prolapse of pelvic organs is into suspensive or resective (involving removal of sections of the bowel wall) classifications. Ventral rectopexy alone is a suspensive type surgery, a category which also includes colposacropexy. Resection rectopexy additionally involves removal of a section of the sigmoid colon (sigmoidectomy). It is thought to have decreased post operative problems of constipation, because the redundant colon is removed and therefore cannot "kink". However, there is no evidence that this improves the outcomes, and the necessary creation of an anastomosis (surgically created joining between two ends of bowel when a section of bowel is removed) increases the risk of severe complications.

Ventral rectopexy with an autologous graft (fascia lata), and then with a synthetic mesh for external rectal prolapse was first reported in 1971. The Orr-Loygue procedure (lateral mesh rectopexy) was described in 1984. The Orr-Loygue procedure involved anterior and posterior mobilization of the rectum to the level of the levator ani muscle and removal of the pouch of Douglas. Mesh was sutured to the lateral surfaces (sides) of the rectum.

Ventral rectopexy was developed as a modification of the Orr-Loygue procedure by D'Hoore in 2004. In ventral rectopexy, there is no posterior dissection and mobilization of the rectum apart from to expose the sacral promontory. With no posterior (dorsal) or lateral dissection, damage to the autonomic nerves is minimized. As a result, there are less problems with post-operative constipation. According to one source, there is no excision of the pouch of Douglas, but another source states that ventral mesh rectopexy results in elimination of the pouch of Douglas. The mesh is placed directly onto the anterior (ventral) surface of the rectum. This procedure aims to suspend the middle and lower sections of the rectum. This modified procedure is now known as the anterior rectopexy or ventral rectopexy. D'Hoore also used a laparoscopic approach (laparoscopic ventral mesh rectopexy, LVMR).

After 2002, the minimally invasive trans-anal approach known as stapled trans-anal rectal resection (STARR) became popular for treating obstructed defecation syndrome. However, over time, there has been a general trend away from STARR towards abdominal rectopexy for surgical treatment of obstructed defecation syndrome.

Ventral mesh rectopexy has become one of the most popular options for rectal prolapse. Ventral rectopexy also provides the opportunity to simultaneously correct any prolapse of the middle compartment of the pelvis, and is sometimes combined with sacrocolpopexy. Some have called for caution with regards to the rapid rise in popularity of ventral mesh rectopexy, citing lack of high quality evidence and concerns about long term efficacy and possible mesh related complications. One author described laparoscopic ventral mesh rectopexy as a possible "bandwagon" phenomenon because there has been overwhelming acceptance of the procedure, despite it being a relatively unproven idea which may eventually be proven valid, or may be abandoned in future.