Is it enough to resect only the redundant sigmoid colon, or resect the entire sigmoid or anything more?
the need for resection is rare
if it is required, resection of redundant colon is adequate
numbers are too small to be asking for evidence
No need for any resection. rarely redundant sigmoid need resection & anastamosis without tension.
Dear Doctors,
Thanks for your responses. I'm not sure of my senior colleague Dr. Lakshminarayanan's opinion in this matter. I quote Medscape:
"Resection rectopexy is the preferred surgical option and is indicated for patients with complete rectal prolapse associated with chronic constipation. Resection rectopexy has been shown to correct constipation symptoms better than suture rectopexy alone. Other indications for resection rectopexy for rectal prolapse include significant sigmoid diverticular disease and excessively redundant sigmoid (which is at risk of volvulus)."
Some Ref.:
Laubert T, Kleemann M, Schorcht A, Czymek R, Jungbluth T, Bader FG. Laparoscopic resection rectopexy for rectal prolapse: a single-center study during 16 years. Surg Endosc. 2010;24(10):2401-6.
Luukkonen P, Mikkonen U, Jarvinen H. Abdominal rectopexy with sigmoidectomy vs. rectopexy alone for rectal prolapse: a prospective, randomized study. Int J Colorectal Dis. 1992;7(4):219-22.
Roblick UJ, Bader FG, Jungbluth T, Laubert T, Bruch HP. How to do it--laparoscopic resection rectopexy. Langenbecks Arch Surg. 2011;396(6):851-5.
In pt's with rectal prolapse associated with constipation,Resection rectopexy is the preferred procedure in particular if there is also redundent sigmoid.This straightens the colorectal segment and thus helps in reducing the degree of recto rectal intussception.It is usually sufficient if redundant sigmoid is resected.
Laparoscopic Ventral mesh rectopexy is an emerging operation which seems to be a good operation for rectal prolapse. Resection rectopexy is reported to worsen the constipation due to division and disturbance of autonomic nerves and plexuses.
Dr surendra Mantoo,Another important aspect of ventral rectopexy is that it prevents the recto rectal intuscception ,usally the point of origin is in the anterir rectum.please see our video on you tube(profpkreddy)
Thank you Dr Reddy, at my previous centre, we have some experience with ventral mesh rectopexies both laparoscopic and robotic. Here are some references
· Surendra Mantoo, Jerome Rigaud, Sophie Naulet, Paul-Antoine Lehur, Guillaume Meurette. Standardized surgical technique and dedicated operating room environment can reduce the operative time during robotic-assisted surgery for pelvic floor disorders. Journal of Robotic Surgery. Mar 2014, Vol. 8, No. 1: 7-12
· Mantoo S, Podevin J, Regenet N, Rigaud J, Lehur PA, Meurette G. Is robotic-assisted ventral mesh rectopexy superior to laparoscopic ventral mesh rectopexy in the management of obstructed defaecation? Colorectal Dis. 2013 Apr 23.
- Wong M, Meurette G, Abet E, Podevin J, Lehur PA. Safety and efficacy of
laparoscopic ventral mesh rectopexy for complex rectocele. Colorectal Dis. 2011
Sep;13(9):1019-23.
Regards
In my opinion ,resection rectopexy is not necessary without constipation and intusseption.
Dear Dr.Kiper,
My question initially was for patients with constipation
A standard anterior resection but with full posterior mobilization which promotes rectal ampulla sacral fixation will solve the prolapse and resolve the constipation problem. Very concern with prosthetic mesh usage esp in setting of bowel resection!
Dr.Lee, do you recommend a formal anterior resection instead of just sigmoidectomy?
Yes, as you know most Chinese have redundant sigmoid and in our experience the problem is the widening of the presacral space combined with large rectal ampulla, shortening the sigmoid appears soundly but might jeopardize the anastomoses due to tension, thus former anterior resection with a tension free anastomosis in association with a low persacral dissection usually ameliorate further prolapse.
Thanks for that interesting info Dr. Lee. In sigmoidectomy, there is no tension because the 'pexy' is done distal to the anastomotic line.
This is a difficult one. It would be nice to think resection of the sigmoid ensures that constipation is no longer a problem - but this just isn't the case. The operation also exposes the patient to the risk of an anastomosis. A lap ventral mesh Rectopexy is arguably safer (even taking into account the risk of mesh erosion). Constipation after this operation often resolves and if not can be treated appropriately. Perhaps this question could be answered by a carefully constructed multi centre randomised trial?
Dear Dr. Gudgeon,
Thanks for your comment. A multi-center RCT is a good idea, but I'm wondering what exactly to compare............
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