Review Surgical Techniques for Rectal Prolapse Sezai Leventoglu 1,*, Bulent Mentes 2, Bengi Balci 3 and Alp Yildiz 4 1 Department of Surgery, Gazi University School of Medicine, Ankara 06570, Turkey 2 Department of Proctology, Ankara Memorial Hospital, Ankara 06520, Turkey; [email protected] 3 Department of Surgery, Ankara Oncology Training and Research Hospital, Ankara 06200, Turkey; [email protected] 4 Department of Surgery, Ankara Yenimahalle Training and Research Hospital, Ankara 06170, Turkey; [email protected] * Correspondence: [email protected]; Tel.:+90-532-446-15-22 Abstract: Complete rectal prolapse or rectal procidentia is a debilitating disease that presents with fecal incontinence, constipation, and rectal discharge. Definitive surgical techniques described for this disease include perineal procedures such as mucosectomy and rectosigmoidectomy, and abdominal procedures such as rectopexy with or without mesh and concomitant resection. The debate over these techniques regarding the lowest recurrence and morbidity rates, and the best functional outcomes for constipation or incontinence, has been going on for decades. The heterogeneity of available studies does not allow us to draw firm conclusions. This article aims to review the surgical techniques for complete rectal prolapse based on the current evidence base regarding surgical and functional outcomes. Citation: Leventoglu, S.; Mentes, B.; Keywords: rectal prolapse; perineal approach; abdominal approach; laparoscopic approach Balci, B.; Yildiz, A. Surgical Techniques for Rectal Prolapse. Gastroenterol. Insights 2021, 12, 310–318. https://doi.org/10.3390/ 1. Introduction gastroent12030028 Complete rectal prolapse or rectal procidentia is defined as a full-thickness protrusion of the rectum through the anal canal, and should be distinguished from the mucosal Academic Editors: Gaetano Gallo, prolapse [1]. Although the definite etiology of this disease is unclear, the most common Ugo Grossi, Atsushi Sakuraba and related pathologies are the redundant sigmoid colon, a deep cul-de-sac, and the diastasis Gaetano Luglio of levator ani muscles [2,3]. The incidence is higher in females, with a peak in the seventh decade [4]. Patients Received: 8 May 2021 usually complain of fecal incontinence, which is thought to be a result of a chronic stretch Accepted: 16 June 2021 Published: 1 July 2021 of the anal sphincter and continuous stimulation of the rectoanal inhibitory reflex by the prolapsed tissue [5,6]. Other symptoms include constipation, pain, bloody or mucous Publisher’s Note: MDPI stays neutral rectal discharge [7]. with regard to jurisdictional claims in The diagnosis can be made by demonstrating the protrusion of the rectal circum- published maps and institutional affil- ferential radial folds with straining maneuvers on clinical examination [7]. However, iations. additional diagnostic tests such as dynamic pelvic magnetic resonance imaging (MRI), anal manometry, and endoanal ultrasonography (EUS) are usually required to detect co-existing anatomical abnormalities and decide on the optimal surgical treatment method [8–12]. Described surgical techniques are varied, and whether the approach is abdominal or perineal, the treatment aims to correct anatomical and functional abnormalities by the Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. fixation of the rectum to the sacrum and/or the resection of the redundant bowel [13]. This article is an open access article In this article, these different techniques are reviewed for their surgical and functional distributed under the terms and outcomes and explained in the technical notes section with figures based on our cases. conditions of the Creative Commons 2. Surgical Techniques Attribution (CC BY) license (https:// As a general consideration, perineal procedures have been associated with reduced creativecommons.org/licenses/by/ complication rates and chosen in frail patients with co-morbidities. However, with recent 4.0/). Gastroenterol. Insights 2021, 12, 310–318. https://doi.org/10.3390/gastroent12030028 https://www.mdpi.com/journal/gastroent Gastroenterol. Insights 2021, 12 311 randomized controlled trials and reviews, perineal and abdominal procedures have been reported to have similar outcomes in expert hands regarding perioperative complications, recurrence rate, and quality of life [14]. A recent Cochrane Database review demonstrated no significant difference in re- currence rates [15], and Mustain et al. reported no difference in terms of postoperative complications between these two approaches [16]. Moreover, Emile et al. revealed that similar recurrence and complication rates were seen, but increased length of hospital stay in perineal procedures and longer operative time in abdominal procedures were noted [17]. 2.1. Abdominal Approach Described techniques, whether rectopexy using a mesh or suture and/or resection, have been proven to be effective and safe via laparoscopy [13]. The laparoscopic approach for rectal prolapse has been associated with shorter hospital stay and less postoperative pain. Moreover, there was no statistical difference in recurrence rates, postoperative constipation, or incontinence scores [18–20]. 2.1.1. Ripstein Procedure (Anterior Mesh Rectopexy) This procedure was first described by Ripstein in 1952 [21]. Reported results ranged from 0 to 13% for recurrence and 0 to 2.8% for mortality, with high complication rates of 33% [22]. Its well-recognized complication was the obstruction and narrowing of the rectum; therefore, patients may complain from newly developed or worsened constipation in the postoperative setting [23]. Laparoscopic anterior mesh rectopexy (LAMR) was reported to have 5.1% morbidity and 3% recurrence rates in a study including 175 consecutive patients [24]. In a review of 12 non-randomized studies, reporting low recurrence rates and favorable functional outcomes in long-term follow-up, LAMR is considered an efficient procedure for complete rectal prolapse [25]. Technical notes: It requires complete rectal mobilization followed by placement of an anterior mesh, fixating the antimesenteric surface and sides of the rectum to the sacral promontory. To achieve a more accurate dissection plane, rectal mobilization should be started from the posterior to the lateral. The anterior mobilization is continued 2–3 cm into the Denonvilier’s fascia. The mesh should be placed in the lower rectum approximately 4–5 cm below the sacral promontory, which results in an anteriorly mesh-wrapped rectum. Then the mesh is fixed with 2-0 prolene sutures to the presacral fascia and to the antimesenteric surface of the rectum [21,26]. 2.1.2. Wells Procedure (Posterior Mesh Rectopexy) With the use of absorbable materials instead of non-absorbable materials, as initially described by Wells, recurrence and complicatons such as pelvic sepsis have been lower with posterior mesh rectopexy [27]. Laparoscopic posterior mesh rectopexy (LPMR) was investigated by several prospec- tive studies [28–30]. Dyrberg et al. reported a recurrence rate of 11%, as well as im- provements in continence and constipation scores (74% and 65%, respectively) [29]. In a comparative study with a mean follow-up of 46 months, recurrence rates were found to be 3%, and this was similar to the laparoscopic ventral mesh rectopexy (LVMR) group, whereas patients with LPMR had less improvement in constipation scores [31]. Technical notes: Historically, an Ivalon sponge (non-absorbable) was used for wrapping around the fully mobilized rectum and then suturing it to the presacral fascia. Because of the high infection rates, this technique has been eventually modified with different meshes and partial mobilization of the rectum on the right and posterior side, which enabled suturing the mesh to the sacral promontory. The rectal mobilization is performed in the mesorectal plane laterally and posteriorly, reaching the level of the pelvic floor, and the anterior dissection is kept limited. The mesh Gastroenterol. Insights 2021, 12 312 is placed in the mid-sacral level, fixated with 2/0 non-absorbable sutures to the presacral fascia, and a loose wrap of <270 around the rectum [32]. 2.1.3. Suture Rectopexy Suture rectopexy was first described by Cutait in 1959, and it aimed to form scar tissue between the rectum and sacrum [33,34]. Presumably, due to extensive rectal mobilization, postoperative constipation rates are increased [15,35]. Laparoscopic suture rectopexy (LSR) has been demonstrated as an efficient procedure for patients with prominent symptoms of incontinence [36,37]. Sahoo et al. revealed that LSR and LPMR have no difference regarding functional outcomes, recurrence, or morbidity [38]. On the other hand, LSR was found to have less improvement in constipation scores and higher recurrence rates than LVMR in a randomized study with a median follow- up of 73 months [39]. Technical notes: This technique requires mobilization of the rectum that varies from limited posterior or anterior to circumferential mobilization. It may include unilateral or bilateral division of the lateral rectal ligaments. After the required mobilization is achieved, the rectum is lifted toward the abdominal wall, and permanent sutures are secured to the right and left sides of the sacral promontory. The sites of sutures should be determined as lateral to hypogastric nerves and medial to ureters [40]. 2.1.4. Frykman-Goldberg Procedure (Resection Rectopexy) In addition to rectopexy, sigmoid resection has been considered effective