Ir J Med Sci DOI 10.1007/s11845-014-1125-0
ORIGINAL ARTICLE
Open versus laparoscopic abdominal rectopexy: an examination of early postoperative outcomes R. Tevlin • A. M. Hanly • A. C. Rogers • J. M. P. Hyland • D. C. Winter • A. E. Brannigan P. R. O’Connell
•
Received: 20 September 2013 / Accepted: 16 April 2014 Ó Royal Academy of Medicine in Ireland 2014
Abstract Background Abdominal rectopexy is used to treat full thickness rectal prolapse and obstructed defecation syndrome, with good outcomes. Use of a laparoscopic approach may reduce morbidity. The current study assessed short-term operative outcomes for patients undergoing laparoscopic or open rectopexy. Methods Rectopexy cases were identified from theater logs in two tertiary referral centers. Patient demographics, intra-operative details and early postoperative outcomes were examined. Results There were 62 patients included over 10 years, a third of whom underwent laparoscopic rectopexy. Laparoscopy was associated with a longer operative time (195.9 versus 129.6 min, p = 0.003), but this did not affect postoperative outcomes, with no significant differences found for complication rates and length of stay between the two groups. Univariable analysis found no influence of laparoscopic approach on the likelihood of postoperative complications, and no factor achieved significance with multivariable analysis. This study included the first laparoscopic cases performed in the involved institutions, and a ‘‘learning curve’’ existed as seen with a decreasing operative duration per case over time (p = 0.002). Conclusions Laparoscopic rectopexy has similar shortterm outcomes to open rectopexy. R. Tevlin (&) A. M. Hanly A. C. Rogers J. M. P. Hyland D. C. Winter P. R. O’Connell Centre for Colorectal Disease, St. Vincent’s University Hospital, Elm Park, Dublin 4, Ireland e-mail: [email protected] R. Tevlin A. E. Brannigan Mater Misericordiae University Hospital, Eccles St, Dublin 7, Ireland
Keywords Laparoscopic Rectopexy Rectal prolapse Obstructed defecation
Introduction Abdominal rectopexy was first described by Pemberton in 1939, and involves suspension and fixation of the rectum [1]. It has since been used to repair full thickness rectal prolapse (FTRP) as well as to restore rectal function in obstructed defecation syndrome (ODS). The optimum surgical strategy for any condition is one which achieves the best results, with the fewest adverse consequences. For decades, perineal repair of FTRP has been considered a safer procedure than abdominal rectopexy, and has been particularly useful in elderly or debilitated patients [2, 3]. However, the technique has been criticized for its poor long-term efficacy, with high recurrence rates [4]. The abdominal approach offers less recurrences, but patients have a higher operative morbidity and mortality. Abdominal rectopexy and perineal rectal resection are also used in ODS management, both with low rates of operative adverse events [5–7], but neither approach claims superiority in long-term outcomes [5, 8]. Laparoscopy offers a minimally invasive option for many colorectal conditions, with good short- and long-term outcomes [9–11]. The limitations of laparoscopy in colorectal surgery include higher perioperative costs and operative time than for open surgery, but these additional costs can be defrayed when improved patient outcomes are considered [12]. Laparoscopic rectopexy may offer a solution for FTRP and ODS that is both safe and effective. The current study assessed short-term operative outcomes for patients with FTRP or ODS undergoing laparoscopic or open rectopexy.
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Ir J Med Sci
Methods
Table 1 Patient characteristics, procedural data and postoperative outcomes
Patient selection A retrospective chart review was performed in departments of colorectal surgery in two tertiary referral centers. Rectopexy cases, both open and laparoscopic, were identified from theatre logs between 1997 and 2011. Patients were included if they had undergone a rectopexy procedure (suture rectopexy/mesh rectopexy/colporectopexy/resection rectopexy) for the management of FTRP or ODS. The patient demographics, indication for surgery, intra-operative details and early postoperative outcomes were examined. The primary outcome studied was length of stay and the secondary outcomes were time to bowel motion and incidence of postoperative complications. Data analysis
Total (n = 62) Patient characteristics Mean age (SD) Female sex
60 (96.77)
Procedural data FTRP as indication
46 (74.19)
Performed laparoscopically
22 (35.48)
Mucosal resection performed Mesh inserted
23 (37.10) 32 (56.61)
Mean minutes operative time (SD)
153.15 (69.8)
Postoperative outcomes Mean days to full diet (SD)
3.4 (3.2)
Mean days to bowel motion (SD)
3.8 (2.8)
Mean days to catheter removal (SD)
1.6 (1.2)
Complications Mean length of stay (SD)
Results were analyzed using Predictive Analytics Software (PASW 18.0.2, SPSS Inc., Chicago, USA). Means were expressed with their standard deviation (SD). Comparative analyses of quantitative data were performed using the chisquared test for categorical variables, the Student’s t test for continuous variables and ANOVA for comparison of more than two means. All tests of significance were twotailed, with p \ 0.05 indicating statistical significance. Univariable logistic regression was used to assess the effects of demographics or procedural information on complications and length of stay, expressed as hazard ratios with 95 % confidence intervals. Variables with p values \0.30 in univariable analysis were included in multivariable logistic regression analysis. Results were considered significant where a HR did not equal 1, the 95 % CI did not cross 1 and the p value was \0.05.
58.8 (17.1)
9 (14.52) 7.0 (3.9)
Percentages are in brackets unless otherwise stated FTRP full thickness rectal prolapse, SD standard deviation
Fig. 1 Study flowchart showing selected cases, indications for surgery and procedural information. ODS obstructed defecation syndrome, FTRP full thickness rectal prolapse
Results Patient characteristics In total, 62 patients underwent rectopexy from 1997 to 2011. The mean age of patients at the time of surgery was 58.8 years (SD 17.1), and only two were male (Table 1). Almost three quarters had the procedure for FTRP, while the remainder were performed for ODS (Fig. 1). Over a third of all procedures were performed laparoscopically. Perioperative antibiotics and low-molecular weight heparin were given in 98.39 %, and a urinary catheter was inserted in 93.55 %. There were no postoperative deaths. Complications occurred in 14.52 %; these included urinary tract infection (n = 3), wound infection (n = 2), bowel obstruction requiring return to theatre (n = 2), a transient
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ischemic attack (n = 1) and rectal hemorrhage requiring transfusion (n = 1), and mean length of stay was 7.0 days (SD 3.9 days). Laparoscopic versus open approach Patients undergoing laparoscopic rectopexy were younger than their open counterparts (50.6 years versus 63.3 years, p = 0.004, Table 2). There was no statistical difference between choice of operative approach between the two diagnostic categories (p = 1.000), nor did the approach influence intra-operative details (mesh insertion, p = 0.434; resection performed, p = 0.104; resection length, p = 0.939). Laparoscopy was associated with a longer operative time (195.9 versus 129.6 min, p = 0.003),
Ir J Med Sci Table 2 Comparison of patient characteristics, procedural data and postoperative outcomes between the laparoscopic and open groups Open rectopexy (n = 40)
Laparoscopic rectopexy (n = 22)
p value
63.3 (16.3)
Female sex
50.6 (15.6)
FTRP as indication Mucosal resection
p value
2.2 (0.5–9.3)
0.290
5.3 (0.8–35.2)
0.084
6.5 (0.4–114.6)
0.271
6.7 (0.3–142.8)
0.223
FTRP as indicationa
1.3 (1.1–1.5)
0.096
Open
2.1 (0.4–11.2) 2.4 (0.6–10.2)
0.471 0.272
1.6 (0.2–14.6)
0.669
Mesh not inserted
0.4 (0.1–2.2)
0.294
0.6 (0.1–7.6)
0.607
Operative time [150 min
3.0 (0.7–13.5)
0.206
5.3 (0.7–37.8)
0.096
22 (100.00)
0.535
30 (75.00)
16 (72.73)
1.000
5 (22.73)
0.104
18 (45.00)
16.1 (4.6)
19 (47.50) 129.6 (40.6)
13 (59.09) 195.9 (90.0)
Procedural data
0.939
Mucosal resection performed
0.434 0.003
Days to full diet (SD)
3.6 (3.7)
3.0 (1.9)
0.424
Days to bowel motion (SD)
4.0 (2.9)
3.5 (2.5)
0.463
Days to catheter removal (SD)
1.8 (1.4)
1.4 (0.6)
0.188
Mean length of stay (SD)
HR (CI)
p value
Male sex
Postoperative outcomes
Complications
HR (CI)
Age over 65
38 (95.00)
15.9 (6.6)
Mesh inserted Minutes of operative time (SD)
Multivariable analysis
0.004
Procedural data
Mean resection length in cm
Univariable analysis
Patient characteristics
Patient characteristics Mean age (SD)
Table 3 Univariable and multivariable analysis of factors leading to postoperative complications
Factors with p values \0.3 were included for multivariate analysis. No factor was significant with multivariate analysis was applied FTRP full thickness rectal prolapse a
7 (17.5) 7.4 (4.3)
2 (9.09) 6.3 (3.0)
0.471
No complications occurred in the ODS group, thus operative indication was not inserted for multivariable analysis
0.254
Percentages are in brackets unless otherwise stated
but this did not affect postoperative outcomes, with no significant differences found for time to resuming diet, bowel function, complication rates and length of stay between the two groups (Table 2). Factors predictive of complications Univariable analysis found no influence of laparoscopic approach on the likelihood of postoperative complications (Table 3). Since no complications occurred in the ODS group, operative indication was not inserted for multivariable analysis. Factors included for multivariable analysis were age over 65, male sex, operative time, and whether a resection was performed or a mesh inserted. No factor achieved significance with multivariable analysis.
Table 4 FTRP subgroup analysis Variable
Laparoscopic (n = 16)
Mean age
50.2 (17.9)
65.3 (17.1)
0.010
5.6 (2.9)
7.6 (4.8)
0.083
166.9 (86.4)
130.8 (44.8)
0.068
Mean length of stay Mean minutes operative time
Open (n = 30)
p value
Mean days to full diet
2.8 (2.0)
3.9 (4.2)
0.219
Mean days to bowel motion
3.0 (2.4)
4.1 (3.3)
0.189
Mean days to catheter removal
1.3 (0.6)
1.9 (1.5)
0.091
Complications (%)
2 (12.50)
7 (23.33)
0.463
SDs are in brackets unless otherwise specified
(Table 4). While the operative time remained higher in the laparoscopic group, the disparity is not significant for this patient cohort (166.9 versus 130.8 min, p = 0.068).
Full thickness rectal prolapse Since patients with ODS were younger and there were no complications in this group, further analysis was performed of the FTRP group alone. Those undergoing laparoscopic surgery were younger but did not illustrate a significant difference in length of stay or early postoperative outcome
Decreased operative duration with procedure proficiency This study included the first laparoscopic cases performed in the two involved institutions, thus the operative time per case was analyzed in chronological order to determine
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Ir J Med Sci
Fig. 2 Chronologic operative times for laparoscopic and open cases The graphs show the operative times in minutes for each consecutive case, grouped by operative approach. Generated linear trendlines are shown in black. The operative time for the open approach has not
changed significantly over time (p = 0.359), while the time to complete a laparoscopic rectopexy shows a significant downward trend (p = 0.002), indicating that the operative time taken for laparoscopic cases decreases with experience
whether a ‘‘learning curve’’ existed. While the operative duration did not change for the open approach, the length of time taken to perform laparoscopic rectopexy decreased significantly with procedural experience (Fig. 2, p = 0.002).
Shorter operative duration leads to decreased postoperative complications such as prolonged ileus or infection, as well as reduced hospital costs [15, 16]. One may infer that following the adaptation period of the new technique, operative duration and thus complications would decrease; however, higher patient numbers would be required to confirm this. The limitations of this study include the small patient number, and the limitations imposed by the retrospective nature of chart review. We were unable to analyze longterm outcomes as many patients were discharged back to primary care.
Discussion Since the first laparoscopic cholecystectomy 20 years ago, the role of laparoscopic surgery as both a diagnostic and therapeutic tool has increased substantially and it now forms an integral part of general surgical practice. The benefits of laparoscopic surgery in terms of faster recovery time, less postoperative pain and fewer wound complications have been demonstrated [9, 12]. The aim of this study was to determine if a laparoscopic approach to rectopexy compared favorably with the open approach in terms of short-term outcomes. The present study found no differences in early postoperative complications between the two groups. This agrees with a meta-analysis of previous studies, which also did not find a significant difference in short-term outcomes between the two groups [13]; however, differs as that study found a significantly shorter hospital stay in those undergoing laparoscopic rectopexy. Laparoscopic rectopexy was associated with a longer theater time than the open approach; this has been described in a meta-analysis of other studies [13]. While the current study shows a significantly higher operative time for laparoscopic cases, it also demonstrates the learning curve frequently associated with the introduction of new operative techniques [14]. Here, the operative duration for laparoscopic rectopexy decreased significantly over time.
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Conclusion Laparoscopic rectopexy is safe and effective as a modality and its short-term outcomes are comparable to open rectopexy; however, there is a paucity of randomized control trials within the literature regarding this subject. The rate of recurrence is fundamentally important, and thus long-term follow-up is required in order to make definite conclusions. Conflict of interest
None.
References 1. Pemberton JD, Stalker LK (1939) Surgical treatment of complete rectal prolapse. Ann Surg 109(5):799–808 2. Ramanujam PS, Venkatesh KS, Fietz MJ (1994) Perineal excision of rectal procidentia in elderly high-risk patients. A ten-year experience. Dis Colon Rectum 37(10):1027–1030 3. Watts JD, Rothenberger DA, Buls JG, Goldberg SM, Nivatvongs S (1985) The management of procidentia. 30 years’ experience. Dis Colon Rectum 28(2):96–102
Ir J Med Sci 4. Riansuwan W, Hull TL, Bast J, Hammel JP, Church JM (2010) Comparison of perineal operations with abdominal operations for full-thickness rectal prolapse. World J Surg 34(5):1116–1122. doi:10.1007/s00268-010-0429-0 5. Tsiaoussis J, Chrysos E, Athanasakis E, Pechlivanides G, Tzortzinis A, Zoras O, Xynos E (2005) Rectoanal intussusception: presentation of the disorder and late results of resection rectopexy. Dis Colon Rectum 48(4):838–844. doi:10.1007/ s10350-004-0850-2 6. Pescatori M (2009) Long-term follow-up of simultaneous abdominoperineal repair of enterorectocele and internal mucosal prolapse. Dis Colon Rectum 52(2):327–335. doi:10.1007/DCR. 0b013e31819a21d8 7. Jayne DG, Schwandner O, Stuto A (2009) Stapled transanal rectal resection for obstructed defecation syndrome: one-year results of the European STARR Registry. Dis Colon Rectum 52(7): 1205–1212. doi:10.1007/DCR.0b013e3181a9120f discussion 1212–1204 8. Kohler K, Stelzner S, Hellmich G, Lehmann D, Jackisch T, Fankhanel B, Witzigmann H (2012) Results in the long-term course after stapled transanal rectal resection (STARR). Langenbeck’s Arch Surg 397(5):771–778. doi:10.1007/s00423012-0920-1 9. Guller U, Jain N, Hervey S, Purves H, Pietrobon R (2003) Laparoscopic vs open colectomy: outcomes comparison based on large nationwide databases. Arch Surg 138(11):1179–1186. doi:10.1001/archsurg.138.11.1179 10. Guillou PJ, Quirke P, Thorpe H, Walker J, Jayne DG, Smith AM, Heath RM, Brown JM (2005) Short-term endpoints of
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conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet 365(9472):1718–1726. doi:10.1016/ S0140-6736(05)66545-2 Kuhry E, Schwenk W, Gaupset R, Romild U, Bonjer J (2008) Long-term outcome of laparoscopic surgery for colorectal cancer: a Cochrane systematic review of randomised controlled trials. Cancer Treat Rev 34(6):498–504. doi:10.1016/j.ctrv.2008.03.011 Delaney CP, Kiran RP, Senagore AJ, Brady K, Fazio VW (2003) Case-matched comparison of clinical and financial outcome after laparoscopic or open colorectal surgery. Ann Surg 238(1):67–72. doi:10.1097/01.sla.0000074967.53451.22 Sajid MS, Siddiqui MR, Baig MK (2010) Open vs laparoscopic repair of full-thickness rectal prolapse: a re-meta-analysis. Colorectal Dis: Off J Assoc Coloproctology G B Irel 12(6):515–525. doi:10.1111/j.1463-1318.2009.01886.x Schlachta CM, Mamazza J, Seshadri PA, Cadeddu M, Gregoire R, Poulin EC (2010) Defining a learning curve for laparoscopic colorectal resections. Dis Colon Rectum 44(2):217–222 Procter LD, Davenport DL, Bernard AC, Zwischenberger JB (2010) General surgical operative duration is associated with increased risk-adjusted infectious complication rates and length of hospital stay. J Am Coll Surg 210(1):60–65. doi:10.1016/j. jamcollsurg.2009.09.034 e61–e62 Solomon MJ, Young CJ, Eyers AA, Roberts RA (2002) Randomized clinical trial of laparoscopic versus open abdominal rectopexy for rectal prolapse. Br J Surg 89(1):35–39. doi:10. 1046/j.0007-1323.2001.01957.x
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ORIGINAL ARTICLE
Open versus laparoscopic abdominal rectopexy: an examination of early postoperative outcomes R. Tevlin • A. M. Hanly • A. C. Rogers • J. M. P. Hyland • D. C. Winter • A. E. Brannigan P. R. O’Connell
•
Received: 20 September 2013 / Accepted: 16 April 2014 Ó Royal Academy of Medicine in Ireland 2014
Abstract Background Abdominal rectopexy is used to treat full thickness rectal prolapse and obstructed defecation syndrome, with good outcomes. Use of a laparoscopic approach may reduce morbidity. The current study assessed short-term operative outcomes for patients undergoing laparoscopic or open rectopexy. Methods Rectopexy cases were identified from theater logs in two tertiary referral centers. Patient demographics, intra-operative details and early postoperative outcomes were examined. Results There were 62 patients included over 10 years, a third of whom underwent laparoscopic rectopexy. Laparoscopy was associated with a longer operative time (195.9 versus 129.6 min, p = 0.003), but this did not affect postoperative outcomes, with no significant differences found for complication rates and length of stay between the two groups. Univariable analysis found no influence of laparoscopic approach on the likelihood of postoperative complications, and no factor achieved significance with multivariable analysis. This study included the first laparoscopic cases performed in the involved institutions, and a ‘‘learning curve’’ existed as seen with a decreasing operative duration per case over time (p = 0.002). Conclusions Laparoscopic rectopexy has similar shortterm outcomes to open rectopexy. R. Tevlin (&) A. M. Hanly A. C. Rogers J. M. P. Hyland D. C. Winter P. R. O’Connell Centre for Colorectal Disease, St. Vincent’s University Hospital, Elm Park, Dublin 4, Ireland e-mail: [email protected] R. Tevlin A. E. Brannigan Mater Misericordiae University Hospital, Eccles St, Dublin 7, Ireland
Keywords Laparoscopic Rectopexy Rectal prolapse Obstructed defecation
Introduction Abdominal rectopexy was first described by Pemberton in 1939, and involves suspension and fixation of the rectum [1]. It has since been used to repair full thickness rectal prolapse (FTRP) as well as to restore rectal function in obstructed defecation syndrome (ODS). The optimum surgical strategy for any condition is one which achieves the best results, with the fewest adverse consequences. For decades, perineal repair of FTRP has been considered a safer procedure than abdominal rectopexy, and has been particularly useful in elderly or debilitated patients [2, 3]. However, the technique has been criticized for its poor long-term efficacy, with high recurrence rates [4]. The abdominal approach offers less recurrences, but patients have a higher operative morbidity and mortality. Abdominal rectopexy and perineal rectal resection are also used in ODS management, both with low rates of operative adverse events [5–7], but neither approach claims superiority in long-term outcomes [5, 8]. Laparoscopy offers a minimally invasive option for many colorectal conditions, with good short- and long-term outcomes [9–11]. The limitations of laparoscopy in colorectal surgery include higher perioperative costs and operative time than for open surgery, but these additional costs can be defrayed when improved patient outcomes are considered [12]. Laparoscopic rectopexy may offer a solution for FTRP and ODS that is both safe and effective. The current study assessed short-term operative outcomes for patients with FTRP or ODS undergoing laparoscopic or open rectopexy.
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Ir J Med Sci
Methods
Table 1 Patient characteristics, procedural data and postoperative outcomes
Patient selection A retrospective chart review was performed in departments of colorectal surgery in two tertiary referral centers. Rectopexy cases, both open and laparoscopic, were identified from theatre logs between 1997 and 2011. Patients were included if they had undergone a rectopexy procedure (suture rectopexy/mesh rectopexy/colporectopexy/resection rectopexy) for the management of FTRP or ODS. The patient demographics, indication for surgery, intra-operative details and early postoperative outcomes were examined. The primary outcome studied was length of stay and the secondary outcomes were time to bowel motion and incidence of postoperative complications. Data analysis
Total (n = 62) Patient characteristics Mean age (SD) Female sex
60 (96.77)
Procedural data FTRP as indication
46 (74.19)
Performed laparoscopically
22 (35.48)
Mucosal resection performed Mesh inserted
23 (37.10) 32 (56.61)
Mean minutes operative time (SD)
153.15 (69.8)
Postoperative outcomes Mean days to full diet (SD)
3.4 (3.2)
Mean days to bowel motion (SD)
3.8 (2.8)
Mean days to catheter removal (SD)
1.6 (1.2)
Complications Mean length of stay (SD)
Results were analyzed using Predictive Analytics Software (PASW 18.0.2, SPSS Inc., Chicago, USA). Means were expressed with their standard deviation (SD). Comparative analyses of quantitative data were performed using the chisquared test for categorical variables, the Student’s t test for continuous variables and ANOVA for comparison of more than two means. All tests of significance were twotailed, with p \ 0.05 indicating statistical significance. Univariable logistic regression was used to assess the effects of demographics or procedural information on complications and length of stay, expressed as hazard ratios with 95 % confidence intervals. Variables with p values \0.30 in univariable analysis were included in multivariable logistic regression analysis. Results were considered significant where a HR did not equal 1, the 95 % CI did not cross 1 and the p value was \0.05.
58.8 (17.1)
9 (14.52) 7.0 (3.9)
Percentages are in brackets unless otherwise stated FTRP full thickness rectal prolapse, SD standard deviation
Fig. 1 Study flowchart showing selected cases, indications for surgery and procedural information. ODS obstructed defecation syndrome, FTRP full thickness rectal prolapse
Results Patient characteristics In total, 62 patients underwent rectopexy from 1997 to 2011. The mean age of patients at the time of surgery was 58.8 years (SD 17.1), and only two were male (Table 1). Almost three quarters had the procedure for FTRP, while the remainder were performed for ODS (Fig. 1). Over a third of all procedures were performed laparoscopically. Perioperative antibiotics and low-molecular weight heparin were given in 98.39 %, and a urinary catheter was inserted in 93.55 %. There were no postoperative deaths. Complications occurred in 14.52 %; these included urinary tract infection (n = 3), wound infection (n = 2), bowel obstruction requiring return to theatre (n = 2), a transient
123
ischemic attack (n = 1) and rectal hemorrhage requiring transfusion (n = 1), and mean length of stay was 7.0 days (SD 3.9 days). Laparoscopic versus open approach Patients undergoing laparoscopic rectopexy were younger than their open counterparts (50.6 years versus 63.3 years, p = 0.004, Table 2). There was no statistical difference between choice of operative approach between the two diagnostic categories (p = 1.000), nor did the approach influence intra-operative details (mesh insertion, p = 0.434; resection performed, p = 0.104; resection length, p = 0.939). Laparoscopy was associated with a longer operative time (195.9 versus 129.6 min, p = 0.003),
Ir J Med Sci Table 2 Comparison of patient characteristics, procedural data and postoperative outcomes between the laparoscopic and open groups Open rectopexy (n = 40)
Laparoscopic rectopexy (n = 22)
p value
63.3 (16.3)
Female sex
50.6 (15.6)
FTRP as indication Mucosal resection
p value
2.2 (0.5–9.3)
0.290
5.3 (0.8–35.2)
0.084
6.5 (0.4–114.6)
0.271
6.7 (0.3–142.8)
0.223
FTRP as indicationa
1.3 (1.1–1.5)
0.096
Open
2.1 (0.4–11.2) 2.4 (0.6–10.2)
0.471 0.272
1.6 (0.2–14.6)
0.669
Mesh not inserted
0.4 (0.1–2.2)
0.294
0.6 (0.1–7.6)
0.607
Operative time [150 min
3.0 (0.7–13.5)
0.206
5.3 (0.7–37.8)
0.096
22 (100.00)
0.535
30 (75.00)
16 (72.73)
1.000
5 (22.73)
0.104
18 (45.00)
16.1 (4.6)
19 (47.50) 129.6 (40.6)
13 (59.09) 195.9 (90.0)
Procedural data
0.939
Mucosal resection performed
0.434 0.003
Days to full diet (SD)
3.6 (3.7)
3.0 (1.9)
0.424
Days to bowel motion (SD)
4.0 (2.9)
3.5 (2.5)
0.463
Days to catheter removal (SD)
1.8 (1.4)
1.4 (0.6)
0.188
Mean length of stay (SD)
HR (CI)
p value
Male sex
Postoperative outcomes
Complications
HR (CI)
Age over 65
38 (95.00)
15.9 (6.6)
Mesh inserted Minutes of operative time (SD)
Multivariable analysis
0.004
Procedural data
Mean resection length in cm
Univariable analysis
Patient characteristics
Patient characteristics Mean age (SD)
Table 3 Univariable and multivariable analysis of factors leading to postoperative complications
Factors with p values \0.3 were included for multivariate analysis. No factor was significant with multivariate analysis was applied FTRP full thickness rectal prolapse a
7 (17.5) 7.4 (4.3)
2 (9.09) 6.3 (3.0)
0.471
No complications occurred in the ODS group, thus operative indication was not inserted for multivariable analysis
0.254
Percentages are in brackets unless otherwise stated
but this did not affect postoperative outcomes, with no significant differences found for time to resuming diet, bowel function, complication rates and length of stay between the two groups (Table 2). Factors predictive of complications Univariable analysis found no influence of laparoscopic approach on the likelihood of postoperative complications (Table 3). Since no complications occurred in the ODS group, operative indication was not inserted for multivariable analysis. Factors included for multivariable analysis were age over 65, male sex, operative time, and whether a resection was performed or a mesh inserted. No factor achieved significance with multivariable analysis.
Table 4 FTRP subgroup analysis Variable
Laparoscopic (n = 16)
Mean age
50.2 (17.9)
65.3 (17.1)
0.010
5.6 (2.9)
7.6 (4.8)
0.083
166.9 (86.4)
130.8 (44.8)
0.068
Mean length of stay Mean minutes operative time
Open (n = 30)
p value
Mean days to full diet
2.8 (2.0)
3.9 (4.2)
0.219
Mean days to bowel motion
3.0 (2.4)
4.1 (3.3)
0.189
Mean days to catheter removal
1.3 (0.6)
1.9 (1.5)
0.091
Complications (%)
2 (12.50)
7 (23.33)
0.463
SDs are in brackets unless otherwise specified
(Table 4). While the operative time remained higher in the laparoscopic group, the disparity is not significant for this patient cohort (166.9 versus 130.8 min, p = 0.068).
Full thickness rectal prolapse Since patients with ODS were younger and there were no complications in this group, further analysis was performed of the FTRP group alone. Those undergoing laparoscopic surgery were younger but did not illustrate a significant difference in length of stay or early postoperative outcome
Decreased operative duration with procedure proficiency This study included the first laparoscopic cases performed in the two involved institutions, thus the operative time per case was analyzed in chronological order to determine
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Ir J Med Sci
Fig. 2 Chronologic operative times for laparoscopic and open cases The graphs show the operative times in minutes for each consecutive case, grouped by operative approach. Generated linear trendlines are shown in black. The operative time for the open approach has not
changed significantly over time (p = 0.359), while the time to complete a laparoscopic rectopexy shows a significant downward trend (p = 0.002), indicating that the operative time taken for laparoscopic cases decreases with experience
whether a ‘‘learning curve’’ existed. While the operative duration did not change for the open approach, the length of time taken to perform laparoscopic rectopexy decreased significantly with procedural experience (Fig. 2, p = 0.002).
Shorter operative duration leads to decreased postoperative complications such as prolonged ileus or infection, as well as reduced hospital costs [15, 16]. One may infer that following the adaptation period of the new technique, operative duration and thus complications would decrease; however, higher patient numbers would be required to confirm this. The limitations of this study include the small patient number, and the limitations imposed by the retrospective nature of chart review. We were unable to analyze longterm outcomes as many patients were discharged back to primary care.
Discussion Since the first laparoscopic cholecystectomy 20 years ago, the role of laparoscopic surgery as both a diagnostic and therapeutic tool has increased substantially and it now forms an integral part of general surgical practice. The benefits of laparoscopic surgery in terms of faster recovery time, less postoperative pain and fewer wound complications have been demonstrated [9, 12]. The aim of this study was to determine if a laparoscopic approach to rectopexy compared favorably with the open approach in terms of short-term outcomes. The present study found no differences in early postoperative complications between the two groups. This agrees with a meta-analysis of previous studies, which also did not find a significant difference in short-term outcomes between the two groups [13]; however, differs as that study found a significantly shorter hospital stay in those undergoing laparoscopic rectopexy. Laparoscopic rectopexy was associated with a longer theater time than the open approach; this has been described in a meta-analysis of other studies [13]. While the current study shows a significantly higher operative time for laparoscopic cases, it also demonstrates the learning curve frequently associated with the introduction of new operative techniques [14]. Here, the operative duration for laparoscopic rectopexy decreased significantly over time.
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Conclusion Laparoscopic rectopexy is safe and effective as a modality and its short-term outcomes are comparable to open rectopexy; however, there is a paucity of randomized control trials within the literature regarding this subject. The rate of recurrence is fundamentally important, and thus long-term follow-up is required in order to make definite conclusions. Conflict of interest
None.
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