Robotic ventral rectopexy: Initial experience in an Indian tertiary health-care centre and review of literature.

BACKGROUND: Minimally invasive ventral rectopexy is a well-described technique for management of rectal prolapse. Robotic system has proven its advantage for surgeries in the pelvis. Applying this technique, ventral rectopexy can be done more precisely with minimal recurrence. With growing experience, the operative duration and cost of robotic ventral rectopexy can be reduced with better outcome. Few case studies have been described in literature with no study from Indian subcontinent. We describe a series of eight cases of robotic ventral rectopexy done for rectal prolapse in a tertiary health-care centre of India.
METHODS: A total of 8 patients were operated for complete rectal prolapse during the period from August 2015 to April 2016. da Vinci Si robotic surgical system was used with prolene or permacol mesh for ventral rectopexy. All patients were prospectively followed for a period minimum of 3 months. Pre- and intra-operative findings were recorded along with post-operative outcome.
RESULTS: Out of eight patients, prolene mesh was used in five patients and permacol mesh (porcine collagen) in three patients. Mean operative time (console time) was 177 min and mean total time was 218 min. Mean blood loss was 23.7 ml. Functional outcome was satisfactory in all patients. There was no significant complication in any patient with mean hospital stay of 2.2 days. With average follow-up of 8.8 months, no patient had recurrence.
CONCLUSION: Robotic ventral rectopexy is a safe technique for rectal prolapse with excellent result in terms of functional outcome, recurrence and complications. With experience, the duration and cost can be comparable to laparoscopic technique.

INTRODUCTION

Abdominal rectopexy for complete rectal prolapse was initially described by Ripstein in 1952. Since then, various modifications of the technique have been done. Amongst numerous procedures, minimally invasive ventral rectopexy is a well-described technique for management of rectal prolapse. Robotic system has proven its advantage for surgeries in pelvis particularly related to colorectal diseases. Applying this technique, ventral rectopexy can be done more precisely with minimal recurrence.[12] Duration of surgery, hospital stay, complications and cost of the robotic procedure have been discussed in various studies. With growing experience, the operative duration and cost of robotic ventral rectopexy can be reduced with better outcome.[34] Few case studies have been described in literature with no study from Indian subcontinent.[5] We describe a series of eight cases of robotic ventral rectopexy done for rectal prolapse in a tertiary health-care centre of India.

METHODS

It is a prospective, observational study which was carried out during the period from August 2015 to April 2016. All patients diagnosed to have complete rectal prolapse in the Department of Colorectal Unit were considered to be included in this study. They were explained about robotic ventral rectopexy and those who opted for it were included. Other patients underwent laparoscopic rectopexy. Out of 11 patients, 8 patients agreed for robotic surgery, 2 opted laparoscopic procedure and 1 patient refused surgery. Detail findings and parameters of all eight patients were noted. da Vinci Si robotic surgical system was used for the eight cases mentioned. Rectopexy was done using either prolene or permacol mesh. Permacol mesh is an absorbable mesh prepared from porcine dermal collagen. It was preferred in cases with prior history of pelvic sepsis. Port placement was done as shown in picture, supraumbilical port for camera and two lateral ports at 10 cm distance on either sides for the robotic arms [Figure 1]. Additional one or two lateral ports were placed for retraction by assistant. Dissection was done using robotic arm anterior to rectum. Mesh fixation was done anteriorly over rectum with PDS or Ethibond sutures three on either side [Figure 2]. Proximal end of the mesh was brought onto the sacral promontory and fixed to it using ProTack tacker. Peritoneum was closed by V-lock absorbable suture [Figure 3]. Post-operative recovery and complications (if any) were recorded. The first visit after discharge was at 30 days and all patients were prospectively followed for a period minimum of 3 months.

Figure 1

Port placement for robotic ventral rectopexy

Figure 2

Robotic mesh fixation

Figure 3

Peritoneal closure over mesh

RESULTS

All eight patients were male with mean age of 30.1 years (ranging from 19 to 43 years). One patient had hypertension and all other patients were without any comorbid illness. Two patients had prior surgery for rectal prolapse. Out of eight patients, prolene mesh was used in five patients and permacol mesh in three patients [Table 1]. Mean operative time (console time) was 177 min and mean total time was 218 min. Mean blood loss was 23.7 ml. No intraoperative untowards event was found in any case. Oral feeding was started 6–8 h after the procedure. All patients were ambulatory 12–18 h after surgery. Average hospital stay was 2.2 days (ranging from 2 to 3 days). Average duration for first bowel movement was 2 days (ranging from 1 to 3 days). Two patients had significant low backache which resolved by 1 week. One of these patients was with history of three surgeries for rectal prolapse before robotic rectopexy. Functional outcome was satisfactory in all patients without any recurrence in the mentioned follow-up period. There was no other significant complication in any patient. With average follow-up of 8.8 months, no patient had recurrence of prolapse.

Table 1

Robotic ventral rectopexy

DISCUSSION

Laparoscopic approach to rectal prolapse has become popular with increased expertise in laparoscopic colorectal procedures. Gurland et al. discussed the advantage and simplicity of ventral rectopexy where the chance of damage to pelvic nerves is minimal with good functional outcome.[6] All our cases underwent ventral rectopexy using robotic surgical system. Randomised trials by Byrne et al. showed lower cost with better outcome by laparoscopic approach than open surgery.[7] With increased use of robotics for colorectal surgery, robotic rectopexy has become an established option for the management of complete rectal prolapse.

All our cases were young male patients unlike studies from Western countries where they are predominantly elder females.[5] This may be due to lack of awareness and impact of social system in developing countries like India.

Amongst the first few case series, Munz et al. reported robotic rectopexy in six patients.[8] The mean hospital stay was 6 days which is higher than the stay in recent series including ours (2.2 days). Subsequently, in 2007, Heemskerk et al. published a comparative study of robotic rectopexy with conventional laparoscopic technique. In his study, nine cases were in robotic group where the average operating time was 152 min with average hospital stay as 3.5 days.[3]

A case-control study by de Hoog et al. compared all three techniques (open, laparoscopic, robotic). Average operating time by robotic procedure was 157 ± 47 min. Functional outcome and recurrence rate were not different amongst these techniques.[9] Our average operating time was 218 min including console time. It was slightly higher because of inclusion of complex cases with prior surgeries.

Mäkelä-Kaikkonen et al. discussed the advantage of robotic ventral rectopexy in twenty patients with minimum follow-up of 3 months. Mean theatre time was 234 min which is slightly higher than ours. Blood loss and complications were not different in either group (laparoscopic vs. robotic). One patient had recurrence of prolapse in laparoscopic group, whereas none had in robotic group.[10] We did not have any recurrence with an average follow-up of 8.8 months. In our study, there was no major complication except minor issues such as low backache in two patients. The average blood loss in our robotic rectopexy cases was 23.7 ml, which is almost the same (25 ml) as the above study.

Study with short-term follow-up (up to 12 months) has shown better outcome with lesser complications in robotic rectopexy patients.[11] In this study by Mehmood et al., pre- and post-operative Wexner and Fecal Incontinence Severity Index scoring were statistically significantly lower in the robotic group (P = 0.042 and P = 0.024, respectively). Similarly, short form-36 questionnaires showed better scoring in physical and emotional component in this group (P = 0.015). Furthermore, study with long-term follow-up (52.5 months) has shown effectiveness of robotics without significant complication or recurrence.[12]

Systematic review and meta-analysis showed decreased intraoperative blood loss, the post-operative complications and the hospital stay which can be reflected in our study. The recurrence rate and conversion rate are similar to laparoscopic rectopexy.[5] Apart from the advantages mentioned, robotic ventral rectopexy can be offered to patients who have previous failed procedures. We have done robotic ventral rectopexy for two patients with prior surgeries for rectal prolapse.

The main disadvantage of robotic rectopexy is its higher costs related to purchase and maintenance of technology, learning curve and longer operating time. However, emerging evidence shows that the console time and total operation time decreases with experience using the robot.[1314] Even in our study, the average cost of robotic rectopexy (Rs. 285,000) is slightly higher than that with laparoscopic procedure (Rs. 240,000) in our centre. The important reasons for the higher cost are the duration of surgery and maintenance cost of robotic system.

Although our study was a small series of cases, the average follow-up, functional outcome and recurrence rate were equal or better than most of the laparoscopic rectopexy groups. Furthermore, this is the initial series of cases in this part of world which is evolving with expertise and experience.

CONCLUSION

Robotic ventral rectopexy is a safe technique for rectal prolapse with excellent result in terms of functional outcome, recurrence and complications. It can be adopted easily in a centre with established laparoscopy unit. With experience, the duration and cost can be comparable to laparoscopic technique.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.