Retrospective case-matched study between reduced port laparoscopic rectopexy and conventional laparoscopic rectopexy for rectal prolapse.

INTRODUCTION: Reduced port laparoscopic Well's procedure (RPLWP) is a novel technique used to overcome the limitations of single-incision laparoscopic surgery. The aim of this study was to compare outcomes between RPLWP and conventional laparoscopic Well's procedure (CLWP) and to investigate the learning curve of RPLWP. PATIENTS AND METHODS: From January 2006 to March 2017, a retrospective review of a prospectively maintained laparoscopic surgery database was performed to identify patients had undergone CLWP and RPLWP. From these patients, each of 10 cases were manually matched for age, sex, body mass index. From January 2006 to March 2015, CLWP was used for all procedures whereas, from April 2015, RPLWP was routinely performed as a standard procedure for rectal prolapse.
RESULTS: No significant differences were observed between the two groups in terms of operating time, blood loss, intraoperative complications, and conversion to CLWP or open rectopexy. Based on the postoperative outcomes, the hospital stay was significantly shorter in the RPLWP group. The estimated learning curve for RPLWP was fitted and defined as y = 278.47e-0.064x with R2 = 0.838; therefore, a significant decrease in operative time was observed by using the more advanced surgical procedure.
CONCLUSIONS: RPLWP is an effective, safe, minimally invasive procedural alternative to CLWP with no disadvantage for patients when a skilled surgeon performs it.

INTRODUCTION

Full-thickness rectal prolapse is defined as the protrusion of all the layers of the rectal wall through the anal sphincter.[1] Laparoscopic rectopexy is becoming the primary surgical procedure for treating full-thickness rectal prolapse.[2]

Reduced port laparoscopic Well's procedure is a single-incision laparoscopic surgery (SILS) combined with one needlescopic instrument to overcome the weak points of SILS. However, only a few studies on RPLWP have been published.[345] The aim of this study was to compare outcomes between RPLWP and conventional laparoscopic Well's procedure (CLWP) and to investigate the learning curve of RPLWP.

PATIENTS AND METHODS

From January 2006 to March 2017, 30 laparoscopic rectopexies for consecutive rectal prolapse patients were performed or supervised by a single surgeon at the Morioka Municipal Hospital. A retrospective review of a prospectively maintained laparoscopic surgery database was performed to identify patients had undergone CLWP and RPLWP. From these patients, each of 10 cases were manually matched for patients’ characteristics such as age, sex, and body mass index (BMI). From January 2006 to March 2015, CLWP was performed, and from April 2015, RPLWP was routinely performed as a standard procedure for rectal prolapse.

Surgical procedure

Each patient was placed in a low-lithotomy position under general anesthesia, after which the umbilicus was everted. A 3-cm skin incision was made through the umbilicus down to the fascia and into the abdominal cavity. A multi-channel port (EZ Access, Hakko, Nagano, Japan) was installed, and three 5 mm trocars were inserted from the platform. For patients undergoing RPLWP, a 3-mm reusable trocar (MIT force 3 mm trocar, Create Medic, Tokyo, Japan) was placed at the left lateral region. The procedure was completed using a 5 mm flexible laparoscope (Olympus, Tokyo, Japan), a fully-integrated ultrasonic and bipolar technology device (Enseal, Johnson, and Johnson, Tokyo, Japan), and 3-mm atraumatic grasping forceps (MIT force 3-mm N-type atraumatic grasping forceps, Create Medic, Tokyo, Japan). Conversely, CLWP was performed using the 5-trocar-technique. The platform placements of both procedures are shown in Figure 1.

Figure 1

Trocar placements

Rectal dissection was initiated using a medial-to-lateral approach, and this opening of the pararectal peritoneum was continued from right to left, and identifying the left ureter and gonadal vessels. The left-side peritoneum was opened, and the retrorectal space was connected [Figure 2a]. The dissection was extended as far as the levator antimuscle, which was freed of its entire surface. A 7 × 5 cm composite mesh (Composix™ E/X mesh, Bard, Warwick, RI, USA) was introduced into the abdominal cavity and fixed to the promontorium with a 5-mm fixation device (ProTack™, Medtronic Japan, Tokyo, Japan) [Figure 2b]. The rectum was then fully retracted into the abdominal cavity, and the mesh was stitched to the lateral serosa of the rectum with four 3-0 monofilament absorbable sutures (Biosyn™, Medtronic Japan, Tokyo, Japan) [Figure 2c]. Next, the bilateral and anterior pelvic peritoneum was completely stitched to the serosa of the rectum using 3-0 monofilament absorbable sutures [Figure 2d]. Finally, the incision was closed in layers without a drainage tube.

Figure 2

(a) The retrorectal space was completely opened, (b) a composite mesh was fixed to the promontrium with a 5-mm fixation device, (c) the mesh was stitched to the lateral serosa of the rectum using a needlescopic instrument, (d) the bilateral pelvic peritoneum was completely closed by employing intracorporeal suturing

Statistical analyses

Continuous data are expressed as the mean ± standard deviation. To compare the treatment groups, a Mann–Whitney U-test was applied to continuous data, and a Chi-square test was applied to categorical data. All statistical tests were performed using StateMate V for Windows (ATMS Co., Ltd., Tokyo, Japan). P < 0.05 was considered to be statistically significant. Based on prior data showing that most learning curves assume a power-law relationship, we applied a power-law curve model (y = alx–a2) to the abstracted learning data (i.e., operating time vs. case number) to obtain a learning curve – both the power-law value and the predicted value from the multivariable model – the curves were examined to identify where the learning curve stabilized.[67]

RESULTS

Patient characteristics and surgical outcomes are shown in Table 1. No significant differences were found between RPLWP and CLWP groups with regard to patient characteristics, including mean BMI and prior history of abdominal surgery. With regard to surgical outcomes, no significant differences were observed between the two groups in terms of operating time, blood loss, intraoperative complications, and conversion to CLWP or open rectopexy. Based on the postoperative outcomes, the time required to resume oral intake was similar between the two groups. However, the length of hospital stay was significantly shorter in the RPLWP group. No recurrence had been observed in both groups at the time of this submission.

Table 1

Patients characteristics and surgical outcomes

	RPLWP (n=10)	CLWP (n=10)	P
Age (years)	82.5±8.9	73.0±12.7	0.069
Sex (male/female)	2/8	3/7	0.606
BMI (kg/m2)	20.4±0.4	20.4±2.2	0.916
Prior abdominal surgery (n)	2	2	1.000
Operating time (min)	198.0	165.9±41.2	0.095
Blood loss (mL)	10.5±9.6	25.2±26.9	0.121
Conversion to CLWP or open (n)	0	0	-
Intraoperative complication (n)	0	0	-
Resumption of oral intake (days)	1.1	1.4	0.134
Postoperative complication (n)	0	0	-
Hospital stay (days)	4.2	7.2	0.027
Follow-up period (months)	10.5±6.2	19.9±15.4	0.089
Recurrence (n)	0	0	-

BMI: Body mass index, CLWP: Conventional laparoscopic Well’s procedure, RPLWP: Reduced port laparoscopic Well’s procedure

The learning curve was evaluated for RPLWP, which was performed sequentially by the single experienced surgeon. The estimated learning curve for RPLWP was fitted and defined as y = 278.47e-0.064x with R2 = 0.838 [Figure 3]. Hence, a significant decrease in operative time was observed. The mean operating time of the last five cases was not significantly but shorter than that of the first five cases [Table 2].

Figure 3

Learning curve of reduced port laparoscopic Well's procedure

Table 2

Comparison of surgical results between first and last five cases in reduced port laparoscopic Well’s procedure

	First five cases	Last five cases	P
Operating time (min)	224.6±39.5	174.8±29.6	0.095
Blood loss (mL)	7.2±7.2	13.8±11.3	0.304

DISCUSSION

Laparoscopic rectopexy is the primary treatment for full-thickness rectal prolapse because this approach offers the benefits of minimally invasive surgery along with comparatively low rates of recurrence.[4] In contrast, perineal procedures tend to be less invasive, but they have significantly higher recurrence rates.[2] For these reasons, perineal procedures are not usually used, and in some cases, they have been abolished.

When performing laparoscopic rectopexy, a combination of rectopexy and sigmoid colectomy is commonly considered because sigmoid colectomy is the best way to address both full-thickness rectal prolapse and incontinence without causing constipation.[8] However, sigmoid colectomy caries the risk of anastomotic complications and mesh infections.[4] Therefore, sigmoid colectomy is not usually performed during laparoscopic rectopexy.[9]

According to the literature on reduced port laparoscopic rectopexy, there have been 13 cases of SILS-rectopexy[35] and one case of RPLWP[4] [Table 3]. Needlescopic instruments partially overcome the main limitation of SILS, namely the lack of instrument triangulation.[10] In addition, needlescopic instruments can be easily inserted through a very small skin incision; hence, the cosmetic outcome is also satisfactory.[10] The role of a needlescopic instrument is to generate countertraction and reveal the cutting line in the mobilization of the rectum like an assistant. Furthermore, it can work as the left hand of the operator during the rectopexy phase, especially for suturing. For these reasons, a needlescopic instrument provides powerful support during RPLWP, even though its shaft is not rigid and its small jaw is not very strong.

Table 3

Reported cases of reduced port laparoscopic Well’s procedure including single-incision laparoscopic surgery rectopexy

	Number of case (n)	Approach	Sigmoidectomy	Operating time (min)	Blood loss (mL)	Morbidity (n)
Adair et al.[3]	3	SILS	+	114-138	ND	0
Miyo et al.[4]	1	RPLWP	+	219	26	0
Ahmed[5]	10	SILS	-	90-150	ND	0

ND: Not described, SILS: Single-incision laparoscopic surgery, RPLWP: Reduced port laparoscopic Well’s procedure

From our results, RPLWP could shorten the length of hospital stay under the influence of the lesser abdominal wall damage and reduction of abdominal pain. Some meta-analyses also revealed that SILS-colectomy was associated with shorter hospital stay compared to conventional laparoscopic colectomy.[1112] In addition, the learning curve revealed a dramatic shortening in operating time as experiences with RPLWP grew; the mean operating time for the last five cases was almost similar to CLWP. These results suggest that RPLWP is an effective, safe, minimally invasive procedural alternative to CLWP with no disadvantage for patients when the well-trained surgeon performs it.

CONCLUSIONS

RPLWP is a technically feasible and safe procedure that overcomes many of the technical difficulties of SILS-rectopexy. In the near future, continuing advances in needlescopic instruments will improve RPLWP, and this procedure can be an alternative choice.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.