Comparison of Laparoscopic and Open Surgery for Total Rectal Prolapse

Purpose Total rectal prolapse is a devastating disorder causing constipation and anal incontinence. We compared open and laparoscopic surgical approaches in a limited series.Methods The subjects of this study were 23 patients who underwent laparoscopic procedures (LP group) and 17 patients who underwent open procedures (OP group) for rectal prolapse. We assessed the preoperative colonic transit time, postoperative pain scoring, pre- and postoperative anal functions, and changes in constipation and related symptoms.Results The median operation time was 140.8min for the LP group and 113.1min for the OP group (P = 0.037). The median postoperative hospital stay was 4.8 days after the LPs and 9.6 days after the OPs (P = 0.001). Less analgesia was needed in the early postoperative period after the LPs (P = 0.007). While more than 70% improvement in continence was seen in the patients who underwent OPs, it was about 85% in those who underwent LPs. Improvement in constipation and related symptoms were similar in both groups. More than 30% of patients still suffered from hard stools and other symptoms of constipation. The colonic transit times were reduced in about 50% of patients who had suffered constipation in both groups. There was no incidence of recurrence in the median follow-up period.Conclusion Although transabdominal rectopexy has been performed conventionally for rectal prolapse for many years, laparoscopic rectopexy and laparoscopic resection rectopexy are associated with lower morbidity and less postoperative pain. We eliminated the total prolapse and cured incontinence in almost all patients, with a short hospital stay.     

腹腔镜下直肠乙状结肠部分切除联合直肠悬吊固定术治疗成人完全性直肠脱垂的疗效

目的探讨腹腔镜下直肠乙状结肠部分切除联合直肠悬吊固定术治疗成人完全性直肠脱垂的疗效。方法对2010年5月至2013年5月期间笔者所在医院科室收治的32例成人完全性直肠脱垂患者行腹腔镜下直肠乙状结肠部分切除联合直肠悬吊固定术,总结手术疗效。结果32例患者的手术过程均顺利,无一例中转开腹手术。平均手术时间为114．7min（95～167min）,平均术中出血量为80mL（55～150mL）,术后平均住院时间为9．8d（6～14d）,均全部治愈出院。术后32例患者获访3个月～4年（平均25．6个月）,均无脱垂症状,肛门功能恢复良好,无术后并发症及复发。结论腹腔镜下直肠乙状结肠部分切除联合直肠悬吊固定术治疗成人完全性直肠脱垂的疗效良好,具有创伤小、恢复快、复发率低等优点,是一种具有较高临床应用价值的术式。     

腹腔镜辅助下盆底腹膜带直肠悬吊术治疗儿童完全性直肠脱垂

目的探讨腹腔镜腹膜带直肠悬吊术治疗儿童完全性直肠脱垂的可行性及临床效果。方法2004年8月～2008年10月,对6例完全性直肠脱垂（年龄2～6岁,平均3.5岁）,在腹腔镜下利用直肠周围盆腔增厚松弛的腹膜,切取成两条＂L＂形带蒂腹膜条,折叠缝合固定于游离的直肠两侧壁,然后缝合在骶骨岬前的筋膜上悬吊直肠,最后将盆腔腹膜切缘缝合于直肠前壁包埋腹膜带并紧缩盆底。结果6例手术均获成功。手术时间95～210min,（120±24）min。术中出血〈10ml。术后随访6～54个月,平均28个月,均无脱垂复发,排便功能正常。结论腹腔镜下腹膜带直肠悬吊术治疗儿童完全性直肠脱垂效果良好,具有创伤小、恢复快、复发率低等优点,是一种具有较高临床应用价值的新术式。     

Outcome of Laparoscopic Rectopexy for Complete Rectal Prolapse in Patients Older than 70 Years Versus Younger Patients

Purpose To evaluate the outcome of laparoscopic rectopexy for complete rectal prolapse in patients above 70 years of age, compared with that in younger patients.Methods Between October 1997 and September 2001, 14 consecutive patients with complete rectal prolapse underwent laparoscopic rectopexy. Nine patients were aged 70 years or older, and five were aged under 70 years. All of the patients were ambulant and well enough to tolerate surgery under general anesthesia. Each patient was monitored pre- and postoperatively, for fecal incontinence, constipation, recurrent prolapse, morbidity, and mortality.Results The median follow-up period was 34.5 (range 5–54) months. No significant differences were noted in the hospitalization, incidence of complications, recurrence rate, and functional outcome.Conclusion The outcome of laparoscopic rectopexy in elderly patients is similar to that in younger patients. Therefore, advanced age alone should not be a contraindication to laparoscopic rectopexy.     

Ⅱ～Ⅲ度直肠脱垂的消痔灵注射疗效分析

目的：探讨Ⅱ～Ⅲ度直肠脱垂的注射疗法的疗效。方法：收集1990．12～2003．12的Ⅱ～Ⅲ度直肠脱垂行消痔灵注射68例疗效资料，术后随访3～10年。结果：有效率94％，且无严重并发症和后遗症。结论：消痔灵注射术对直肠脱垂是一种痛苦小、恢复快、易于推广的治疗方法。     

直肠三间隙注射治疗小儿直肠脱垂146例

为了探索治疗小儿直肠脱垂的有效方法，采用5％明矾注射液，按3个部位分别注入骨盆直肠间隙或直肠后深间隙，术后配合换药休息。结果显示，平均住院10d（3～18d），未出现肛管直肠狭窄，随访1～10年，无复发，有效率100％。结果表明，以5％明矾注射液行直肠三间隙注射治疗小儿直肠脱垂，疗效显著，无明显并发症和后遗症。     

Laparoscopic rectopexy

Abdominal rectopexy has been advocated as the treatment of choice for complete rectal prolapse. Recurrence rates are low raging from 0–12% and fecal continence has been documented to improve in 3–75% of patients. As most patients are elderly and not always fit enough to undergo abdominal procedure, various perineal approaches have been advocated. Depending on the type and extent of the operation, these procedures have a recurrence of up to 38%. Laparoscopic rectopexy represents the latest development in the evolution of surgical treatment of rectal prolapse. This technique aims to combine the good functional outcome of the open abdominal procedure with the low postoperative morbidity of minimal invasive surgery. We present a laparosocpic rectopexy on 72-year-old lady with a 10-year history of fecal incontinence and mucosal rectal prolapse. Electronic supplementary material is available for this article at Presented at the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) Annual Meeting, Dallas, April 28, 2006     

腹腔镜微创治疗高龄完全性直肠脱垂

目的探讨腹腔镜微创治疗高龄完全性直肠脱垂的手术方法,总结手术操作体会及临床治疗经验。方法总结2012年6月~2017年6月收治的22例完全性直肠脱垂患者的临床资料,患者年龄67~79岁,均在腹腔镜下行悬吊固定。结肠造影和术中均可见明显增厚且冗长的乙状结肠,直肠周围组织宽松,膀胱直肠窝或子宫直肠窝之间脂肪结缔组织明显增厚,尤其是直肠前壁。术中切除直肠周围增厚的脂肪结缔组织,切除冗长的乙状结肠和直肠上端,行结肠直肠吻合。结果所有患者手术顺利,无中转开腹。手术时间平均(86.59±14.84)min,出血量平均(63.41±23.67)ml,术后住院时间平均(10.01±1.57)d。无吻合口出血、感染、肠瘘等并发症发生,无术中死亡或术后2周内死亡病例。22患者均获得临床治愈,随访2~4年,平均(2.81±0.91)年,患者排便次数1~2次/d,肛门功能正常,无复发。结论腹腔镜下微创切除直肠周围增厚的结缔组织、切除冗长的乙状结肠和直肠上端,是一种较好的微创治疗高龄直肠脱垂的方法。     

腹腔镜骶骨阴道固定术治疗重度子宫脱垂

目的：探讨腹腔镜骶骨阴道固定术治疗重度子宫脱垂的临床疗效。方法2011年1月～2013年4月对22例POP-Q分期Ⅲ、Ⅳ期的重度子宫或阴道穹隆脱垂患者行腹腔镜下“Y”形聚丙烯网片骶骨阴道固定术,合并阴道前、后壁膨出者分别于膀胱阴道间隙和直肠阴道间隙增加植入网片的长度,合并中度以上压力性尿失禁（ stress urinary incontinence ,SUI）者同期行经闭孔无张力尿道中段吊带术（transobturator tension-free vaginal tape, TVT-O）,采用POP-Q分期法和盆底功能障碍性疾病症状问卷-20（PFDI-20）、盆底疾病生活质量影响问卷短表-7（PFIQ-7）、盆腔器官脱垂/尿失禁性生活质量问卷-12（PISQ-12）分别评价解剖和功能疗效。结果22例均成功完成手术,1例因合并重度SUI同期行TVT-O,术中未发生膀胱、输尿管、直肠他大血管损伤。手术时间（134．3±36．6）min,术中出血量（77．3±37．8）ml,术后2～3 d拔尿管均能自主排尿,无尿潴留。22例术后随访（17．5±8．2）月,无手术失败及术后复发,无网片侵蚀、暴露;POP-Q分期Aa、Ba、C、Ap、Bp各指示点解剖位置中位数由术前1．5、3．0、2．0、-2．3、-1．5 cm分别恢复为术后-3．0、-3．0、-8．0、-3．0、-3．0 cm。 PFIQ-7、PFDI-20评分中位数由术前66．7、66．2分恢复为术后12．0、14．6分,PISQ-12评分由术前（69．4±10.3）分提高到（86．9±10．0）分（t＝12．351,P＝0．000）;UDI-6术前后无改善（Z＝-0．337,P＝0．736）。术后新发SUI 3例,急迫性尿失禁1例。术前6例尿失禁,术后2例症状减轻,4例症状加重,其中1例术后8个月行 TVT-O,3例功能锻炼并观察。患者主观满意度为95．4％（21/22）。结论腹腔镜骶骨阴道固定术是治疗重度子宫或穹隆脱垂的一种安全、有效的方法,但有诱发或加重尿失禁的风险。     

涤纶补片经腹直肠悬吊术在重度直肠脱垂中的应用

为探讨应用涤纶补片行经腹直肠悬吊术治疔重度直肠脱垂的疗效,回顾应用涤纶补片行经腹直肠悬吊术治疗的15例重度直肠脱垂患者资料。结果显示,本组15例患者均顺利完成手术。手术时间1．6～2．6h．术中出血量50～100ml。术后除2例患者出现尿潴留外．其余均未出现并发症。患者均一期愈合,平均住院时间9．5d。术后随访1～2年,均无复发,均肛门功能良好,排便通畅。结果表明,涤纶补片经腹直肠悬吊术治疗重度直肠脱垂疗效确切,术后并发症少,是一种安全有效的方法。     

Laparoscopic suture rectopexy in the treatment of persisting rectal prolapse in children

Background The repair of choice for persistent rectal prolapse (PRP) in children is disputed. Laparoscopic suture rectopexy (LSRP) is effective in adults, but its usefulness in pediatric PRP is unknown. We compared LSRP with posterosagittal rectopexy (PSRP). Methods Sixteen children, with a median age of 6.5 years (range, 0.8–16.8) and duration of symptoms of 2.8 years (range, 0.5–10.2), underwent surgery for PRP. Eight (1991–2000) had PSRP, and eight (2002–2005) had LSRP. Three patients with LSRP were healthy; the others had mental retardation and epilepsy (n = 1), cerebral palsy (n = 1), Aspeger’s syndrome (n = 1), meningomyelocele (n = 1), and bladder extrophy (n = 1). Preoperative cologram (n = 6), sigmoideoscopy (n = 3), and anorectal manometry (n = 2) were normal in patients with LSRP. In LSRP, the rectum was mobilized and sutured to the sacral periosteum. Results Median operation time for LSRP was 80 min (range, 62–90) and for PSRP 40 min (range, 25–70) (p < 0.05); median hospital time was 6 days (range, 3–8) for LSRP and 6 days (range, 3–9) for PSRP (not significant). Six patients with LSRP had a median follow-up of 13 months (range, 4–24). None have had recurrences, and two patients (33%) require laxatives. Of the patients with PSRP, two (25%) had recurrence and underwent abdominal rectopexy with sigmoid resection. Conclusion Medium-term results indicate that LSPR is effective in pediatric PRP. Constipation is the only postoperative problem in a significant proportion of patients.     

Impalement Injury with Transanal Prolapse of Bowel Content Due to Intraperitoneal Rectal Tear

A 48-eight-year-old female patient came with prolapse of small intestines per rectum (Fig. 1) due to impalement injury with iron rod at a construction site. As the patient was hemodynamically unstable, she was taken for emergency laparotomy. A large rent in the intraperitoneal rectum was found (Fig. 2), with prolapse of intestines. Luckily for the patient, there was no other intra-abdominal organ injury. As there was no fecal contamination at all, a decision against proximal colostomy was made. The rent was closed in two layers after re-placing the small bowel contents with thorough lavage. Patient made a swift recovery thereafter.Open in a separate windowFig. 1Patient presented with prolapse of bowel contents per rectum due to injuryOpen in a separate windowFig. 2Intraoperative picture showing the perforation involving the rectum     

中老年直肠脱垂60例护理体会

为提高中老年患者直肠脱垂的治疗效果，缩短疗程，有效防止复发，减少并发症的发生，提高其生活质量，结合60例直肠脱垂患者临床护理经验，得出主要护理体会：（1）重视术前护理；（2）加强术后护理；（3）注意术后出院指导。     

Recurrence and Quality of Life Following Perineal Proctectomy for Rectal Prolapse

Background  Surgical outcome and quality of life (QOL) following perineal proctectomy for rectal prolapse remain poorly documented. Methods  From 1994 to 2004, patients with full-thickness rectal prolapse were treated exclusively with perineal proctectomy independent of age or comorbidities. Subjective patient assessments and recurrences were determined retrospectively from hospital and clinic records. Consenting patients completed the gastrointestinal quality of life index (GIQLI). Results  Perineal proctectomy was performed in 103 consecutive patients with a median age of 75 years (range 30–94). Most patients underwent concurrent levatorplasty (anterior 85.8%, posterior 67.9%). Durable results were obtained in all patients; the recurrence rate was 8.5% over a mean follow-up of 36 months. Preoperatively, 75.5% of patients reported fecal incontinence, and 32.1% had obstructed defecation. Incontinence significantly improved post-proctectomy (41.5%, p < 0.001), as did constipation (10.4%, p < 0.001). GIQLI respondents reported satisfaction following proctectomy with 63% scoring within one standard deviation of healthy controls. Patients with recurrent prolapse reported a lower QOL. Risk factors for recurrence included duration of prolapse, need for posterior levatorplasty, and prior anorectal surgery. Conclusions  Perineal proctectomy provides significant relief from fecal incontinence and obstructive symptoms caused by rectal prolapse, with an acceptable recurrence rate and low morbidity. This study was supported exclusively using institutional funding.     

腹腔镜下直肠癌根治术62例治疗体会

通过技术改进和经验积累,在不降低直肠癌手术安全性、有效性和微创性的基础上,探讨扩大腹腔镜下直肠癌根治术的适用范围。应用4～5孔法实施于术,术中根据肿瘤位置和大小,确定肠系膜保留位置,为术后盆壁腹膜化重建做好准备,按照标准的直肠全系膜切除术要求,循解剖间隙实施手术。肠系膜血管采用解剖性游离然后结扎切断和提出腹腔外处理两种方法。充分显露腹膜返折及以下盆腔空间,腹腔镜下使用五叶拉钩,较好地解决了空间不利于显露的缺点。消化道的重建采用完全腹腔镜手术、腹腔镜辅助手术、肛门拖出吻合器吻合以及人工吻合等方法。盆底腹膜主要用连续缝合关闭（84％）,部分（9％）采用腹膜整合使大部分腹膜关闭,少量（5％）采用完全不关闭。结果显示,62例中57例手术成功,1例直肠中动脉出血,4例晚期肿瘤侵犯周围脏器中转开腹。手术时间平均175min,术中出血量平均70ml,术后住院时间平均9d,无严重并发症。本组患者随访3～36个月,平均15个月,失访率5％,1年生存率91％,3年生存率76％。6例拖出式吻合患者排便次数较多,6～9个月后好转。结果表明,经过技术改进,腹腔镜下直肠癌根治术可以被更广泛地应用。     

腹腔镜直肠癌根治术的相关解剖要点分析

目的根据直肠癌根治术全直肠系膜切除（total mesorectal excision,TME）的要求,从肿瘤根治和膀胱功能、性功能保护的角度探讨腹腔镜直肠癌根治术关键步骤的解剖学要点。方法2006年11月～2008年8月施行32例腹腔镜直肠癌根治术,从Toldt间隙的分离、肠系膜下动脉的处理、侧腹膜的解剖、骶前间隙和骶直肠筋膜的分离、直肠侧韧带的分离及直肠前方间隙的分离6个关键性步骤对TME手术的相关解剖进行观察和描述。结果Toldt间隙和骶前间隙是一个相互延续的筋膜间隙,走行于该间隙的腹下神经与直肠固有筋膜关系密切。骶直肠筋膜是盆壁筋膜和直肠固有筋膜在盆底部的融合,是TME手术盆腔分离的重要标志。在精囊腺平面以下,直肠前方和前侧方的解剖层面最为致密,适度的牵拉暴露和锐性分离有利于寻找正确解剖间隙和保护神经丛。结论紧贴直肠固有筋膜分离并保持该筋膜的完整是直肠癌根治手术中贯彻TME概念并保护膀胱功能和性功能的基本策略。     

Efficacy of Laparoscopic Sacrocervicopexy for Apical Support of Pelvic Organ Prolapse

Background and Objectives:

To evaluate the efficacy of laparoscopic sacrocervicopexy for apical support in sexually active patients with pelvic organ prolapse.

Methods:

One-hundred thirty-five women with symptomatic prolapse of the central compartment (Pelvic Organ Prolapse Quantitative [POP-Q] stage 2) underwent laparoscopic sacrocervicopexy. The operating physicians used synthetic mesh to attach the anterior endopelvic fascia to the anterior longitudinal ligament of the sacral promontory with subtotal hysterectomy. Anterior and posterior colporrhaphy was performed when necessary. The patients returned for follow-up examinations 1 month after surgery and then over subsequent years. On follow-up a physician evaluated each patient for the recurrence of genital prolapse and for recurrent or de novo development of urinary or bowel symptoms. We define “surgical failure” as any grade of recurrent prolapse of stage II or more of the POP-Q test. Patients also gave feedback about their satisfaction with the procedure.

Results:

The mean follow-up period was 33 months. The success rate was 98.4% for the central compartment, 94.2% for the anterior compartment, and 99.2% for the posterior compartment. Postoperatively, the percentage of asymptomatic patients (51.6%) increased significantly (P < .01), and we observed a statistically significant reduction (P < .05) of urinary urge incontinence, recurrent cystitis, pelvic pain, dyspareunia, and discomfort. The present study showed 70.5% of patients stated they were very satisfied with the operation and 18.8% stated high satisfaction.

Conclusion:

Laparoscopic sacrocervicopexy is an effective option for sexually active women with pelvic organ prolapse.     

腹腔镜直肠癌根治术80例临床分析

目的探讨腹腔镜直肠癌根治术的可行性和安全性。方法2004年3月～2008年1月,施行腹腔镜直肠癌根治术80例。遵循肿瘤根治原则,切除肿瘤两端足够的肠管及相应的系膜并清扫淋巴脂肪组织,直肠低位前切除（Dixon）术在腹腔镜下完成吻合术,Miles术行乙状结肠造口。结果中转开腹4例,其余76例均完成腹腔镜手术。其中Dixon术44例,手术时间（178±38）min,术中出血（61±17）ml,切除淋巴结数（11.3±2.9）枚,术后住院时间（7.1±3.2）d;Miles术32例,手术时间（231±49）min,术中出血（210±178）ml,切除淋巴结数（12.9±3.7）枚,术后住院时间（9.3±4.1）d。所有标本远近切缘无癌残留。术后人工造口狭窄1例,会阴部切口积液5例,吻合口漏1例,早期排尿困难6例。无术后出血、手术死亡等并发症。70例随访9～48个月,5例肿瘤复发,2例术后死于肿瘤多处转移造成脏器功能衰竭,粘连性肠梗阻5例。结论在严格掌握适应证和丰富的开腹大肠癌手术经验和熟练的腹腔镜手术技术的基础上,腹腔镜直肠肿瘤根治手术是安全可行的。     

Delorme 术与 PPH 二联术治疗Ⅱ度直肠脱垂的临床观察

目的：比较 Delorme 术与 PPH 联合直肠周围三间隙硬化剂注射术治疗Ⅱ度直肠脱垂的临床疗效。方法：回顾性分析 30 例Ⅱ度直肠脱垂患者，15 例应用 Delorme 术治疗，15 例应用 PPH 联合直肠周围三间隙硬化剂注射术治疗，比较两种手术方法治疗Ⅱ度直肠脱垂的临床疗效及手术相关问题。结果：两组在总有效率、平均住院时间、术后肛门功能改善方面无显著差异（P>0.05）。Delorme 术组术中出血量（100.0±15.5）mL、手术时间（60.0±11.3）min、治疗费用（8023.5±201.5）元与 PPH 术组术中出血量（25.0±8.6）mL、手术时间（45.0±9.2）min、治疗费用（11 016.5±276.9）元比较，差异具有统计学意义（P<0.05）。结论：两组手术治疗Ⅱ度直肠脱垂均安全有效，手术操作均相对简单，各有优缺点，Delorme 术组在病例选择面及费用方面占优，PPH 术组在手术时间、出血量方面占优。二组术后均可改善肛门功能，但改善程度不一，个体差异较大。     

Incarcerated Recurrent Rectal Prolapse with Ileal Strangulation: Report of a Case

We report a rare case of incarcerated rectal prolapse with ileal strangulation occurring after a Gant-Miwa procedure with anal encircling (Thierschs procedure) for recurrent rectal prolapse. The patient was a 78-year-old woman who presented to our outpatient clinic the day after sudden rectal protrusion had occurred. She had undergone a Gant-Miwa procedure for rectal prolapse 4 years previously, and another Gant-Miwa procedure with anal encircling for recurrent rectal prolapse 18 months earlier. The patient attempted to reduce the prolapse manually, but was unsuccessful. On admission, a 10 × 4-cm semispherical mass was observed extra-anally, with a necrotic surface. We performed an emergency laparotomy, which rerealed a prolapse of the anterior wall of the rectum with part of the ileum protruding into the sac formation. Thus, we resected the incarcerated ileum followed by primary anastomosis and proctectomy (Hartmanns procedure) with good results. This case demonstrates that ileal strangulation can occur as a complication of rectal prolapse recurrence after perineal repair.