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What is a laparoscopic posterior suture rectopexy?

The term “rectopexy” refers to an operation in which the rectum (the part of the bowel that is nearest the anus) is put back into its normal position in the body. It uses keyhole surgical technique and sutures to fix the rectum into its normal position.

When is laparoscopic posterior rectopexy performed?

The most common reason for a Laparoscopic Suture Rectopexy, or otherwise known as Laparoscopic Posterior Suture Rectopexy (‘LPSR’ for short) is to repair an external rectal prolapse (bowel coming out through the anus). Another reason for surgery is internal prolapse or “intussusception” when the rectum ‘telescopes’ in on itself, without coming out of the anus. This may cause Obstructive Defecation Syndrome (ODS), a sensation of a blockage in the bowel, difficulty in passing a motion (having a poo) and prolonged, often unsuccessful visits to the toilet. It can also mean you need to apply pressure with a finger or hand on the perineum (skin between the vagina/testicles and the anus), or into the rectum to empty your bowels. Internal rectal prolapse sometimes also causes faecal incontinence (when you are unable to hold a bowel movement in).

Because LPSR uses sutures only, and does not involve a mesh, it is suitable for patients who either already had mesh rectopexy (LVMR) in the past, or do not wish to have mesh implanted inside their body. It is also suitable for male patients.

What other tests will I need before the operation?

We will need to see you in clinic to assess your symptoms and to perform an examination. Most patients who have this operation will have an endoscopic (telescope) test on the bowel. We may also look at how well the back passage muscles (anal sphincter muscle) work using manometry (to assess the strength of the sphincter muscles) and an ultrasound scan to look at the sphincter muscles. We may also assess the motility of the gut with an X-ray (slow transit study). This is because some patients who have Obstructive Defecation Syndrome (ODS) could have a slow colon (also known as slow transit constipation) which if not managed, could affect the results of the operation. These tests are helpful to check that having a laparoscopic posterior suture rectopexy is right for you.

What does the operation involve?

The operation is laparoscopic (keyhole surgery) and it involves a little cut just below the umbilicus (belly button) and two other small cuts on the right side of the tummy. There may be another small cut on the left side of the tummy. It is performed under general anaesthetic (whilst you are asleep) and usually takes about 2-3 hours.

This operation pulls the bowel up out of the pelvis and uses sutures to hold the rectum in its normal position in the pelvis, to prevent the bowel to prolapse down internally (telescope itself) or outside the anus.

What is the recovery like after surgery?

After the operation you may have a drip in your arm. You will be allowed to eat and drink as soon as you want to after the operation, and your drip will be removed once you are drinking enough. Your anaesthetist will talk about pain control with you before the operation, but usually painkilling tablets and liquids will be enough. Please be aware that medication containing codeine is likely to cause some constipation.

Usually, your catheter will be removed in the operating theatre at the end of the procedure, or the morning after, and you can walk to the toilet to pass urine. You would likely be able to go home the following day of the operation. It is important to avoid constipation and straining in the first few weeks after surgery. We will give you laxatives to take (usually Laxido) until you are reviewed in the clinic.

Good toilet position to avoid straining              

You should be fit to drive after 2 weeks and return to work after 2-4 weeks. You should not lift anything heavier than a full kettle for at least 6 weeks as this can cause excess strain on the pelvic floor muscles and can delay healing; this includes supermarket shopping, housework, lifting children and sports.

   Unsuccessful outcomes

• Operation makes no difference to symptoms (about 1 in 5 or 20%).

• Prolapse recurs (about 1 in 10 or 10%)

• Constipation gets worse not better (very uncommon).

Specific complications

•  Bowel leakage (incontinence) is not resolved, or can become worse, especially if the surgery is for an external prolapse. Occasionally new-onset incontinence can occur (uncommon).

•  Wound infection (more than 1 in 20)

•  Bleeding (rarely significant).

•  Rectal injury requiring repair (rare). An injury to the rectum may result in an infection requiring a stoma.

•  Pelvic abscess/collection (less than 1 in 20)

•  Urinary retention (<10%) or worsening of urinary incontinence.

•  Sexual dysfunction (impotence) in men (less than 1 in 20).

•  Severe constipation (rare).

•  Infection of the sacrum (inflammation of one of the discs of the spine) (rare).

•  Injury to other abdominal structures (rare).

•  Pelvic pain and / or back pain.

•  Blood clots in the legs / lungs (thrombosis) (rare).

•  Hernia from keyhole incision (port-site)

This is a relatively low risk surgery because no bowel is removed. It can be a technically more challenging procedure if you have had previous mesh rectal prolapse surgery or this is a re-do surgery, due to scarring of tissues (adhesions) and the mesh involved.

Some patients with obstructed defecation and incontinence will not have a significant improvement in their symptoms, but are rarely worse after rectopexy. You will have the opportunity to discuss all the risks and benefits of the operation with your surgeon before signing the consent form.

Is anyone not suitable for LPSR surgery?

Patients would need to be fit enough for a general anaesthetic. We have operated on elderly patients (over 85 years old) with external prolapse with good results, though these patients are at increased risk due to their age. Occasionally it is impossible to perform this operation on patients who have had extensive previous abdominal surgery because of adhesions (scar tissue in the abdomen), though a previous appendicectomy or hysterectomy is not normally a problem.

Is laparoscopic posterior suture rectopexy better than other prolapse operations?

A laparoscopic (keyhole) procedure leaves less scarring and is less painful than open surgery (a cut down the middle of the tummy). We carefully avoid damaging the important pelvic nerves which can cause constipation. Prolapse rarely comes back after laparoscopic surgery (3-9%) as opposed to operations through the perineum (10-30%).

Figure 1: Principle of laparoscopic posterior suture rectopexy. The surgeon dissects behind the rectum down to the pelvic floor to free up and pull up the rectum into its normal position

Figure 2: The rectum is sutured into position on to the top of the sacrum (backbone).

Figure 3: Diagram showing the rectum telescoping down into itself. In this diagram, this is an internal prolapse though in time, this may progress to an external prolapse.

DO’s                               

Do get up and about both during your hospital stay and after going home.

Do take regular laxatives (we usually recommend Laxido 1 sachet 2 times a day) to keep your motions soft.

Do gradually reduce your laxatives in the 8 weeks after surgery, if your bowels are too loose, remain taking a small dose. Patients differ enormously in their need for laxatives but it is important that for 8 weeks, your bowels are on the loose side of normal.

Do take exercise in the form of walking and swimming as soon as comfortable.

Do expect that your bowel function will be different after surgery compared to before

Don't 

Don’t lift anything heavier that a kettle for 6 weeks after surgery.

Don’t get constipated or strain when on the toilet.

Don’t ignore the urge to go to the toilet.

Don’t be concerned if you do not open your bowel for 4-5 days after surgery. This is quite normal.

Don’t do running or gym work for 6 weeks after the surgery.

Don’t have sexual intercourse for 4 weeks after the surgery.

Don’t drive for 2 weeks after surgery.

Don’t suffer discomfort unnecessarily.

You should take paracetamol regularly if needed. This will not cause constipation.

Do drink plenty of fluids after surgery