Introduction: Rectal prolapse is a relatively common, usually self-limiting illness in children. Peak incidence is between 1 and 3 years. The intervention is required for the persistent rectal prolapse (PRP). Only scanty experience is available with laparoscopic rectopexy in children. There is no available work using both mesh and suture laparoscopic rectopexy in literature. This work is unique that it presents our clinical experience with both mesh and suture laparoscopic rectopexy in children. This is a prospective clinical study for the outcome of laparoscopic rectopexy (LRP) by both mesh and suture technique in children with persistent rectal prolapse (PRP). Materials and Methods: Fourteen cases of PRP were managed with LRP from February 2008 to August 2012. Results: Of the 14 children, 10 (71.42%) were males and 4 (28.57%) were females. Male to female ratio was 2:1. The mean age of presentation was 5 years (range 3 - 8 years). The presenting complaints were mass descending per rectum along with bleeding per rectum lasting from 1 to 3 years. All had rectal prolapse of 5 - 7 cm in length. 12 out of 14 children had recurrence even after sclerotherapy before referral to laparoscopic rectpexy. The mean duration of surgery was 30 minutes (range 20 - 60 minutes). No intraoperative complications were reported; only one case got constipation and was managed conservatively and no recurrence. Conclusion: LRP is safe, feasible in children and gives satisfactory results after failure of all conservative even sclerotherapy injection.
Rectal prolapse is a relatively common, usually self-limiting illness in children. Peak incidence is between 1 and 3 years [
This is a prospective clinical study of 14 children managed with LRP (mesh and suture techniques) for PRP from April 2008 to September 2012. The conservative management of nutritional support, bowel habit regulation, and dietary manipulation for managing the prolapse had failed in all cases and were referred for surgical intervention. 12 of the 14 patients were managed with sclerotherapy using ethanolamine oliat injected submucosally in three to four sittings before being referred to laparoscope rectopexy. Cases with rectal prolapse who did not respond to conservative management over 1 to 2 years were defined as PRP and were subjected to LRP. The decision to operate was based on the age of patient, duration of conservative management (>12 months) and frequency of recurrent prolapse (two or more episodes requiring manual reduction with or without sedation per month), along with symptoms of pain, rectal bleeding, edema, ulceration, difficult reduction and recurrent prolapse. The record of age, sex, weight, and initial presentation, duration of symptoms, precipitating events and co-morbidities was maintained. Preoperative evaluation included physical examination, routine laboratory investigation, plain X-Ray anterior-posterior & lateral view, defecography and proctoscopy in all patients. The ethical committee approved the technique. Written consent was obtained from the family after full information about the surgery and the post-operative squeal.
All children were given enemas on the morning of the surgery. Prophylactic antibiotics were given at the time of induction of anesthesia. All were operated under general anesthesia with endotracheal intubation. After full anesthesia and under complete sterilization catheter inserted to evacuate the urinary bladder. Supra umbilical transverse skin incision was done for ENDOPATH XCEL port with 5-mm 0˚ scope introduction to the peritoneum under vision on the laparoscope monitor, then CO2 insufflation to peritoneum up to 12 mmHg intra-abdominal pressure was operand with hemodynamic and respiratory monitoring by anesthesia. Introduction of 5-mm, 30˚ scope at umbilicus port and two 5-mm working ports in mid-clavicular line followed this over the line joining mid-inguinal point and both costal margins. The position of the working ports varied with the child height and abdominal cavity size, ensuring acceptable ergonomics according to the child body built. Trendelenburg position helped in moving away the small bowel from the operative field.
The rectosigmoid was grasped and mobilized after dividing the right side peritoneal fold starting from the sacral promontory (
between each suture in the rectum) seromuscular sutures of PDS size 3/0 using intra-corporeal knotting (
Of the 14 children, 10 (71.42%) were males and 4 (28.57%) were females. Male to female ratio was 2:1. The mean age of presentation was 5 years (range 3 - 8 years). The presenting complaints were mass descending per rectum along with bleeding per rectum lasting from 1 to 3 years. All had rectal prolapse of 5 - 7 cm in length. Two children were under neuro-psychiatric treatment and one had walking problem. The two children under neuro-psychatric treatment were males and weighted 17.4 kg and 18.2 kg at ages 7 years and 9 years, respectively. The child with walking problem was a female aged 6 years and weighted 13.8 kg, which was below the
5th centile as per NCHS weight for age charts. The remaining 11 out of 14 children were normal in weight and fell between the 20th and 50th centile by NCHS standards.
The mean duration of surgery was 30 minutes (range 20 - 60 minutes). No intraoperative complications were reported. Redundancy of recto-sigmoid was noticed in all patients except the two with neuropsychiatric problem. Pelvic floor laxity was found in those two cases. No intraoperative problems were encountered and no case required conversion. Mean postoperative hospitalization was 3 days (range 2 - 5 days). All were followed up for an average of 10 months (range 4 - 12 months), with no recurrence reported in any caseduring the follow-up period. One child complained of postoperative constipation, which improved with dietary manipulation and stool softeners. Also there was no urinary or fecal control problems in all cases at the follow-up period.
The exact etiology of rectal prolapse in children is unknown. They thought to be related to several anatomic considerations such as the vertical configuration of the sacrum, greater mobility of the sigmoid colon, and a loosely attached rectal mucosa to the underlying muscularis, and the absence of Houston’s valves in approximately 75% of infants younger than 1 year of age [
Mostly conservative treatment is successful [
Literature is replete with various procedures for this condition, which is a testimony to the lack of consensus over an ideal procedure. Broadly, the operative procedures can be classified as abdominal [
Abdominal rectopexy is advocated for the recurrent or PRP in children. In adults, in a recent meta-analysis comparing outcomes using the laparoscopic technique with an open procedure, no differences in operative morbidity and recurrence rates were found [
As experience is being gained in the pediatric cases with the laparoscopic approach, it has been shown to have good results [
Koivusalo et al. reported a median operation time of 80 minutes (range 62 - 90 minutes) for LSRP and a median hospital time of 6 days (range 3 - 8 days) [
The recurrence rates reported for PRP are as much as 6.9% at 5 years and 10.8% at 10 years [
Koivusalo [
Although this is a single center experience without a control group, the results are satisfactory. Whereas larger randomized control studies are required to secure conclusive evidence for the superiority of LRP over the conventional open procedure, paucity of PRP cases in a single center remains the limiting factor. We conclude that LRP is an effective and safe minimal invasive procedure alternative to the open procedures with similar success rates and no additional complications.