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Mokhtar et al. Laparoscopic rectosigmoidopexy for intractable rectal prolapse in children

INTRODUCTION done by open or laparoscopic approach. Laparoscopy
is gaining wide acceptance in the management of
Complete rectal prolapse is defined as the protrusion rectal prolapse in children. [6,7,11,12]
of all layers of the rectal wall through the anal canal.
If prolapse of the rectal wall occurred but does The laparoscopic approach facilitates many minimally
not protrude through the anus it is called “rectal invasive techniques that proved to be effective
intussusception” or “occult rectal prolapse”. Complete and simple with many advantages including better
rectal prolapse should be distinguished from mucosal cosmesis, rapid return of intestinal motility, short
prolapse, in which mucosal prolapse the only protrusion hospital stay, low morbidity and low recurrence rate.
is the anal mucosa. In children it usually presents as a We propose our concept of laparoscopic rectopexy and
self-limiting disorder. The peak incidence is between 1 sigmoidopexy by 3-point fixation is a new concept for
and 3 years of age and it has equal gender distribution. [1-3] management of complete persistent rectal prolapse.

Prolapse can be either partial or complete. The METHODS
majority of cases have no obvious cause, though in
western countries it is usually related to excessive From July 2015 to July 2016, a total of 65 children with
straining, constipation, cystic fibrosis or functional complete rectal prolapse presented to Pediatric Surgery
defecation disorder, however, gastroenteritis and Department in El Shatby University Hospital were
parasitic infestation associated with rectal prolapse are enlisted and evaluated. Detailed history from all patients
commonly seen in third-world countries. [4-6] including: age, gender, weight, history of the presenting
symptoms, duration of the prolapse. Associated
Conservative measures are considered the first line of symptoms e.g. bleeding, constipation, incontinence,
treatment in all cases of rectal prolapse in children. It straining and ulcers, associated comorbidities as ectopia
proved to be effective in controlling prolapse in most of vesicae, nutritional history and history of previous
primary cases. This includes reduction of the prolapse operations for treatment of rectal prolapse such as
[7]
to decrease edema, bleeding and mucosal ulceration. injection sclerotherapy and the Thiersch operation.
Supporting the perineum during defecation, defecation They were subjected to clinical examination in the
in recumbent position, and taping the buttocks to form of general examination, inspection of perineum
prevent the prolapse from recurring spontaneously,
may be helpful as well as proper toilet training. for externally visible prolapse, and rectal examination
Medical and dietary treatment for the predisposing to detect ulcers and polyps, degree of prolapse and
factors with stool softeners, laxatives, adequate fluid prolapse length. Routine laboratory investigations and
intake and high fiber diet for treatment of constipation stool analysis for parasitic infestation was performed.
and avoidance of straining is important. Further,
treatment for parasitic infestations and investigation Conservative measures were attempted in all cases
and treatment for malabsorption and cystic fibrosis are in the form of proper toilet training, reduction of the
among conservative measures. prolapsed bowel, adhesive strapping of the buttocks,
avoidance of squatting position on defecation, adequate
Surgical treatment should be reserved for cases fluid intake, high fiber diet, stool softeners and laxatives
resistant to adequate conservative measures. Surgical for 3 months. Twelve of 65 cases were filtered. The
treatment includes a wide range of abdominal or inclusion criteria included cases with complete persistent
perineal surgical operations. With such a wide variety rectal prolapse more than 3 months with optimum
of treatment options and variable success rates, the conservative measures, recurrent or persistent prolapse
optimal treatment for this condition in children is widely after previous trials of injection sclerotherapy or other
controversial. [3,4,7,8] previous surgery for rectal prolapse correction. The
exclusion criteria were grade I prolapse, complete rectal
The aim of surgical management of full-thickness prolapse grade II responding to conservative measures
prolapse is to eliminate the external prolapse of the and patients with spinal or sacral anomalies.
rectum, improve bowel function, and reduce the
incidence of recurrence. [9,10] Presacral rectopexy has Cystic fibrosis testing was deemed unnecessary due
become one of the successful approaches to the to the extremely low incidence in our population. All
treatment of rectal prolapse. This technique has many children with persistent rectal prolapse after successful
modifications in addition to the use of different types of treatment of secondary causes, as well as those who
mesh. However, all involved mobilization and upward had recurrence after previous surgery, underwent
fixation of the rectum to the presacral fascia and was Laparoscopic rectopexy and sigmoidopexy. Patients

Mini-invasive Surgery ¦ Volume 1 ¦ March 31, 2017 25