Laparoscopic management of persistent complete rectal prolapse in children.
BACKGROUND
Rectal prolapse is a relatively common condition in children. The multiplicity of surgical approaches used for rectal prolapse indicates that there is no single approach universally accepted and applicable to all cases. The laparoscopic approach promises to become the criterion standard for the management of full-thickness rectal prolapse in children. The aim of this study was to review our experience over the last 5 years and to evaluate the results that can be achieved by using laparoscopy in management of complete rectal prolapse in children.


METHODS
Forty patients presented with complete rectal prolapse and fecal incontinence grades (3-4) according to Rintala scale (37 secondary to prolapse and 3 neuropathic) had been operated upon laparoscopically from August 2003 to August 2008. They were subjected to clinical examination, investigations, pre- and postoperative electromyogram activities for external sphincter, puborectalis, and pelvic floor muscles. The pathophysiologic changes for each case was identified and dealt with laparoscopically (laparoscopic suture rectopexy, laparoscopic mesh rectopexy, laparoscopic resection rectopexy, and laparoscopic levatorplasty).


RESULTS
Among the 40 children with complete rectal prolapse, 22 were males and 18 females. Their median age was 9 years (range, 4-14 years). All cases (n = 40) showed a redundant rectosigmoid junction. Additional laxity of the pelvic floor was present in 32, rectoanal intussusception in 27, anterior wall rectoanal intussusception in 3, and rectosacral hernia in 5 cases. All procedures were completed laparoscopically. The median duration of surgery was 60 minutes (range, 50-70 minutes) for suture rectopexy, 90 minutes (range, 60-110 minutes) for mesh rectopexy, 110 minutes (range, 95-160 minutes) for resection rectopexy, and 120 minutes (range, 100-150 minutes) for laparoscopic levatorplasty. No intraoperative complications occurred in this study. Median postoperative hospitalization was 3 days (range, 2-5 days). Electromyogram studies showed statistically significant improvement during rest, minimal volition, and squeezing in all cases except those children with spina bifida and meningomyelocele. The only complications were postoperative constipation and external colonic fistula. Significant improvement of the continence score was achieved in all cases. The average follow-up time was 36 months. There were no recurrences.


CONCLUSIONS
The use of laparoscopy in the management of complete rectal prolapse is safe, effective, and associated with improved functional outcome. It saved the patients multiple operations and is associated with minimal postoperative pain and short hospital stay.
Ismail
Magid
M
Pediatric Surgery Unit, Al-Azhar University, Cairo, Egypt.
Gabr
Khaled
K
Shalaby
Rafik
R
D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D004576:Electromyography / Q000379:methods; D005242:Fecal Incontinence / Q000150:complications / Q000175:diagnosis*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D010535:Laparoscopy / Q000379:methods; D008297:Male; D011183:Postoperative Complications / Q000503:physiopathology; D011351:Proctoscopy / Q000379:methods*; D012005:Rectal Prolapse / Q000150:complications / Q000175:diagnosis* / Q000601:surgery*; D012007:Rectum / Q000601:surgery; D012008:Recurrence; D012016:Reference Values; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D013526:Surgical Mesh; D013536:Suture Techniques; D013997:Time Factors; D016896:Treatment Outcome