Zusammenfassung
GRUNDLAGEN: Das Ziel der chirurgischen Therapie beim Rektalprolaps ist die Korrektur sowohl des Prolapses als auch der Stuhlinkontinenz. Dieses Ziel kann dadurch erreicht werden, 1. dass der gelockerte Darmabschnitt reseziert oder fixiert wird und/oder 2. dass das Rektum am Sakrum fixiert wird. Der Sinn der Rektumfixation liegt darin, das Rektum bis zur Entstehung ausreichender fixierender Vernarbungen zwischen Darmhinterwand und Sakrum in hochgehobener Position zu halten. Bisher wurden verschiedene Operationstechniken entwickelt, keine dieser Techniken erzielte jedoch den Konsensus das Verfahren der Wahl zu sein. Das Ziel dieser Review ist die Bewertung der aktuellen Literatur in Bezug auf die laparoskopischen Therapieoptionen beim Rektumprolaps. METHODIK: In Abhängigkeit des Zugangs kann die chirurgische Therapie des Rektumprolapses auf zwei Arten erfolgen: perineal oder transabdominal. Jedes chirurgische Verfahren, welches mit einer ausgedehnten Mobilisation des Rektums einhergeht, scheint für die Therapie ausreichend zu sein und weist relativ geringe Rezidivraten auf. ERGEBNISSE: Allgemein weisen die transabdominell geführten Eingriffe geringere Rezidivraten auf, sodass dieser Zugang von Einigen als Verfahren der Wahl der Vorzug gegeben wird. Die multizentrisch gesammelten Daten von 643 Patienten haben zwischen Naht- und Netzrektopexie keinen Unterschied in Bezug auf die Rezidivrate gezeigt. SCHLUSSFOLGERUNGEN: Diese Übersicht ist auf laparoskopisch durchgeführte Abdominaleingriffe gerichtet. Die Kontroversen bezüglich der Bedeutung, welcher Schritt bei transabdominellen Eingriffen für den Erfolg verantwortlich ist, konnten bisher nicht geklärt werden. Die Autoren teilen die in der Literatur ebenfalls vertretene Meinung, dass Rektopexie mit Nähten genauso ausreichend ist wie die Netzfixation. Eine gegenwärtig in Durchführung befindliche randomisiert kontrollierte Studie soll klären, ob eine zusätzlich zu Mobilisation des Rektums durchgeführte Rektopexie tatsächlich notwendig und zielführend ist.
Summary
BACKGROUND: The purpose of rectal prolapse surgery is to correct the prolapse itself and restore fecal continence. This can be achieved by (1) resection or plication of the redundant bowel and/or (2) fixation of the rectum to sacrum. The rational for rectal fixation is to keep the rectum attached in the desired elevated position until it becomes fixed by scar tissue. A number of surgical procedures have been developed to treat rectal prolapse, but there is no consensus on the operation of choice. This review aims to evaluate the current literature with respect to laparoscopic treatment options for rectal prolapse. METHODS: The surgical treatment of rectal prolapse can be broadly classified into transabdominal approach and perineal approach. Any surgical procedure that involves extensive rectal mobilization and fixation is likely to correct the rectal prolapse with relatively low recurrence rate. RESULTS: As the recurrence rate is generally lower with the abdominal approach, some consider it to be the treatment of choice for rectal prolapse. A multicenter pooled analysis of 643 patients showed no difference in recurrence rates between suture rectopexy and mesh rectopexy. CONCLUSIONS: This review focuses on abdominal procedures with particular emphasis on laparoscopic management. Controversies have not yet been resolved as to which step of the abdominal procedure for full-thickness rectal prolapse makes the greatest contribution to the containment of recurrence rates. The authors concur with the literature suggesting that rectopexy is as effective with sutures as with mesh. A randomized controlled trial has been started to evaluate whether the addition of rectopexy to mobilization of the rectum significantly decreases recurrence rates.
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Essani, R., Bergamaschi, R. & Uranues, S. Surgical management of rectal prolapse: in the era of laparoscopic surgery. Eur Surg 41, 203–208 (2009). https://doi.org/10.1007/s10353-009-0484-7
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DOI: https://doi.org/10.1007/s10353-009-0484-7