Types of Rectopexy Procedures
Rectopexy procedures are broadly divided into two main surgical approaches: abdominal (transabdominal) and perineal, with multiple specific techniques within each category that differ in their use of fixation methods, mesh materials, and whether bowel resection is included.
Abdominal (Transabdominal) Approaches
The abdominal route offers lower recurrence rates (0-8%) and is preferred for younger, medically fit patients 1.
Key Abdominal Rectopexy Types:
Suture Rectopexy: Direct fixation of the rectum to the sacral promontory using sutures alone, without mesh 2, 3
Posterior Mesh Rectopexy: Placement of mesh posterior to the rectum with fixation to the sacrum. Critical caveat: Posterior rectopexy causes severe constipation in 50% of patients 1
Ventral Mesh Rectopexy (D'Hoore's procedure): Mesh placed in the rectovaginal space anteriorly, which has become increasingly popular with lower constipation rates 4, 5
Resection Rectopexy: Combines rectopexy with sigmoid resection. This approach is associated with lower rates of postoperative constipation but should be avoided in patients with preexisting diarrhea or incontinence as these symptoms may worsen 1
Stapled Rectopexy: Uses staples for fixation 2
Laparoscopic vs. Open Approach:
Laparoscopic rectopexy is associated with fewer postoperative complications and shorter hospital stays than open rectopexy, with equivalent functional outcomes and recurrence rates 1, 3. The laparoscopic approach should be preferred when technical expertise is available.
Perineal Approaches
Perineal procedures have higher recurrence rates (5-21%) but lower perioperative morbidity 1. These are the procedures of choice for elderly patients, those with significant medical comorbidities, or contraindications for abdominal surgery 1.
Key Perineal Rectopexy Types:
Perineal Proctosigmoidectomy (Altemeier procedure): Perineal resection of prolapsed rectum and sigmoid colon 1, 2, 3
Delorme's Operation: Mucosal stripping with muscular plication 2, 3
Transperineal Levatoroplasty: May be combined with Altemeier procedure to reduce recurrence risk 1
Important Technical Considerations
Lateral Ligament Management:
Division of lateral ligaments is associated with less recurrent prolapse but causes more postoperative constipation compared to preservation 1. This represents a trade-off between recurrence and functional outcomes.
Modified Techniques:
Newer approaches like the laparoscopic modified mesh rectopexy combine partial posterior-lateral mobilization with posterior suture fixation and absorbable mesh in the rectovaginal space, showing promising results with 13.8% recurrence and no mesh-related complications 6.
Clinical Decision Algorithm
For young, fit patients: Choose abdominal approach (preferably laparoscopic)
- If constipation-prone: Consider resection rectopexy or ventral mesh rectopexy
- If normal bowel function: Suture rectopexy or ventral mesh rectopexy acceptable
- Avoid posterior mesh rectopexy due to high constipation rates
For elderly or high-risk patients: Choose perineal approach
- Altemeier procedure preferred over Delorme for better outcomes 3
- Consider adding levatoroplasty to reduce recurrence
Critical contraindication: Never perform resection rectopexy in patients with preexisting diarrhea or fecal incontinence 1.