The Cochrane Review in 2008 [2] reported that there is not enough data to determine whether the abdominal or perineal approach is superior, and no difference is observed in the methods used for fixation during rectopexy. Additionally, this review noted that division of the lateral ligaments during rectopexy reduces the recurrence rate, but is also associated with an increased incidence of postoperative constipation. Furthermore, operating time is significantly longer, but hospital stay is significantly shorter, and postoperative complications are significantly less common in the laparoscopic group compared with the open group.
The PROSPER trial [14]; the largest randomized trial in rectal prolapse that included patient-assessed quality of life with longer follow-up time was published in 2013. The results showed that there was no significant difference in recurrence rates, bowel function, or quality of life between any of the treatments (abdominal vs. perineal surgery, suture vs. resection rectopexy for those receiving an abdominal procedure, and Altemeir’s vs. Delorme’s for those receiving a perineal procedure). The recurrence rate was higher after abdominal surgery than previously reported.
Therefore, if the patient’s general condition permits, it is preferable to perform rectopexy, and if technically possible, laparoscopic rectopexy is the preferred option. It has been reported that in elderly patients with full-thickness rectal prolapse, laparoscopic ventral mesh rectopexy is associated with fewer postoperative complications and a lower recurrence rate compared to perineal stapler resection [15]. While a perineal approach may be considered for elderly patients or those with comorbidities, laparoscopic rectopexy is also considered feasible for this population [16]. Previously, we performed open rectopexy, but we began laparoscopic surgery around 2006, and have been performing laparoscopic rectopexy using the Wells method as the standard procedure since around 2012. The Wells method is reported to have a recurrence rate of 3–10% and a mortality rate of 1–2%, which is comparable to other rectopexy techniques [16].
Rectal prolapse is common in elderly people. In this study, the median age was 75 years, with the oldest patient being 89 years old, and patients aged 80 years or older accounted for 15 of the 37 cases. Important postoperative complications in elderly patients include respiratory complications, circulatory complications, liver failure, and psychiatric disorders such as postoperative delirium. Postoperative delirium is a major complication in elderly patients undergoing surgery, and postoperative pain is a well-known precipitating factor. Tei et al. reported that there was no significant difference in the incidence of delirium between open and laparoscopic surgery for colorectal cancer [17].
We previously reported that single-site laparoscopic colectomy significantly reduced postoperative pain compared to conventional multiport laparoscopic colectomy [12]. Nishizawa et al. reported that the rate of postoperative delirium was significantly lower in the single-incision laparoscopic surgery group than in the conventional multiport laparoscopic surgery group for colorectal cancer [18]. As demonstrated in our previous study, reduced port surgery (RPS) is considered to have the advantage of reducing pain. This reduction in pain may be particularly beneficial in the context of rehabilitation for elderly patients, where early mobilization is crucial. Therefore, RPS may prove to be a valuable approach for this population. In this study, the methods for postoperative pain control in both RPS and MPS, such as epidural anesthesia and intravenous patient-controlled analgesia, were chosen at the discretion of the attending physician and anesthesiologist, resulting in effective pain management.
This study, being a retrospective analysis conducted at a single institution, has its limitations, one of which is the small number of cases examined. The second limitation is the absence of statistical matching. The third limitation is that there were more patients with high BMI in the MPS group, leading to differences in patient backgrounds. Additionally, rectal prolapse is a benign disease, and patients often discontinue follow-up appointments once their symptoms improve, if no further issues arise. Consequently, cases with a favorable course tend to have shorter follow-up periods, potentially leading to insufficient monitoring for recurrence.
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