Laparoscopic Ventral Rectopexy Versus Laparoscopic Wells Rectopexy for Complete Rectal Prolapse: Long-Term Results

Abstract

Background:

There is no agreement about which laparoscopic rectopexy technique is best for treating complete rectal prolapse. Purpose was to compare functional outcome, the recurrence rate, and quality of life in patients treated with laparoscopic ventral rectopexy (LVR) versus the laparoscopic Wells rectopexy (LWR) for complete rectal prolapse.

Materials and Methods:

A retrospective review of a prospectively maintained database of consecutive patients who presented with complete rectal prolapse. Patients were divided into two cohorts: first one had LVR and the other one had LWR. Exclusion criteria were previous major abdominal surgery, slow transit constipation, Hirschsprung's disease, inflammatory bowel disease, pregnancy, and patients on drugs that cause constipation. Patients were assessed preoperatively by clinical examination to evaluate constipation using the Wexner constipation scale (WCS), incontinence using the Wexner incontinence score (WIS), and quality of life using the gastrointestinal quality of life index (GIQOL). The primary outcome measures were disappearance of prolapse and recurrences. Secondary outcome parameters were operative time, complications, length of hospital stay, effect on perineal descent, functional outcome (constipation and continence), and quality of life.

Results:

A total of 74 patients (mean age of 55 years) with complete rectal prolapse had LVR (n = 41) and LWR (n = 33). Sixty (81%) patients were females. Operative time was significantly longer in LVR (122 minutes versus 105 minutes; P = .001). Also, length of stay was significantly longer in LVR (4.5 days versus 3.7 days; P = .04). Recurrences were reported in 1 patient in each group. Perineal descent improved >50% in defecogram 6 months postoperatively in 79% in LVR versus 21% in LWR. In LVR, mean WCS decreased from 11.3 to 5.1 postoperatively (P < .0001), while in LWR it decreased from 8.9 to 6.9 (P = .11). Mean WIS decreased in LVR from 5.9 to 3.8, P = .01, while in LWR, it decreased from 6.6 to 2.8; P = .001. GIQOL improved from 74.4 to 124.9 in LVR and from 79.3 to 112.6 in LWR. The change in both groups was statistically significant (P = .0001).

Conclusions:

In this study, both LVR and LWR successfully and safely corrected the prolapse and prevented recurrence in patients after long-term follow-up. Operative time and hospital length of stay are significantly shorter in LWR. High incontinence scores and age >70 are potential predictors of bad continence postoperatively. LVR appears to be more suitable for patients with a high constipation score and abnormal perineal descent.

Introduction

Complete rectal prolapse is a benign condition that leads to problems with fecal incontinence and obstructed defecation. It has a negative effect on the patient's quality of life.¹ Surgical management can be done through abdominal or perineal approaches. The perineal approach has been traditionally reserved for older and debilitated patients as it is better tolerated and associated with a lower rate of complications, however, there are functional changes (urgency and frequency) and higher recurrence rates.^2,3

Abdominal approaches are associated with lower rates of recurrence, but often with more complications.⁴ Laparoscopic surgery combines the advantages of low recurrence rates and minimal complications.^5,6 Many laparoscopic approaches have been developed for the treatment of complete rectal prolapse, such as resection rectopexy, posterior rectopexy, Well's rectopexy, and ventral rectopexy.

Laparoscopic resection rectopexy is ideal for patients complaining of constipation with good continence.⁷ Weakness of both the anal sphincters and pelvic floor muscles especially in multiparous females is an obstacle for this procedure. Moreover, complications of colon resection, including leaks, should be kept in mind.⁸ Laparoscopic Wells rectopexy (LWR) has the advantage of low mortality rates and the lowest recurrence rates (close to 3%). Improvement of fecal incontinence postoperatively occurs in up to 90% of patients.⁹ However, up to 20% of patients experience postoperative constipation.^10,11

Laparoscopic ventral rectopexy (LVR) is gaining popularity in the treatment of complete rectal prolapse. Posterior dissection is limited to exposure of the sacral promontory, so there is little possibility for nerve injury. Studies reported the postoperative reduction in fecal incontinence in up to 90% of patients with complication rates ranging from 1.4% to 47%.¹²

Until now, there are no clear data indicating whether LVR leads to a better outcome than LWR when considering recurrence rate, effect on perineal descent, and functional outcome

The aim of this study was to compare functional outcome, the recurrence rate, and quality of life in patients treated with LVR versus the LWR for complete rectal prolapse.

Materials and Methods

A retrospective review of a prospectively maintained database of all consecutive patients (from July 2006 to July 2014) who were presented with complete rectal prolapse to the units of colorectal surgery in both the Alexandria University Hospitals and Health Insurance Institute. Patients were divided into two cohorts: one had D'Hoore LVR¹³ and the other had LWR¹⁰ according to surgeon preference. The inclusion criterion for rectopexy was patient with full-thickness rectal prolapse confirmed by physical examination. Exclusion criteria were previous major abdominal surgery, slow transit constipation, Hirschsprung's disease, inflammatory bowel disease; malignancy, diverticular disease, pregnancy, antidepressants or drugs that cause constipation, and patients with comorbid illnesses as severe cardiac disease or chronic renal failure.

The study was performed after approval of the Alexandria University ethics committee. All procedures were done by 2 surgeons who passed the learning curve. Data were collected by chart reviews, database registration, and sometimes phone calls. All patients were assessed preoperatively for body mass index and American Society of Anesthesiologists (ASA) score to measure the global health.¹⁴ Clinical examination was done to evaluate constipation using the Wexner grading scale (best = 0, worst = 30),¹⁵ incontinence using the Wexner incontinence score (WIS) (best = 0, worst = 20),¹⁶ and preoperative quality of life using the gastrointestinal quality of life index (GIQOL) (best = 144, worst = 0).¹⁷ Defecogram and Dynamic pelvic MRI were done to assess pelvic floor muscles, perineal descent, and anal sphincters.

Postoperative treatment

Deep venous thrombosis prophylaxis using low-molecular-weight heparin was continued during the hospital stay. Oral fluids were started once peristalsis was regained with progress to a normal diet as tolerated. Discharge criteria included tolerance of three solid meals and passage of flatus or stool.

Data were collected prospectively, including operative time, length of hospital stay, morbidity, and mortality.

Patients were considered constipated if they had <2 bowel movements per week without using laxatives or enemas.¹⁸ Obstructed defecation was defined as “difficulty in evacuation or emptying the rectum, which may occur even with frequent visits to the toilet and even with passing soft motions”.¹⁹

All patients were followed up at 6-month intervals in the first year and then annually. Follow-up duration ranged from 2 to 7 years. At the time of follow-up, patients were assessed by clinical review and a standardized questionnaire addressing the issues of recurrence (defined as extrusion of full thickness of the wall of the rectum beyond the anal verge determined by clinical examination), constipation, incontinence, and quality of life using the same preoperative scores.

Outcome parameters

The primary outcome measures were disappearance of prolapse and recurrences. Secondary outcome parameters were operative time, complications, length of hospital stay, effect on perineal descent, functional outcome (constipation and continence), and quality of life.

Statistical analysis

Statistical analysis was performed by IBM SPSS 22 software. Continuous data were presented as means and standard deviations if normally distributed or median and range if not normally distributed. Categorical data presented as frequencies and percentages. Categorical variables were compared using Fisher's exact or the chi-square tests. Continuous variables were compared using the Wilcoxon rank sum test or Mann–Whitney's test. Because of the low number of events per variable, the analysis of risk factors potentially associated with bad continence was done only by means of univariate analysis with unadjusted odds ratios and confidence intervals (no multivariate analysis was done). For the analysis of differences in preoperative and postoperative scores within the same group, repeated measure analysis of variance (ANOVA) was used. To investigate differences in self-reported bowel motions, obstructed defecation episodes and incontinence episodes, the McNemar's test, which looks at related nominal data, was employed. A regression analysis (analysis of covariance) was done for Wexner constipation scale (WCS), WIS, and GIQOL data by the type of surgery. Kaplan–Meier method was used to estimate the cumulative incidence of recurrence in each therapy group, and log-rank test was used to compare the two groups. All tests were two tailed and performed at a significance level of .05.

Results

A total of 74 patients >30 years of age (mean age: 55.07 years ±13.3; range 32–84 years) with complete rectal prolapse had LVR (n = 41) and LWR (n = 33) during the study period. Sixty patients (81%) were females. Mean duration of complaints was 5.1 years (range 2–8 years). Demographic data, age distribution, and preoperative characteristics in both groups are listed in Table 1. Thirty-two (43%) patients had a degree of fecal incontinence (WIS ≥4). Other complaints were constipation (n = 46, 62%), bleeding per rectum (n = 7, 9.5%), and obstructed defecation (n = 52, 70%). Twelve of the 60 women (20%) had undergone hysterectomy.

Table 1.

Demographic and Clinical Data of Patients in Both Study Groups

Variable	Whole group	Group A (LVR) n = 41	Group B (LWR) n = 33	P
Mean age (years)	55.07 ± 13.3	57.5 ± 12.2	52.1 ± 18.1	.14^a
Age distribution
<70	57	32	25	.99^b
≥70	17	9	8
Sex
Male	14	5	9	.14^b
Female	60	36	24
ASA score
I	41	21	20	.55^c
II	15	10	5
III	18	9	9
Fecal incontinence (WIS >4)	32	18	14	.99^b
Constipation (WCS >8)	46	24	22	.63^b
Bleeding per rectum	7	4	3	.92^b
Obstructed defecation	52	27	25	.44^b
Hysterectomy	12	6	6	.99^b
Anal surgery	10	6	4	.74^b
Others	5	1	4	NA
Abnormal perineal descent	36	22	14	.35^b
BMI (mean)	28.25 ± 3.45	28.3 ± 3.4	28. 1 ± 3.5	.82^a

Mann Wittney U test.

Fisher Exact test.

Chi square test.

ASA, American Society of Anesthesiologists; BMI, body mass index; LVR, laparoscopic ventral rectopexy; NA, not applicable; WIS, Wexner incontinence score; WCS, Wexner constipation scale.

There were only two conversions (4.5%) to open surgery in the LVR group. Mean operative time was significantly longer in LVR (122.3 ± 26.1 minutes versus 105.5 ± 19.4 minutes; P = .001). Also, mean length of stay was significantly longer in LVR (4.5 days versus 3.7 days; P = .04). Estimated blood loss was minimal in both groups. No patient in either group was readmitted due to surgical complications. Operative results are listed in Table 2.

Table 2.

Operative Results of Patients in Both Study Groups

	Laparoscopic ventral rectopexy (n = 41)	Laparoscopic Wells rectopexy (n = 33)	P
OR time (minutes)	122.3 ± 26.1	105.5 ± 19.4	.001^a
Conversion	2	0	.49^b
Morbidity	3 patients	2 patients	.99^b

Mann–Whitney U test.

Fisher's exact test.

OR, operative.

There was no postoperative mortality. Postoperative complications are listed in Table 3. Thirty-day postoperative morbidity was not significantly different between both groups, P = .99.

Table 3.

Postoperative Morbidity

	Laparoscopic ventral rectopexy	Laparoscopic Wells rectopexy
Urinary retention	0	1
Urinary tract infection	3	0
Wound infection	0	2
Prolonged ileus	3	1
Mesh erosion in vagina	1	0

Prolapse disappeared in all patients after surgery. Recurrences were reported in 1 patient in each group over a mean follow-up period of 46 months (range 24–84 months). A Kaplan–Meier method with log rank test showed no significant difference in recurrence between both groups, P = .93.

Perineal descent improved >50% in defecogram 6 months postoperatively in 77% in LVR versus 21% in LWR.

Functional results are shown in Tables 4 and 5. In LVR, 24 patients complained of constipation preoperatively, 50% of them reported improvement of their bowel frequency and none complained of worsening or de novo constipation.

Table 4.

Changes in the Clinical Symptoms After Surgery

	Laparoscopic ventral rectopexy			Laparoscopic Wells rectopexy
	Preoperative	1 year	P^a	Preoperative	1 year	P^a
Bowel motions <2/week	24	12	<.001	22	17	.07
Incontinence	18	6	<.0001	14	6	<.001
Obstructed defecation	27	11	<.0001	25	13	<.001
Abnormal perineal descent	22	5	<.0001	14	11	.11

McNemar's test.

Table 5.

Functional Results After Surgery

	Laparoscopic ventral rectopexy			Laparoscopic Wells rectopexy
	Preoperative (mean ± SD)	1 year (mean ± SD)	P^a	Preoperative (mean ± SD)	1 year (mean ± SD)	P^a
WCS	11.3 ± 3.1	5.1 ± 4.1	.0001	8.6 ± 4.2	6.9 ± 3.4	.11
WIS	5.9 ± 2.6	3.8 ± 1.9	.01	6.6 ± 2.3	2.8 ± 3.2	.001
GIQOL	74.4 ± 24.3	124.9 ± 10.1	.0001	79.3 ± 21.5	112.6 ± 19.5	.0001

One-way repeated measure ANOVA.

GIQOL, gastrointestinal quality of life scale; SD, standard deviation; WCS, Wexner constipation scale; WIS, Wexner incontinence score.

In the LWR group, 22 patients had preoperative constipation, only 23% experienced improvement of their symptoms. Obstructed defecation and incontinence symptoms improved significantly in both groups (Table 4).

Repeated measure ANOVA was done to compare the score change within each group (Table 5). Wexner constipation score in LVR decreased 1 year postoperatively from 11.3 ± 3.1 to 5.1 ± 4.1 (P = .001) versus from 8.6 ± 4.2 to 6.9 ± 3.4 (P = .11) in LWR.

The mean WIS decreased in LVR from 5.9 ± 2.6 to 3.8 ± 1.9, P = .01, and in LWR it decreased from 6.6 ± 2.3 to 2.8 ± 3.2, P = .0001.

After 1 year, GIQOL had improved in all patients in the two groups. The overall score improved from 74.4 ± 24.3 to 124.9 ± 10.1 in LVR and from 79.3 ± 21.5 to 112.6 ± 19.5 in LWR. The change in both groups was statistically significant (P = .0001 in both groups) (Table 5).

Analysis of covariance was done to compare change in WIS, WCS, and GIQOL according to procedure status without being affected by baseline values. There was no significant difference in the amount of change between groups as regard to WIS (P = .22). Improvements of WCS and GIQOL were significantly higher after LVR (P = .04 and .05, respectively).

Univariate analysis of factors predicting continence outcome was performed (Table 6). Higher preoperative WIS, abnormal perineal descent, and age ≥70 proved to be predictive factors for poor outcome as regard to continence.

Table 6.

Univariate Analysis of Factors Predicting Continence Outcome

	≥50%b reduction of FI score (n = 40)	<50%b reduction of FI score (n = 10)	P
Demographics
Female, %	80	80	.99
Age at surgery (years)	73.4 ± 3.6	80.6 ± 4.1	.005
Duration of FI (years)	3.9 ± 2.1	4.4 ± 1.9	.59
Previous pelvic or anorectal surgery	2	1	.75
Preoperative Wexner incontinence score	8.1 ± 2.4	12.5 ± 3.2	.02
Preoperative Wexner constipation score	8.3 ± 3.3	10.9 ± 4.6	.24
Abnormal perineal descent	16	8	.03
Surgical procedure
LVR	18	5	.68
LWR	22	5

FI, fecal incontinence, LVR, laparoscopic ventral rectopexy; LWR, laparoscopic Wells rectopexy.

Discussion

Laparoscopic rectopexy has been demonstrated to be as effective as open rectopexy in treatment of complete rectal prolapse and associated with a low recurrence rate. There are significant reductions in postoperative pain, hospital length of stay, recovery time, and complications compared to open abdominal rectopexy.^7,20

In this study, we compared two laparoscopic rectopexy techniques: LWR and LVR. The comparison included operative parameters, morbidity, hospital length of stay, postoperative improvement in fecal incontinence, changes in constipation status, and recurrence.

We found that operative time was significantly shorter in LWR compared to LVR (105 minutes versus 122 minutes, P < .01). Also, hospital length of stay was significantly shorter in LWR (3.7 days versus 4.5 days; P = .04).

Complications occurred in 7% of patients in LVR and in 6% in LWR (P = .99). In their systematic review, Samaranayake et al.¹² reported complication rates in LVR ranging from 1.4% to 47%. On the other hand, complication rates reported after LWR ranged from 0% to 20%.^{10,11,21–23} The fact that 45% of our patients had an ASA score of 2 or 3 indicates that both techniques are safe in patients with comorbidities.

The risk of mesh erosion into the rectum or vagina although very rare was of concern and was explained to our patients before surgery. Mesh erosion into the vagina was reported in 1 LVR patient after 13 months. Many publications have reported mesh erosion into the rectum²⁴ or posterior vaginal wall.²⁵ The overall rate of reported erosion after mesh rectopexy ranged between 1% and 5%.^26,27 Factors that were found contributing to poor wound healing and subsequent infection, erosion, include uncontrolled diabetes mellitus, smoking, and previous pelvic irradiation.²⁸ Moreover, some surgical technical errors like unrecognized vaginal injury during dissection or bigger sized mesh that folds after fixation might be possible causes for erosion.²⁹ Having optimum size of the mesh to avoid folding and confirmation of intact wall of vagina by methylene blue injection might help to avoid this complication.

Disappearance of prolapse and recurrence rate was considered the milestones in judging the success of the procedures. In this study, prolapse disappeared after surgery in all patients. The recurrence rate was 2.7% (2.4% in LVR versus 3.1% in LWR) at mean follow-up period of 46 months. Boons et al.³⁰ reported 2% recurrences after LVR after a median follow-up of 19 months. Many reports on the Wells procedure reported no recurrences,^7,10 yet others reported recurrence rates between 1%²¹ and 10%.³¹ We think that old age with possible weak pelvic floor muscle might push the recurrence a bit high.

Incontinence associated with complete rectal prolapse is attributed to sphincter dilation, intermittent activation of the rectoanal inhibitory reflex by the prolapsed rectal bolus, and pudendal nerve neuropathy due to nerve traction by the prolapse. In this study, there was significant postoperative improvement of fecal incontinence. Dulucq et al.²¹ reported similar results in their LWR patients. Formijne Jonkers et al. reported improvement in fecal incontinence after LVR from 59% preoperative to 14% postoperative.⁸ A systematic review of ventral rectopexy reported that improvement in the fecal incontinence score after LVR ranged from 45% to 95% in short-term follow-up.¹² The mechanism of recovery of continence following rectopexy remains undetermined. It might be due to correction of chronic strain on the pudendal nerve, improvement of rectal compliance, or abolition of high-pressure rectal waves.^12,21

Obstructed defecation symptoms were improved significantly in both groups. These results coincide with many series that reported a significant reduction of obstructed defecation symptoms after rectopexy.^21,32,33

In this study, there were 50% improvements in preexisting constipation after LVR. In concordance with our results, D'Hoore et al. reported improving constipation in 80%, with no severe worsening or new onset of constipation after LVR.¹³

After LWR, the improvement of constipation in this study was 23%. Analysis of covariance showed that the improvement of constipation after LVR was significantly higher than LWR.

Finally, GIQOL improved after both procedures denoting that both procedures are satisfactory for the patients. However, the improvement was significantly higher after LVR. This might be due to more improvement in the constipation score and perineal descent.

Limitations of this study include selection bias as it was retrospective. The possible selection bias was eliminated by including all patients who had LWR or LVR during the study period.

Conclusions

Authors' Contributions

K.M.: Conception and design, acquisition of data, and analysis and interpretation of data, and drafting and revising the article. M.Y.: Acquisition of data and drafting of the article.

Footnotes

Disclosure Statement

No competing financial interests exist.

References

Tou

, Brown

, Malik

, Nelson

. Surgery for complete rectal prolapse in adults. Cochrane Database Syst Rev, 2008;(4):CD001758.

Habr-Gama

, Jacob

, Jorge

, et al. Rectal procidentia treatment by perineal rectosigmoidectomy combined with levator ani repair. Hepatogastroenterology, 2006; 53:213–217.

Lieberth

, Kondylis

, Reilly

, Kondylis

. The Delorme repair for full-thickness rectal prolapse: A retrospective review. Am J Surg, 2009; 197:418–423.

Senagore

, Madbouly

, Fazio

, Duepree

, Brady

, Delaney

. Advantages of laparoscopic colectomy in older patients. Arch Surg, 2003; 138:252–256.

Delaney

. Laparoscopic management of rectal prolapse. J Gastrointest Surg, 2007; 11:150–152.

Nunoo-Mensah

, Efron

, Young-Fadok

. Laparoscopic rectopexy. Surg Endosc, 2007; 21:325–326.

Madbouly

, Senagore

, Delaney

, Duepree

, Brady

, Fazio

. Clinically based management of rectal prolapse. Surg Endosc, 2003; 17:99–103.

Formijne Jonkers

, Maya

, Draaisma

, et al. Laparoscopic resection rectopexy versus laparoscopic ventral rectopexy for complete rectal prolapse. Tech Coloproctol, 2014; 18:641–646.

Senagore

. Management of rectal prolapse: The role of laparoscopic approaches. Semin Laparosc Surg, 2003; 10:197–202.

10.

Himpens

, Cadiere

, Bruyns

, Vertruyen

. Laparoscopic rectopexy according to Wells. Surg Endosc, 1999; 13:139–141.

11.

Hernandez

, Targarona

, Balague

, et al. [Laparoscopic treatment of rectal prolapse]. Cir Esp, 2008; 84:318–322.

12.

Samaranayake

, Luo

, Plank

, Merrie

, Plank

, Bissett

. Systematic review on ventral rectopexy for rectal prolapse and intussusception. Colorectal Dis, 2009; 12:504–512.

13.

D'Hoore

, Cadoni

, Penninckx

. Long-term outcome of laparoscopic ventral rectopexy for total rectal prolapse. Br J Surg, 2004; 91:1500–1505.

14.

Owens

, Felts

, Spitznagel

Jr . ASA physical status classifications: A study of consistency of ratings. Anesthesiology, 1978; 49:239–243.

15.

Agachan

, Chen

, Pfeifer

, Reissman

, Wexner

. A constipation scoring system to simplify evaluation and management of constipated patients. Dis Colon Rectum, 1996; 39:681–685.

16.

Jorge

, Wexner

. Etiology and management of fecal incontinence. Dis Colon Rectum, 1993; 36:77–97.

17.

Decker

, Borie

, Bouamrirene

, et al. Gastrointestinal quality of life before and after laparoscopic heller myotomy with partial posterior fundoplication. Ann Surg, 2002; 236:750–758; discussion 758.

18.

Lechaux

, Trebuchet

, Siproudhis

, Campion

. Laparoscopic rectopexy for full-thickness rectal prolapse: A single-institution retrospective study evaluating surgical outcome. Surg Endosc, 2005; 19:514–518.

19.

Zbar

, Wexner

, eds. Coloproctology. New York: Springer, 2010.

20.

Solomon

, Young

, Eyers

, Roberts

. Randomized clinical trial of laparoscopic versus open abdominal rectopexy for rectal prolapse. Br J Surg, 2002; 89:35–39.

21.

Dulucq

, Wintringer

, Mahajna

. Clinical and functional outcome of laparoscopic posterior rectopexy (Wells) for full-thickness rectal prolapse. A prospective study. Surg Endosc, 2007; 21:2226–2230.

22.

Kohler

, Athanasiadis

. The value of posterior levator repair in the treatment of anorectal incontinence due to rectal prolapse—A clinical and manometric study. Langenbecks Arch Surg, 2001; 386:188–192.

23.

Michalopoulos

, Papadopoulos

, Panidis

, et al. Surgical management of rectal prolapse. Tech Coloproctol, 2011; 15 Suppl 1:S25–S28.

24.

Faucheron

, Voirin

, Riboud

, Waroquet

, Noel

. Laparoscopic anterior rectopexy to the promontory for full-thickness rectal prolapse in 175 consecutive patients: Short- and long-term follow-up. Dis Colon Rectum, 2012; 55:660–665.

25.

Portier

, Iovino

, Lazorthes

. Surgery for rectal prolapse: Orr-Loygue ventral rectopexy with limited dissection prevents postoperative-induced constipation without increasing recurrence. Dis Colon Rectum, 2006; 49:1136–1140.

26.

Mathew

, Parmar

, Reddy

. Mesh erosion after laparoscopic posterior rectopexy: A rare complication. J Minim Access Surg, 2014; 10:40–41.

27.

, Wells

, Hundley

, Connolly

, Williams

, Visco

. Mesh erosion in abdominal sacral colpopexy with and without concomitant hysterectomy. Am J Obstet Gynecol, 2006; 194:1418–1422.

28.

Nazemi

, Kobashi

. Complications of grafts used in female pelvic floor reconstruction: Mesh erosion and extrusion. Indian J Urol, 2007; 23:153–160.

29.

Nivatvongs

, Young-Fadok

. Rectal prolapse: Abdominal approach. In: Fischer

, Bland

(eds). Mastery of Surgery, 5th ed. II. Philadelphia: Lippincott Williams & Wilkins, 2007, pp. 1582–1590.

30.

Boons

, Collinson

, Cunningham

, Lindsey

. Laparoscopic ventral rectopexy for external rectal prolapse improves constipation and avoids de novo constipation. Colorectal Dis, 2009; 12:526–532.

31.

Atkinson

, Taylor

. Wells procedure for complete rectal prolapse. A ten-year experience. Dis Colon Rectum, 1984; 27:96–98.

32.

Auguste

, Dubreuil

, Bost

, Bonaz

, Faucheron

. Technical and functional results after laparoscopic rectopexy to the promontory for complete rectal prolapse. Prospective study in 54 consecutive patients. Gastroenterol Clin Biol, 2006; 30:659–663.

33.

Douard

, Frileux

, Brunel

, Attal

, Tiret

, Parc

. Functional results after the Orr-Loygue transabdominal rectopexy for complete rectal prolapse. Dis Colon Rectum, 2003; 46:1089–1096.