Advanced technologies in surgery for rectal prolapse
Emma van der Schans is a PhD student in the Department Robotics and Mechatronics. (Co)Promotors are prof.dr. I.A.M.J. Broeders from the Faculty of Electrical Engineering, Mathematics and Computer Science, prof.dr. E.C.J. Consten, University of Groningen and dr. P.M. Verheijen, Meander Medical Center.
In this thesis surgical treatment modalities of rectal prolapse were studied to look how current practice can be optimized. Special focus was put on the long-term sequelae of the ventral mesh rectopexy (VMR) in order to improve patient counselling and to see what methods are best to address or even avoid complications. Moreover, the process of learning several innovative techniques was studied.
In section I, an overview is given on the diagnostic work-up and surgical treatment options for rectal prolapse. The treatment of first choice in most countries, including the Netherlands, is the minimal invasive VMR. In patients suffering from multicompartment prolapse a multidisciplinary approach is advised to see if a patient will benefit from sacrocolpo-rectopexy (VMR combined with sacrocolpopexy). The long-term outcomes of this robot-assisted surgery were analyzed. A recurrence rate of 10% after 4-year follow-up was found. Significant functional improvement was seen, although a substantial part still experienced functional bowel symptoms underlying the complexity of multicompartment pelvic organ prolapse.
In section II focus was put on the possible consequences and complications of VMR. First of all, a systematic review and meta-analysis was carried out to look for evidence supporting the use of biologic over synthetic mesh (or vice versa), based on recurrence and mesh exposure rates. However, no evidence-based preference in mesh material can be made. Secondly, the morbidity of robot-assisted redo surgery was studied, categorized in surgery for recurrent prolapse, for mesh exposure and for mesh removal related to chronic pelvic pain. Good safety outcomes were found in the first category. In the latter two categories higher morbidity rates were found compared to primary VMR. This supports the idea that redo surgery should be focused in tertiary referral centers. Finally, the prevalence of pain was studied in pre- and post VMR patients. Surprisingly high prevalence rates around 60% were found both before and after surgery.
Section III focusses on the process of learning advanced endoscopic techniques. The learning curves of robot-assisted VMR, the transition of a surgical team to a new robotic device and different endoscopic suturing techniques were studied.
