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August 2001, Volume 51, Issue 8

Letter to the Editor

An Unusual Complication of Ripstein Rectopexy

Dear Madam,
Rectopexv is one ot the standard operations described for the surgical management of rectal prolapse. We report a rare and hitherto unreported complication of ripstein rectopexy and its subsequent management is discussed.
A 78-year-old Caucasian female presented to the outpatient clinic with complaints of loose stools, tenesmus as well as passing fresh blood per rectum for 4 months. Three years prior to presentation. she had undergone a ripstein rectopexy for rectal prolapse. General physical and abdominal examinations were normal. At flexible sigmoidoscopy, an inflamed, friable area of rectal mucosa on the left lateral wail was seen, that also bled on contact. In the center of this inglamed area, a loop of blue suture material with an intact knot was seen. The suture was grasped with a biopsy forceps, drawn into the lumen and divided. A length of 8cm of suture was removed, carerful examination revealed that this was potypropelene (prolene) that had been used to fix the marlex mesh to the rectal wall.
Her postoperative recovery was normal and the symptoms disappeared by the fourth postoperative day. A repeat sigmoidoscopy six weeks after the operation showed completely normal looking rectal mucosa at the site of the original inflammation. The patient remains well at follow­up with no evidence of recurrence of the rectal prolapse.
Rectal prolapse is a distressing condition where the rectal mucosa protrudes through the anus, it is commoner in females especially in the 7th and 8th decades. Several procedures have been described for the surgical management of rectal prolapse, but ripstein’s rectopexy has emerged as a safe and effective procedure1-3. Originally described in 1963 the procedure involves mobilizing and then anchoring a straightened rectum using a marlex mesh on to the sacrum4. The operation has a success rate of’ around 80%. Faecal incontinence can persist after the operation in a third of patients and at least a similar number become constipated5. It is thought that the constipation is caused by a tight mesh causing luminar stenosis. Sling erosion into the rectum is a disastrous complication that usually leads to fatal infection6. A similar complication has been documented after abdominal sacroco lpopexy7.
Our patient had erosion of the suture material into the rectal lumen which was causing the symptoms. Such a complication has not been reported before and simple removal of the suture material was sufficient to cure the patient’s symptoms.
Consequently, fixation of the mesh to the rectal wall must be performed carefully taking special care not to penetrate the rectal mucosa8. If in doubt, a sigmoidoscopic examination of the rectum at the operation can be performed.
in conclusion ripstein’s rectopexy is a safe and effective procedure for rectal prolapse. Key to the success of the operation is complete mobilization and secure fixation of the rectum using a mesh. Suture erosion into the rectum is a rare complication and may present similar to the case described above. Simple removal of the suture endoscopically results in an effective cure.

References

1.Keighley MR. Fielding AW. Alexander Williams J. Results of unarlex mesh abdominal rectopexv for rectal prolapse in 100 consccutive cases Br. J. Surg.. 1983:70:229-32.
2.Launer DP. Fazio VW, Weakly FL. et al. The ripstein procedure: a 16-year
experience. Dis colon rectum 1982:25:41-45.
3.Tjandra Ji. Fazio VW, Church JM et al. The ripstein procedure is an effective treatment for rectal prolapse without constipation Dis colon rectum 1993.36 501-7.
4.Ripstein CB, Launter B. Etiology and surgical therapy for massive prolapse of the rectum Ann, Surg.. 1 963:157:259­.
5.Yoshioka K. Heyen F, Keighlev MR Functional results after posterior abdominal rectopexv for prolapse. Dts colon rectum 1989.32.
6.Gorden PH. Hoexkr B. Complications of the ripstem procedure Dis colon rectum 1978:21:277-80.
7.Kohi N. Walsh PM, Roat TM et al. Mesh erosion after abdominal scarosolpopexy.. Obstet gynaecol. 1998:92:999-1004.
8.O’ Leary JP. The ripstetn procedure for rectal prolapse in Master of Surgery. Nyhus LM, Baker RJ (Eds) Little Brown and Company. Bostoti 1987pp.1038­-43.

ED. Babu. AZ. Khan. B. Balasubramanian. N Escofet.
Department ot’ General Surgery Northampton General Hospital Northampton NN 1 5BD UK. Worthing Hospital Worthing. West Sussex BN11 21 IX.

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