Laparoscopic-Total Extraperitoneal Anterior Rectopexy (L-TEAR)-A preliminary report

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Minimally invasive ventral mesh rectopexy, the current standard, being transperitoneal entails risks of vascular, bowel injury, adhesions, besides mesh and tac fixation issues. This study evaluates the feasibility, safety, and short-term outcomes of a novel total extraperitoneal anterior rectopexy that avoids peritoneal transgression and sacral fixation. Methods In this prospective single-center study conducted from July 2024 till date, 20 patients (11 males, 9 females; mean age 34.6 ± 14.2 years) with complete rectal prolapse, body mass index < 28 kg/m², without prior abdominal surgery underwent this procedure which involved transfascial rectal fixation to the abdominal wall with preperitoneal mesh placement. Operative variables, complications, recurrence, functional outcomes [St. Mark’s Incontinence Score (SMIS), Obstructed Defecation Syndrome (ODS) score, quality-of-life questionnaires] sigmoidoscopy, manometry, and defecography were assessed. Results Mean operative time was 181.2 ± 41.6 minutes, blood loss 70.6 ± 30.6 mL, and hospital stay 4.1 ± 2.7 days. During median 8-month follow-up, two patients (10%) experienced partial recurrence. There was no mortality or major complications. Four patients developed transient hematuria, resolving conservatively. Significant improvements were observed in SMIS (18.6 ± 2.4 to 15.4 ± 2.8; p = 0.036) and ODS scores (16.3 ± 3.2 to 8.1 ± 3.9; p < 0.0001). Quality-of-life improved, while manometric and defecographic parameters were not significantly altered. Conclusions Total extraperitoneal anterior rectopexy is feasible and safe, avoiding peritoneal entry and sacral fixation while achieving favorable early outcomes. Larger, long-term validation is needed. Rectal prolapse extraperitoneal anterior rectopexy minimally invasive Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Introduction Rectal Prolapse is a debilitating, pathophysiological condition, causing significant impairment of quality of life. Clinical manifestations include physical symptoms of prolapse, mucus discharge, bleeding as well as functional symptoms of obstructed defecation and fecal incontinence. The overall incidence is 2.5/10,000 population being more common in the elderly multiparous females[ 1 ]. However, in Southeast Asia, there is a cohort of young male patients in whom rectal prolapse is commonly observed[ 2 , 3 ]. The definitive management remains surgery, which can be performed either through abdominal or the perineal route[ 4 , 5 , 6 ]. The perineal procedures (Delorme and Altemiers) are preferred in elderly comorbid patients with higher recurrence[ 5 , 6 ]. Abdominal transperitoneal procedures which are usually performed in younger patients, fix the rectum either ventrally or posteriorly to the sacrum using either sutures or a mesh. However, minimally invasive techniques have increasingly made these procedures feasible in elderly also. Laparoscopic or Robotic ventral mesh Rectopexy is the current preference for patients of prolapse and have better functional outcomes unlike most posterior abdominal approaches[ 7 ]. However, the potential concerns remain transgressing the peritoneum with the consequent risk of vessel, bowel injury, post operative adhesions, besides mesh and tac fixation issues[ 8 , 9 , 10 ] Our technique, total extraperitoneal anterior rectopexy addresses the above concerns. The technique fixes the rectum to the under surface of anterior abdominal wall extraperitoneally and is potentially less invasive. It also avoids posterior rectal dissection, sparing of lateral ligaments and nerves resulting in good functional outcomes. Additionally, it has the advantage of using sutures alone, or in combination with a mesh, besides avoiding breaching the peritoneum and its consequent complications. Objective: This study aims to present the preliminary report of our new technique Laparoscopic-Total Extraperitoneal Anterior Rectopexy (L-TEAR) in terms of feasibility, outcomes and safety. Study design: Prospective cohort study. Materials and methods This study was reviewed and approved by the institutional ethics committee of King George’s medical University, Lucknow, Uttar Pradesh, India vides protocol 11678 / 2024 dated 7/18/24. It was conducted at the Department of Surgical Gastroenterology of the Institute. Initial Studies: Initially 5 cadaveric dissections were carried out to define the anatomy of extraperitoneal rectum. The preperitoneal- retropubic space was entered behind the rectus muscle and expanded using C0 2 insufflation. The extraperitoneal rectum was suture fixed to the undersurface of anterior abdominal wall after separating it from the bladder, and transilluminating from below to aid in dissection. (Unpublished data, supplementary material). Subsequently the procedure was successfully performed in 7 human subjects and reported as a feasibility study[ 11 ]. Inclusion criteria: Patients of isolated complete rectal prolapse were duly explained the procedure and those willing to participate were included in the study. Informed consent was obtained from all participating subjects and routine fitness for general anesthesia obtained. Patients between 18 to 70 years of age BMI less than 28 kg/m 2 Exclusion criteria: Medically co-morbid patients unfit for anesthesia Patients who have underwent previous abdominal surgeries Irreducible rectal prolapse Multi compartment prolapse Preoperative work up: The Subjective evaluation included standard questionnaires for incontinence [SMIS (St. Marks Incontinence Score)][ 12 ], obstructive defecation syndrome (ODS) score[ 13 ], and a locally validated World Health Organization (WHO) score for quality-of-life assessment[ 14 ]. Objective assessment of patients was done by sigmoidoscopy, high-resolution anal manometry, and magnetic resonance (MR) defecography. All data was recorded in a standard format. Preoperative preparation: Patients were kept nil orally at least six hours prior to surgery. Preoperative mechanical bowel preparation was done using polyethylene glycol (PEGLEC)[ 15 ]. All patients were routinely catheterized, using a Foley catheter. External length of prolapsed rectum was measured from its apex to the anal verge. Equipment used: 1) Previously described indigenous Endo luminal fixator device, having a transparent silicone gel head and a hollow shaft, facilitating passage of a flexible endoscope within its lumen was used[ 16 ]. This instrument was inserted transanally to reduce the prolapsed rectum and to transilluminate it by transmitting light of the endoscope through the transparent gel head. This helped identify the pelvic rectum in extraperitoneal space. (Fig. 1 ) 2) Standard high-definition Karl Storz laparoscope (RUBINA4K32B) with 10 MM camera and 5 mm instruments were used for the procedure. Low insufflation CO 2 (10 mm Hg) was used to create the extraperitoneal- retropubic space. Procedure description: All surgeries were performed under general anaesthesia in modified lithotomy position. Prophylactic intravenous antibiotic (2nd generation cephalosporin) was administered at the time of induction. The procedure was performed in the following steps: Creation of extraperitoneal space- the ‘TEP plane’: 10 mm camera port was inserted 1 cm to left of umbilicus after incising the skin, subcutaneous tissue and anterior rectus sheath. The rectus muscle was then split to expose its posterior sheath. The camera and its port were inserted between the rectus and its posterior sheath beyond the arcuate line with simultaneous CO 2 insufflation. Together with gentle to and fro movement of the camera and ongoing low pressure (10 mmHg) CO 2 inflation, the extra peritoneal space was created. Gradually both the pubic rami were visualized, and the space expanded on either side till anterior superior iliac spine (Fig. 2 ). Two 5 mm working ports were then inserted in this space lateral to the linea semilunaris in the right lower abdomen (Fig. 3 ). Inadvertent entry into the peritoneum occurred in 3 patients. This required placement of a Veress needle intraperitoneally at the palmers point to let out CO2 and maintain the extraperitoneal space. Defining the anatomy: Identification of ureters: At the start, cystoscopic left ureter catheterization was done for intraoperative visualization of left ureter and bladder using ICG. (initial eight patients) Dissection was begun by visualizing vas deferens (in males), round ligament (in females) laterally emerging from the deep ring in front of the iliac vessels at the edge of peritoneum. These structures were traced medially towards the urinary bladder, defining the medial umbilical ligament. The left ureter was then identified lying below the medial part of vas or the round ligament (Fig. 4 a, 4 b). This was aided by 10 ml ICG injected through the ureteric catheter in the initial eight cases. (Fig. 4 c) Separation of urinary bladder and extraperitoneal rectum: The prolapsed rectum which lies to the left side of bladder (in males) and vagina (in females) was then gently separated from these structures by blunt dissection. The lower extra peritoneal rectum is flanked by obturator internus, arcus tendineus and obturator vessels laterally and the urinary bladder medially, below the pubic arch (Fig. 5 ). The dissection of rectum was done lateral to bladder, carefully avoiding the prevesical plexus of Santorini, which is anterior and in the midline[ 17 ]. Reduction and elevation of prolapsed rectum: The previously described indigenous endorectal fixator was used transanally to reduce and push the rectum inside. This also helped in its identification by transillumination from below and defining the recto vesical/ vaginal groove (Fig. 6 ). Preparation and fixation of mesh: A 2 cmx 10 cm dual mesh (Parietex, Covidien) was used for this purpose, 2 cm longer than the measured length of the prolapse (determined preoperatively). A traction suture was preplaced at the distal edge of the mesh strip. (Fig. 7 ). The mesh was rolled and inserted into the extraperitoneal space through the camera port. First pair of seromuscular PDS 2 − 0 sutures were taken at the distal most part of the rectum where levator merges with the arcus tendineus. The free ends of the suture were left inside, after passing the seromuscular suture bites through the distal most rectum and the mesh. Next, a stab incision was made at left inguinal ligament, anteriorly just lateral to the pubic tubercle. Suture passer needle was then passed into the retropubic space through this stab piercing the ileo pectineal ligament catching the free ends of the seromuscular bites which were then brought out through the abdominal wall (Fig. 8 a, 8 b). Series of 6–8 such seromuscular sutures were taken through the lower rectum and the mesh. These were then serially brought out through the respective stabs at the lower anterior abdominal wall, transfascially using the suture passer. Finally, the traction suture was delivered outside through a separate stab incision created 2cm above the proximal free end of the mesh, thereby providing adequate tension. (Fig. 9 ). Deflation of space and tying of sutures: The space was gradually deflated, abutting the anterior rectal wall with the mesh against the)undersurface of anterior abdominal wall. The free ends of all sutures were then tied off at the anterior abdominal wall serially, supported by the fixator device from below (transanally). This fixed the anterior rectum with the mesh to the anterior abdominal wall undersurface, within the extraperitoneal space. Video link- https://figshare.com/s/3f2bda751a41549ef43bss Completion cystoscopy and sigmoidoscopy: Before final closure of the port sites, routine cystoscopy and sigmoidoscopy was done to rule out any bladder or bowel injury and to ensure that the apex of prolapse had been pulled up and fixed. Post Operative Care: All patients were observed for 2 days following the procedure and carefully observed for any complications. Four patients had transient hematuria in the immediate post operative period which settled conservatively. Oral diet was started the next day and patients discharged on post operative day 2, after passage of first stools. Postoperative Follow-up Our postoperative follow-up protocol included ODS score for evaluation of constipation, SMIS for measuring incontinence, and a locally validated questionnaire to assess quality of life. These parameters were assessed at 1 month and 6 months after the procedure for all patients. Post procedure anal manometry, sigmoidoscopy, and MR defecography was also performed at 1 month on follow-up. Statistical analysis: Data were collected in a standard proforma and statistically analyzed using GraphPad Prism 10.0 (GraphPad Prism software, Inc., CA). Quantitative data were expressed as a percentage and mean with SD. The student t-test and the paired t-test were used for quantitative data analysis. Groups were compared using Student t test (unpaired) and Fisher exact probability test. The p value of < 0.05 was considered statistically significant. Results 30 patients with rectal prolapse were admitted in the department of Surgical Gastroenterology, King George’s Medical University during the study period. Of these 27 patients, 3 had recurrent disease, 3 had multi compartment prolapse, 2 were above 70 years while 2 were medically unfit for surgery and hence were excluded. A total of 20 patients (11 males, 9 females) with a mean age of 34.65 ± 14.23 (15–56) years and complete rectal prolapse underwent the procedure. Mean BMI of the group was 22.35 ± 5.06. Duration of symptoms ranged from 7 months to 36 years. 5 (25%) and 15 (75%) of the patients had incontinence and constipation before the procedure, respectively. 5 (25%) patients had history of bleeding per rectum. Table 1 Demographics and Clinical Presentation: Total No. of patients 20 Age 34.65 +/- 14.23 Gender 1. Male, n (%) 11 (55%) 2. Female, n (%) 9 (45%) BMI (kg/m2) 22.35 +/- 5.06 Duration of Symptoms 7 months to 36 years Fecal incontinence, n (%) 5 (25%) Constipation, n (%) 15 (75%) Bleeding per rectum, n (%) 5 (25%) The mean duration of the surgery was 181.25 ± 41.61 min, with a blood loss of 70.63 ± 30.65 mL, and a hospital stay of 4.1 ± 2.67 days. There was significant improvement in scores in patients with constipation (ODS score 16.34 ± 3.23 vs. 8.06 ± 3.85, p = < 0.0001) and with incontinence (SMIS 18.57 ± 2.43 vs. 14.43 ± 2.75, p = 0.0357) postoperatively. However, there was no significant change in resting (48.9 ± 22.12 vs. 59.35 ± 16.25, p = 0.0968) and squeeze (73.55 ± 31.79 vs. 84.88 ± 20.43, p = 0.1879) pressures on anorectal manometry after the procedure. There was improvement in anorectal angles at rest (114.37 ± 16.25 vs. 106.36 ± 12.02, p = 0.0844), on straining (117.9 ± 20.15 vs. 108.77 ± 14.41, p = 0.1076) and during defecation (124.40 ± 20.12 vs. 115.54 ± 14.56, p = 0.1189) measured on MR Defecography. However, this was not significant. Table 2 Preoperative and postoperative symptom scores, anorectal manometric pressures, and anorectal angles on MR defecography: Parameter Pre operative Post operative p Value ODSscore (patientswith constipation) 16.34 +/- 3.23 8.06 +/- 3.85 < 0.0001 SMIS (patients with incontinence) 18.57 +/- 2.43 15.43 +/- 2.75 0.0357 Analcanal pressure (mm Hg) 1. Resting 48.90 +/- 22.12 59.35 +/- 16.25 0.0968 2. Squeeze 73.55 +/- 31.79 84.88 +/- 20.43 0.1879 Anorectalangle (degrees) 1. Resting 114.37 +/- 16.25 106.36 +/- 12.02 0.0844 2. Straining 117.90 +/- 20.15 108.77 +/- 14.41 0.1076 3. Defecation 124.40 +/- 20.12 115.54 +/- 14.56 0.1189 4 (20%) patients developed transient hematuria in the post op period which resolved spontaneously. All patients are being followed up at the time of publication of this article. 2 patients had partial recurrence after a median follow up of 8 months. Perineal mucosal excision was done for one patient while the other is under observation. Patients reported a significant improvement in their quality- of-life as assessed using the locally validated World Health Organization (WHO) score for quality-of-life assessment. There was no mortality and two patients minor port site infections which responded to conservative treatment. Table 3 Intra operative and postoperative variables: Parameter Values Duration of surgery, min 181.25 +/- 41.61 Hospital stay, days 4.1 +/- 2.67 Blood Loss, mL 70.63 +/- 30.65 Recurrence (partial), n (%) 2 (10%) Recurrence (complete), n (%) 0 (0) Hematuria, n (%) 4 (20%) Discussion Complete rectal prolapse is intussusception of rectum through the anal verge. Besides the physical morbidity, it is often associated with functional abnormalities of obstructed defecation and fecal incontinence[ 4 ]. Although increasingly seen in elderly females, causing significant alteration in their quality of life, it is also common in young males in this part of the world[ 2 , 3 ]. Surgery remains the only curative treatment. Perineal approaches (Delorme/Altemiers) are preferred for elderly high-risk patients, but entail a higher risk of recurrence[ 5 , 6 ]. Minimally invasive abdominal approaches are preferred treatment options due to their better outcomes. Laparoscopic or robotic ventral mesh rectopexy is the current preferred treatment. It has a recurrence rate of 11.74% in the long-term, and improves functional symptoms of incontinence and obstructed defecation associated with prolapse[ 18 ]. This is attributed to avoiding posterior rectal dissection, preserving hypogastric nerves and the lateral stalk. However, some of the disadvantages of LVMR include transgression of abdominal cavity, mandatory use of a prosthetic mesh and complications of its fixation to the sacral promontory. The entry of peritoneal cavity entails risk of visceral and vascular injury, besides post operative adhesions of the bowel in the area of mesh fixation. The incidence of small bowel obstruction after LVMR varies from 1–4%, often due to adhesions in the retroperitonized mesh area[ 19 ]. The creation of pneumoperitoneum itself during the procedure impairs venous return, reducing cardiac output, a concern in compromised patients[ 20 ]. The use of a prosthetic mesh is controversial and a potential cause for litigation. Its use has now been discouraged for other procedures (stress urinary incontinence). In addition, tack fixation of the proximal mesh in this procedure has risks of bleeding, nerve dysfunction and spondylodiscitis[ 21 , 22 , 10 , 23 ]. In a recent cadaveric study, there was a significant variation in tack placement, with only 42.3% found on the right surface of the S1 vertebra, where actual deployment was planned[ 24 ]. Also, the average distance of a tack from major vessels (internal iliac) was just 10.5 mm and 32.1 mm from the right ureter, both causes of concern. All 14 hypogastric nerve plexus dissected, were found to be affected by tacks[ 10 ]. Transperitoneal anterior fixation of rectum to the abdominal wall as a treatment for rectal prolapse had been described by Pemberton but largely forgotten[ 25 ]. This however restores the natural ‘7S’ configuration of rectum which resists the positive intraabdominal pressure thereby preventing further organ prolapse[ 26 ]. Total extraperitoneal anterior rectopexy described restores the same configuration without entering the peritoneal cavity. The procedure also obviates the effects of pneumoperitoneum in compromised patients, besides reducing the risk of major visceral or major vascular injury and post operative small bowel adhesions. The risk of port site hernia after total extraperitoneal approach is reduced since the posterior sheath is intact[ 8 ]. Recently extraperitoneal colonic resections have also been reported[ 27 ]. Robotic extraperitoneal approach addressing uretero-vesical anomalies is described and found to be feasible and safe[ 28 ]. The expansion of extraperitoneal space displaces the pelvic peritoneum caudally, subsequent pulling up and anterior fixation of the rectum within this space also obliterates the deep cul-de-sac. The landmark for distal mesh fixation is the ileo-pectineal ligament and all sutures are taken above it below upwards, fixing the mesh along with the anterior rectum to the abdominal wall extraperitoneally. The procedure thus avoids tack fixation of the mesh to the sacrum and its associated risks. There is no posterior rectal dissection and damage to the hypogastric nerves, reflected in improved functional outcomes. The placement of mesh in extra peritoneal space may also reduce mesh related concerns. Additionally, the use of mesh may also be completely avoided and only sutures can be used instead in this procedure as reported previously[ 11 ]. The use of sutures alone is not possible in Laparoscopic / Robotic ventral mesh rectopexy. Our procedure is feasible and safe in its preliminary evaluation. All patients had a smooth post operative recovery. Transient hematuria, observed in initial 4 patients, resolved spontaneously. All patients were pain free next day and tolerated oral diet. Average hospital stay was 2 days, indicating early recovery. The SMIS and ODS scores were significantly better following surgery reflecting improved functional outcomes. However, there was no change in anal resting/squeeze pressures post operatively. Postoperative MR defecogram showed improvement in anorectal angles which could also contribute to better functional outcomes. The two early partial recurrences are reflection of the learning curve. This report has several limitations. It is a small, single centre study and requires a universal registry carefully documenting every case performed. Additionally, long term validation in a larger cohort of patients is necessary. Most surgeons are not familiar with the extraperitoneal surgical anatomy of this procedure. Identification of the left ureter and avoiding injury to the urinary bladder is critical. The use of indocyanine green (ICG) through intraoperative placement of ureteric catheter to visualise the left ureter, and through Foley’s catheter to visualise the bladder helps in their identification initially, (our first 8 patients). Ureteric catheterization may be avoided by just injecting ICG through the left ureteric orifice and not advancing the ureteric catheter. The use of novel fluorescent intravenous dyes to visualize the ureter intraoperatively may avoid ureteric catheterization altogether[ 29 ]. As one overcomes the learning curve (our initial 8 cases) this may not be required at all. Conclusion Laparoscopic Total extraperitoneal anterior rectopexy (L-TEAR) for complete rectal prolapse is feasible and safe in its preliminary evaluation. Its advantages include avoidance of entering the peritoneal cavity, placement of mesh in extraperitoneal space or use of just sutures alone to fix the rectum. It has good functional outcomes as well due to lack of posterior dissection. However, it requires familiarity with extraperitoneal pelvic anatomy and long-term validation in a larger patient cohort. Future directions: This procedure can be promising in elderly patients having multicompartment prolapse as it has hemodynamic advantages of extraperitoneal surgery. Besides it can be of advantage in patients with previous abdominal surgeries as the extraperitoneal plane would be virgin in this subset. The application of robotic surgery in future could make working in the limited extraperitoneal space technically easier. Declarations Conflict of interest: “Abhijit Chandra (corresponding author), Deeban Ganesan, Mahesh R, Arun Manoharan, Akash Agrawal, Pritheesh Rajan, Utkarsh Srivastava, Julie Shah have no conflict of interest or financial ties to disclose.” Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Previous presentation and submission: This study was not previously submitted nor presented anywhere. Video abstract statement: We agree to provide the video abstract after provisional acceptance of the manuscript. Word Count: Abstract: 249 words; Manuscript (excluding abstract, references, figures, tables and legends): 2992 words. Category for paper : Pelvic floor Order of Authors (With contributory roles) : 1. Abhijit Chandra (Conceptualization, Methodology, Formal Analysis, writing original draft, writing-review & editing, Supervision) 2. Deeban Ganesan (Conceptualization, Methodology, writing-review & editing) 3. Mahesh Rajashekhara (Methodology, writing-review & editing, Supervision) 4. Arun Manoharan (Data Curation, Methodology, Formal Analysis, writing review & editing) 5. Akash Agrawal (Data Curation, Methodology, Formal Analysis, writing review & editing) 6. Pritheesh Rajan (Methodology, writing-original draft, writing-review & editing, Supervision) 7. Rohit Jain (Methodology, writing-review & editing, Supervision) 8. Julie Shah (Data Curation, Methodology, Formal Analysis, writing review & editing) Author Contribution A.C. and D.G. did the conceptualization, A.C. and P.R. wrote the main manuscript, A.C., A.M., A.A., J.S. did formal analysis, A.M., A.A., J.S. did data curation, A.C., A.A, A.M. prepared all the figures and videos while A.C., M.R., P.R., R.J. provided supervision, and all authors did the Methodology and writing-review & editing. References Kairaluoma MV, Kellokumpu IH. 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Intraoperative ureter visualization using a near-infrared imaging agent. J Biomed Opt. 2019;24(6):1–8. doi: 10.1117/1.JBO.24.6.066004 Additional Declarations No competing interests reported. Supplementary Files CadaverFig1.jpg CadaverFig2.jpg CadaverFig4.jpg CadaverFig5.jpg cadavarfinalvideo.mp4 tearfinalvideo.mp4 Cite Share Download PDF Status: Published Journal Publication published 02 Mar, 2026 Read the published version in Techniques in Coloproctology → Version 1 posted Editorial decision: Revision requested 21 Nov, 2025 Reviews received at journal 18 Nov, 2025 Reviews received at journal 22 Oct, 2025 Reviewers agreed at journal 22 Oct, 2025 Reviewers agreed at journal 25 Sep, 2025 Reviewers invited by journal 25 Sep, 2025 Editor assigned by journal 21 Sep, 2025 Submission checks completed at journal 17 Sep, 2025 First submitted to journal 13 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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08:24:33","extension":"png","order_by":64,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":56734,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage9.png","url":"https://assets-eu.researchsquare.com/files/rs-7607010/v1/15710f9d82c8823ec1ff505d.png"},{"id":93018875,"identity":"1a50f955-1cf0-4312-ab22-1461a0c1b39e","added_by":"auto","created_at":"2025-10-08 08:24:33","extension":"xml","order_by":65,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":108803,"visible":true,"origin":"","legend":"","description":"","filename":"788c33f58533414b9a34279a870ffa761structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7607010/v1/cd703d0ecee8e84f68081726.xml"},{"id":93018877,"identity":"9b75e29e-9f3d-45e5-9869-74998597cf76","added_by":"auto","created_at":"2025-10-08 08:24:34","extension":"html","order_by":66,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":126154,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7607010/v1/02991ea215775be8b903cadc.html"},{"id":93018830,"identity":"6788f46b-7084-481c-aa09-ad610041ab2e","added_by":"auto","created_at":"2025-10-08 08:24:31","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":178051,"visible":true,"origin":"","legend":"\u003cp\u003eIndigenous Endo luminal fixator device\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7607010/v1/40b858b631660193ef86df67.png"},{"id":93019142,"identity":"5ed347ed-9215-4c90-a521-7772810100e3","added_by":"auto","created_at":"2025-10-08 08:32:33","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":469404,"visible":true,"origin":"","legend":"\u003cp\u003eExtraperitoneal space.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7607010/v1/02030bc811f9b88694dd7f23.png"},{"id":93018834,"identity":"3ac9fac0-39b2-43cd-bfd2-415fec83fbfd","added_by":"auto","created_at":"2025-10-08 08:24:31","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":440648,"visible":true,"origin":"","legend":"\u003cp\u003ePort positions.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7607010/v1/0641e39a4da78af8e3b6deca.png"},{"id":93019120,"identity":"e8c1abca-59d3-4792-801a-e967becad03a","added_by":"auto","created_at":"2025-10-08 08:32:31","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":237560,"visible":true,"origin":"","legend":"\u003cp\u003e4a Schematic relationship of extraperitoneal pelvic ureter, rectum, vas deferens and other structures.\u003c/p\u003e\n\u003cp\u003e4b Relationship of extraperitoneal pelvic ureter with vas deferens and medial umbilical ligament\u003c/p\u003e\n\u003cp\u003e4c Identification of extraperitoneal pelvic ureter using ICG\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7607010/v1/5b1acc263ddd4baae24a1505.png"},{"id":93018832,"identity":"fd0cc7b2-0e2e-40ed-a97b-ca8309dbface","added_by":"auto","created_at":"2025-10-08 08:24:31","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":401373,"visible":true,"origin":"","legend":"\u003cp\u003eExtraperitoneal pelvic anatomy demonstrating the operative field.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-7607010/v1/4ea78f5a4303085cd7529994.png"},{"id":93018825,"identity":"ca077627-7549-473c-83d6-6f9020b2584b","added_by":"auto","created_at":"2025-10-08 08:24:31","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":422319,"visible":true,"origin":"","legend":"\u003cp\u003eTransillumination of Rectum and the recto-vesical groove\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-7607010/v1/10b87e6b480f1f9bd3ab451b.png"},{"id":93018822,"identity":"537c8178-bf6e-448e-aa4d-52f93eb22290","added_by":"auto","created_at":"2025-10-08 08:24:31","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":397923,"visible":true,"origin":"","legend":"\u003cp\u003eMesh with pre placed traction suture\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-7607010/v1/b895980b66b1e1ad8f3343cb.png"},{"id":93018862,"identity":"041ac323-091c-4ae1-807c-8dc58c7f89a4","added_by":"auto","created_at":"2025-10-08 08:24:33","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":250722,"visible":true,"origin":"","legend":"\u003cp\u003e8a Distal seromuscular suture through rectum and mesh\u003c/p\u003e\n\u003cp\u003e8b Passage of suture passer through the abdominal wall and ileo-pectineal ligament into the extraperitoneal space.\u003c/p\u003e","description":"","filename":"8.png","url":"https://assets-eu.researchsquare.com/files/rs-7607010/v1/0f4814ad875235eba98596e2.png"},{"id":93019121,"identity":"a6c6a8b3-e946-47c0-a143-455ec3dafa25","added_by":"auto","created_at":"2025-10-08 08:32:31","extension":"png","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":363255,"visible":true,"origin":"","legend":"\u003cp\u003eTransfascially placed anchoring seromuscular sutures and traction suture delivered at the anterior abdominal wall.\u003c/p\u003e","description":"","filename":"9.png","url":"https://assets-eu.researchsquare.com/files/rs-7607010/v1/c74b54e340073537de3cd4d3.png"},{"id":104251558,"identity":"c6b1ae27-6131-401d-89bc-4c1b768a22f7","added_by":"auto","created_at":"2026-03-09 16:14:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5176093,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7607010/v1/6cb4c4b3-6663-4138-84ef-7b0f5ba82821.pdf"},{"id":93019125,"identity":"4b607670-d4f2-45d5-8364-ce491b03de3a","added_by":"auto","created_at":"2025-10-08 08:32:31","extension":"jpg","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":101902,"visible":true,"origin":"","legend":"","description":"","filename":"CadaverFig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7607010/v1/21e0787089ff641818289855.jpg"},{"id":93018817,"identity":"b982f7c0-ae18-408f-8a3b-a39839b0e599","added_by":"auto","created_at":"2025-10-08 08:24:31","extension":"jpg","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":65824,"visible":true,"origin":"","legend":"","description":"","filename":"CadaverFig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7607010/v1/7a387d2742a73ba12b02953b.jpg"},{"id":93019124,"identity":"31fa19a3-ff24-47c8-aa45-088a01702fdc","added_by":"auto","created_at":"2025-10-08 08:32:31","extension":"jpg","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":62801,"visible":true,"origin":"","legend":"","description":"","filename":"CadaverFig4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7607010/v1/f6b909caa2f1912deee36fc2.jpg"},{"id":93018819,"identity":"b2505f4b-1935-41c4-85c2-11559d77298d","added_by":"auto","created_at":"2025-10-08 08:24:31","extension":"jpg","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":112954,"visible":true,"origin":"","legend":"","description":"","filename":"CadaverFig5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7607010/v1/41441adeb057fd59a50fa420.jpg"},{"id":93018836,"identity":"a77f1192-d221-4457-a489-3dca7d89283e","added_by":"auto","created_at":"2025-10-08 08:24:32","extension":"mp4","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":11764790,"visible":true,"origin":"","legend":"","description":"","filename":"cadavarfinalvideo.mp4","url":"https://assets-eu.researchsquare.com/files/rs-7607010/v1/96195221c4b592ae6cfcab57.mp4"},{"id":93018882,"identity":"f6eb2594-0a21-4fb2-a0c9-5fd15381344e","added_by":"auto","created_at":"2025-10-08 08:24:37","extension":"mp4","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":114810629,"visible":true,"origin":"","legend":"","description":"","filename":"tearfinalvideo.mp4","url":"https://assets-eu.researchsquare.com/files/rs-7607010/v1/ecb597fce79a8d30c119ab0a.mp4"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eLaparoscopic-Total Extraperitoneal Anterior Rectopexy (L-TEAR)-A preliminary report\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRectal Prolapse is a debilitating, pathophysiological condition, causing significant impairment of quality of life. Clinical manifestations include physical symptoms of prolapse, mucus discharge, bleeding as well as functional symptoms of obstructed defecation and fecal incontinence. The overall incidence is 2.5/10,000 population being more common in the elderly multiparous females[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, in Southeast Asia, there is a cohort of young male patients in whom rectal prolapse is commonly observed[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The definitive management remains surgery, which can be performed either through abdominal or the perineal route[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The perineal procedures (Delorme and Altemiers) are preferred in elderly comorbid patients with higher recurrence[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Abdominal transperitoneal procedures which are usually performed in younger patients, fix the rectum either ventrally or posteriorly to the sacrum using either sutures or a mesh. However, minimally invasive techniques have increasingly made these procedures feasible in elderly also. Laparoscopic or Robotic ventral mesh Rectopexy is the current preference for patients of prolapse and have better functional outcomes unlike most posterior abdominal approaches[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, the potential concerns remain transgressing the peritoneum with the consequent risk of vessel, bowel injury, post operative adhesions, besides mesh and tac fixation issues[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eOur technique, total extraperitoneal anterior rectopexy addresses the above concerns. The technique fixes the rectum to the under surface of anterior abdominal wall extraperitoneally and is potentially less invasive. It also avoids posterior rectal dissection, sparing of lateral ligaments and nerves resulting in good functional outcomes. Additionally, it has the advantage of using sutures alone, or in combination with a mesh, besides avoiding breaching the peritoneum and its consequent complications.\u003c/p\u003e\u003cp\u003eObjective:\u003c/p\u003e\u003cp\u003eThis study aims to present the preliminary report of our new technique Laparoscopic-Total Extraperitoneal Anterior Rectopexy (L-TEAR) in terms of feasibility, outcomes and safety.\u003c/p\u003e\u003cp\u003eStudy design:\u003c/p\u003e\u003cp\u003eProspective cohort study.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eThis study was reviewed and approved by the institutional ethics committee of King George\u0026rsquo;s medical University, Lucknow, Uttar Pradesh, India vides protocol 11678 / 2024 dated 7/18/24. It was conducted at the Department of Surgical Gastroenterology of the Institute.\u003c/p\u003e\u003cp\u003eInitial Studies:\u003c/p\u003e\u003cp\u003eInitially 5 cadaveric dissections were carried out to define the anatomy of extraperitoneal rectum. The preperitoneal- retropubic space was entered behind the rectus muscle and expanded using C0 2 insufflation. The extraperitoneal rectum was suture fixed to the undersurface of anterior abdominal wall after separating it from the bladder, and transilluminating from below to aid in dissection. (Unpublished data, supplementary material). Subsequently the procedure was successfully performed in 7 human subjects and reported as a feasibility study[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eInclusion criteria:\u003c/p\u003e\u003cp\u003ePatients of isolated complete rectal prolapse were duly explained the procedure and those willing to participate were included in the study. Informed consent was obtained from all participating subjects and routine fitness for general anesthesia obtained.\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003ePatients between 18 to 70 years of age\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eBMI less than 28 kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eExclusion criteria:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eMedically co-morbid patients unfit for anesthesia\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003ePatients who have underwent previous abdominal surgeries\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eIrreducible rectal prolapse\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eMulti compartment prolapse\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003ePreoperative work up:\u003c/p\u003e\u003cp\u003eThe Subjective evaluation included standard questionnaires for incontinence [SMIS (St. Marks Incontinence Score)][\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], obstructive defecation syndrome (ODS) score[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], and a locally validated World Health Organization (WHO) score for quality-of-life assessment[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Objective assessment of patients was done by sigmoidoscopy, high-resolution anal manometry, and magnetic resonance (MR) defecography. All data was recorded in a standard format.\u003c/p\u003e\u003cp\u003ePreoperative preparation:\u003c/p\u003e\u003cp\u003ePatients were kept nil orally at least six hours prior to surgery. Preoperative mechanical bowel preparation was done using polyethylene glycol (PEGLEC)[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. All patients were routinely catheterized, using a Foley catheter. External length of prolapsed rectum was measured from its apex to the anal verge.\u003c/p\u003e\u003cp\u003eEquipment used:\u003c/p\u003e\u003cp\u003e1) Previously described indigenous Endo luminal fixator device, having a transparent silicone gel head and a hollow shaft, facilitating passage of a flexible endoscope within its lumen was used[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This instrument was inserted transanally to reduce the prolapsed rectum and to transilluminate it by transmitting light of the endoscope through the transparent gel head. This helped identify the pelvic rectum in extraperitoneal space. (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e2) Standard high-definition Karl Storz laparoscope (RUBINA4K32B) with 10 MM camera and 5 mm instruments were used for the procedure. Low insufflation CO\u003csub\u003e2\u003c/sub\u003e (10 mm Hg) was used to create the extraperitoneal- retropubic space.\u003c/p\u003e\u003cp\u003eProcedure description:\u003c/p\u003e\u003cp\u003eAll surgeries were performed under general anaesthesia in modified lithotomy position. Prophylactic intravenous antibiotic (2nd generation cephalosporin) was administered at the time of induction. The procedure was performed in the following steps:\u003c/p\u003e\u003cp\u003eCreation of extraperitoneal space- the \u0026lsquo;TEP plane\u0026rsquo;:\u003c/p\u003e\u003cp\u003e10 mm camera port was inserted 1 cm to left of umbilicus after incising the skin, subcutaneous tissue and anterior rectus sheath. The rectus muscle was then split to expose its posterior sheath. The camera and its port were inserted between the rectus and its posterior sheath beyond the arcuate line with simultaneous CO\u003csub\u003e2\u003c/sub\u003e insufflation. Together with gentle to and fro movement of the camera and ongoing low pressure (10 mmHg) CO\u003csub\u003e2\u003c/sub\u003e inflation, the extra peritoneal space was created. Gradually both the pubic rami were visualized, and the space expanded on either side till anterior superior iliac spine (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Two 5 mm working ports were then inserted in this space lateral to the linea semilunaris in the right lower abdomen (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Inadvertent entry into the peritoneum occurred in 3 patients. This required placement of a Veress needle intraperitoneally at the palmers point to let out CO2 and maintain the extraperitoneal space.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eDefining the anatomy:\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eIdentification of ureters:\u003c/p\u003e\u003cp\u003eAt the start, cystoscopic left ureter catheterization was done for intraoperative visualization of left ureter and bladder using ICG. (initial eight patients)\u003c/p\u003e\u003cp\u003eDissection was begun by visualizing vas deferens (in males), round ligament (in females) laterally emerging from the deep ring in front of the iliac vessels at the edge of peritoneum. These structures were traced medially towards the urinary bladder, defining the medial umbilical ligament. The left ureter was then identified lying below the medial part of vas or the round ligament (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e4\u003c/span\u003ea, \u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e4\u003c/span\u003eb). This was aided by 10 ml ICG injected through the ureteric catheter in the initial eight cases. (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e4\u003c/span\u003ec)\u003c/p\u003e\u003cp\u003eSeparation of urinary bladder and extraperitoneal rectum:\u003c/p\u003e\u003cp\u003eThe prolapsed rectum which lies to the left side of bladder (in males) and vagina (in females) was then gently separated from these structures by blunt dissection. The lower extra peritoneal rectum is flanked by obturator internus, arcus tendineus and obturator vessels laterally and the urinary bladder medially, below the pubic arch (Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e5\u003c/span\u003e). The dissection of rectum was done lateral to bladder, carefully avoiding the prevesical plexus of Santorini, which is anterior and in the midline[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eReduction and elevation of prolapsed rectum:\u003c/p\u003e\u003cp\u003eThe previously described indigenous endorectal fixator was used transanally to reduce and push the rectum inside. This also helped in its identification by transillumination from below and defining the recto vesical/ vaginal groove (Fig.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePreparation and fixation of mesh:\u003c/p\u003e\u003cp\u003eA 2 cmx 10 cm dual mesh (Parietex, Covidien) was used for this purpose, 2 cm longer than the measured length of the prolapse (determined preoperatively). A traction suture was preplaced at the distal edge of the mesh strip. (Fig.\u0026nbsp;\u003cspan refid=\"Fig10\" class=\"InternalRef\"\u003e7\u003c/span\u003e). The mesh was rolled and inserted into the extraperitoneal space through the camera port.\u003c/p\u003e\u003cp\u003eFirst pair of seromuscular PDS 2\u0026thinsp;\u0026minus;\u0026thinsp;0 sutures were taken at the distal most part of the rectum where levator merges with the arcus tendineus. The free ends of the suture were left inside, after passing the seromuscular suture bites through the distal most rectum and the mesh. Next, a stab incision was made at left inguinal ligament, anteriorly just lateral to the pubic tubercle. Suture passer needle was then passed into the retropubic space through this stab piercing the ileo pectineal ligament catching the free ends of the seromuscular bites which were then brought out through the abdominal wall (Fig.\u0026nbsp;\u003cspan refid=\"Fig12\" class=\"InternalRef\"\u003e8\u003c/span\u003ea, \u003cspan refid=\"Fig12\" class=\"InternalRef\"\u003e8\u003c/span\u003eb).\u003c/p\u003e\u003cp\u003eSeries of 6\u0026ndash;8 such seromuscular sutures were taken through the lower rectum and the mesh. These were then serially brought out through the respective stabs at the lower anterior abdominal wall, transfascially using the suture passer.\u003c/p\u003e\u003cp\u003eFinally, the traction suture was delivered outside through a separate stab incision created 2cm above the proximal free end of the mesh, thereby providing adequate tension. (Fig.\u0026nbsp;\u003cspan refid=\"Fig13\" class=\"InternalRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eDeflation of space and tying of sutures:\u003c/p\u003e\u003cp\u003eThe space was gradually deflated, abutting the anterior rectal wall with the mesh against the)undersurface of anterior abdominal wall. The free ends of all sutures were then tied off at the anterior abdominal wall serially, supported by the fixator device from below (transanally). This fixed the anterior rectum with the mesh to the anterior abdominal wall undersurface, within the extraperitoneal space. Video link- \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://figshare.com/s/3f2bda751a41549ef43bss\u003c/span\u003e\u003cspan address=\"https://figshare.com/s/3f2bda751a41549ef43bss\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003cp\u003eCompletion cystoscopy and sigmoidoscopy:\u003c/p\u003e\u003cp\u003eBefore final closure of the port sites, routine cystoscopy and sigmoidoscopy was done to rule out any bladder or bowel injury and to ensure that the apex of prolapse had been pulled up and fixed.\u003c/p\u003e\u003cp\u003ePost Operative Care:\u003c/p\u003e\u003cp\u003eAll patients were observed for 2 days following the procedure and carefully observed for any complications. Four patients had transient hematuria in the immediate post operative period which settled conservatively. Oral diet was started the next day and patients discharged on post operative day 2, after passage of first stools.\u003c/p\u003e\u003cp\u003ePostoperative Follow-up\u003c/p\u003e\u003cp\u003eOur postoperative follow-up protocol included ODS score for evaluation of constipation, SMIS for measuring incontinence, and a locally validated questionnaire to assess quality of life. These parameters were assessed at 1 month and 6 months after the procedure for all patients. Post procedure anal manometry, sigmoidoscopy, and MR defecography was also performed at 1 month on follow-up.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis:\u003c/h2\u003e\u003cp\u003eData were collected in a standard proforma and statistically analyzed using GraphPad Prism 10.0 (GraphPad Prism software, Inc., CA). Quantitative data were expressed as a percentage and mean with SD. The student t-test and the paired t-test were used for quantitative data analysis. Groups were compared using Student t test (unpaired) and Fisher exact probability test. The p value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e30 patients with rectal prolapse were admitted in the department of Surgical Gastroenterology, King George\u0026rsquo;s Medical University during the study period. Of these 27 patients, 3 had recurrent disease, 3 had multi compartment prolapse, 2 were above 70 years while 2 were medically unfit for surgery and hence were excluded. A total of 20 patients (11 males, 9 females) with a mean age of 34.65\u0026thinsp;\u0026plusmn;\u0026thinsp;14.23 (15\u0026ndash;56) years and complete rectal prolapse underwent the procedure. Mean BMI of the group was 22.35\u0026thinsp;\u0026plusmn;\u0026thinsp;5.06. Duration of symptoms ranged from 7 months to 36 years. 5 (25%) and 15 (75%) of the patients had incontinence and constipation before the procedure, respectively. 5 (25%) patients had history of bleeding per rectum.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographics and Clinical Presentation:\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal No. of patients\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e34.65 +/- 14.23\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e1. Male, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e11 (55%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e2. Female, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e9 (45%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBMI (kg/m2)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e22.35 +/- 5.06\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDuration of Symptoms\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e7 months to 36 years\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFecal incontinence, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e5 (25%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eConstipation, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e15 (75%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBleeding per rectum, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e5 (25%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe mean duration of the surgery was 181.25\u0026thinsp;\u0026plusmn;\u0026thinsp;41.61 min, with a blood loss of 70.63\u0026thinsp;\u0026plusmn;\u0026thinsp;30.65 mL, and a hospital stay of 4.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.67 days.\u003c/p\u003e\u003cp\u003eThere was significant improvement in scores in patients with constipation (ODS score 16.34\u0026thinsp;\u0026plusmn;\u0026thinsp;3.23 vs. 8.06\u0026thinsp;\u0026plusmn;\u0026thinsp;3.85, p\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) and with incontinence (SMIS 18.57\u0026thinsp;\u0026plusmn;\u0026thinsp;2.43 vs. 14.43\u0026thinsp;\u0026plusmn;\u0026thinsp;2.75, p\u0026thinsp;=\u0026thinsp;0.0357) postoperatively.\u003c/p\u003e\u003cp\u003eHowever, there was no significant change in resting (48.9\u0026thinsp;\u0026plusmn;\u0026thinsp;22.12 vs. 59.35\u0026thinsp;\u0026plusmn;\u0026thinsp;16.25, p\u0026thinsp;=\u0026thinsp;0.0968) and squeeze (73.55\u0026thinsp;\u0026plusmn;\u0026thinsp;31.79 vs. 84.88\u0026thinsp;\u0026plusmn;\u0026thinsp;20.43, p\u0026thinsp;=\u0026thinsp;0.1879) pressures on anorectal manometry after the procedure.\u003c/p\u003e\u003cp\u003eThere was improvement in anorectal angles at rest (114.37\u0026thinsp;\u0026plusmn;\u0026thinsp;16.25 vs. 106.36\u0026thinsp;\u0026plusmn;\u0026thinsp;12.02, p\u0026thinsp;=\u0026thinsp;0.0844), on straining (117.9\u0026thinsp;\u0026plusmn;\u0026thinsp;20.15 vs. 108.77\u0026thinsp;\u0026plusmn;\u0026thinsp;14.41, p\u0026thinsp;=\u0026thinsp;0.1076) and during defecation (124.40\u0026thinsp;\u0026plusmn;\u0026thinsp;20.12 vs. 115.54\u0026thinsp;\u0026plusmn;\u0026thinsp;14.56, p\u0026thinsp;=\u0026thinsp;0.1189) measured on MR Defecography. However, this was not significant.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePreoperative and postoperative symptom scores, anorectal manometric pressures, and anorectal angles on MR defecography:\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026minus;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026minus;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParameter\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePre operative\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePost operative\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep Value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eODSscore\u003c/p\u003e\u003cp\u003e(patientswith constipation)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16.34 +/- 3.23\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.06 +/- 3.85\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e\u0026lt;\u0026thinsp;0.0001\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSMIS (patients with incontinence)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18.57 +/- 2.43\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15.43 +/- 2.75\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e0.0357\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAnalcanal pressure (mm Hg)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e1. Resting\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e48.90 +/- 22.12\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e59.35 +/- 16.25\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.0968\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e2. Squeeze\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e73.55 +/- 31.79\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e84.88 +/- 20.43\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.1879\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAnorectalangle (degrees)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e1. Resting\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e114.37 +/- 16.25\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e106.36 +/- 12.02\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.0844\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e2. Straining\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e117.90 +/- 20.15\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e108.77 +/- 14.41\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.1076\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e3. Defecation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e124.40 +/- 20.12\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e115.54 +/- 14.56\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.1189\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e4 (20%) patients developed transient hematuria in the post op period which resolved spontaneously. All patients are being followed up at the time of publication of this article. 2 patients had partial recurrence after a median follow up of 8 months. Perineal mucosal excision was done for one patient while the other is under observation. Patients reported a significant improvement in their quality- of-life as assessed using the locally validated World Health Organization (WHO) score for quality-of-life assessment. There was no mortality and two patients minor port site infections which responded to conservative treatment.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eIntra operative and postoperative variables:\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParameter\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eValues\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDuration of surgery, min\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e181.25 +/- 41.61\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHospital stay, days\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.1 +/- 2.67\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBlood Loss, mL\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e70.63 +/- 30.65\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRecurrence (partial), n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e2 (10%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRecurrence (complete), n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e0 (0)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHematuria, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e4 (20%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eComplete rectal prolapse is intussusception of rectum through the anal verge. Besides the physical morbidity, it is often associated with functional abnormalities of obstructed defecation and fecal incontinence[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Although increasingly seen in elderly females, causing significant alteration in their quality of life, it is also common in young males in this part of the world[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSurgery remains the only curative treatment. Perineal approaches (Delorme/Altemiers) are preferred for elderly high-risk patients, but entail a higher risk of recurrence[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Minimally invasive abdominal approaches are preferred treatment options due to their better outcomes. Laparoscopic or robotic ventral mesh rectopexy is the current preferred treatment. It has a recurrence rate of 11.74% in the long-term, and improves functional symptoms of incontinence and obstructed defecation associated with prolapse[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This is attributed to avoiding posterior rectal dissection, preserving hypogastric nerves and the lateral stalk.\u003c/p\u003e\u003cp\u003eHowever, some of the disadvantages of LVMR include transgression of abdominal cavity, mandatory use of a prosthetic mesh and complications of its fixation to the sacral promontory. The entry of peritoneal cavity entails risk of visceral and vascular injury, besides post operative adhesions of the bowel in the area of mesh fixation. The incidence of small bowel obstruction after LVMR varies from 1\u0026ndash;4%, often due to adhesions in the retroperitonized mesh area[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The creation of pneumoperitoneum itself during the procedure impairs venous return, reducing cardiac output, a concern in compromised patients[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The use of a prosthetic mesh is controversial and a potential cause for litigation. Its use has now been discouraged for other procedures (stress urinary incontinence). In addition, tack fixation of the proximal mesh in this procedure has risks of bleeding, nerve dysfunction and spondylodiscitis[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In a recent cadaveric study, there was a significant variation in tack placement, with only 42.3% found on the right surface of the S1 vertebra, where actual deployment was planned[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Also, the average distance of a tack from major vessels (internal iliac) was just 10.5 mm and 32.1 mm from the right ureter, both causes of concern. All 14 hypogastric nerve plexus dissected, were found to be affected by tacks[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTransperitoneal anterior fixation of rectum to the abdominal wall as a treatment for rectal prolapse had been described by Pemberton but largely forgotten[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. This however restores the natural \u0026lsquo;7S\u0026rsquo; configuration of rectum which resists the positive intraabdominal pressure thereby preventing further organ prolapse[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Total extraperitoneal anterior rectopexy described restores the same configuration without entering the peritoneal cavity. The procedure also obviates the effects of pneumoperitoneum in compromised patients, besides reducing the risk of major visceral or major vascular injury and post operative small bowel adhesions. The risk of port site hernia after total extraperitoneal approach is reduced since the posterior sheath is intact[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Recently extraperitoneal colonic resections have also been reported[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Robotic extraperitoneal approach addressing uretero-vesical anomalies is described and found to be feasible and safe[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe expansion of extraperitoneal space displaces the pelvic peritoneum caudally, subsequent pulling up and anterior fixation of the rectum within this space also obliterates the deep cul-de-sac. The landmark for distal mesh fixation is the ileo-pectineal ligament and all sutures are taken above it below upwards, fixing the mesh along with the anterior rectum to the abdominal wall extraperitoneally. The procedure thus avoids tack fixation of the mesh to the sacrum and its associated risks. There is no posterior rectal dissection and damage to the hypogastric nerves, reflected in improved functional outcomes. The placement of mesh in extra peritoneal space may also reduce mesh related concerns. Additionally, the use of mesh may also be completely avoided and only sutures can be used instead in this procedure as reported previously[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The use of sutures alone is not possible in Laparoscopic / Robotic ventral mesh rectopexy.\u003c/p\u003e\u003cp\u003eOur procedure is feasible and safe in its preliminary evaluation. All patients had a smooth post operative recovery. Transient hematuria, observed in initial 4 patients, resolved spontaneously. All patients were pain free next day and tolerated oral diet. Average hospital stay was 2 days, indicating early recovery. The SMIS and ODS scores were significantly better following surgery reflecting improved functional outcomes. However, there was no change in anal resting/squeeze pressures post operatively. Postoperative MR defecogram showed improvement in anorectal angles which could also contribute to better functional outcomes. The two early partial recurrences are reflection of the learning curve.\u003c/p\u003e\u003cp\u003eThis report has several limitations. It is a small, single centre study and requires a universal registry carefully documenting every case performed. Additionally, long term validation in a larger cohort of patients is necessary.\u003c/p\u003e\u003cp\u003eMost surgeons are not familiar with the extraperitoneal surgical anatomy of this procedure. Identification of the left ureter and avoiding injury to the urinary bladder is critical. The use of indocyanine green (ICG) through intraoperative placement of ureteric catheter to visualise the left ureter, and through Foley\u0026rsquo;s catheter to visualise the bladder helps in their identification initially, (our first 8 patients). Ureteric catheterization may be avoided by just injecting ICG through the left ureteric orifice and not advancing the ureteric catheter. The use of novel fluorescent intravenous dyes to visualize the ureter intraoperatively may avoid ureteric catheterization altogether[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. As one overcomes the learning curve (our initial 8 cases) this may not be required at all.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eLaparoscopic Total extraperitoneal anterior rectopexy (L-TEAR) for complete rectal prolapse is feasible and safe in its preliminary evaluation. Its advantages include avoidance of entering the peritoneal cavity, placement of mesh in extraperitoneal space or use of just sutures alone to fix the rectum. It has good functional outcomes as well due to lack of posterior dissection. However, it requires familiarity with extraperitoneal pelvic anatomy and long-term validation in a larger patient cohort.\u003c/p\u003e\u003cp\u003eFuture directions:\u003c/p\u003e\u003cp\u003eThis procedure can be promising in elderly patients having multicompartment prolapse as it has hemodynamic advantages of extraperitoneal surgery. Besides it can be of advantage in patients with previous abdominal surgeries as the extraperitoneal plane would be virgin in this subset. The application of robotic surgery in future could make working in the limited extraperitoneal space technically easier.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eConflict of interest: \u0026ldquo;Abhijit Chandra (corresponding author), Deeban Ganesan, Mahesh R, Arun Manoharan, Akash Agrawal, Pritheesh Rajan, Utkarsh Srivastava, Julie Shah have no conflict of interest or financial ties to disclose.\u0026rdquo;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFunding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePrevious presentation and submission: This study was not previously submitted nor presented anywhere.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eVideo abstract statement: We agree to provide the video abstract after provisional acceptance of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWord Count: Abstract: 249 words; Manuscript (excluding abstract, references, figures, tables and legends): 2992 words.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCategory for paper : Pelvic floor\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOrder of Authors (With contributory roles) :\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1. Abhijit Chandra (Conceptualization, Methodology, Formal Analysis, writing original draft, writing-review \u0026amp; editing, Supervision)\u003c/p\u003e\n\u003cp\u003e2. Deeban Ganesan (Conceptualization, Methodology, writing-review \u0026amp; editing)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3. Mahesh Rajashekhara (Methodology, writing-review \u0026amp; editing, Supervision)\u003c/p\u003e\n\u003cp\u003e4. Arun Manoharan (Data Curation, Methodology, Formal Analysis, writing review \u0026amp; editing)\u003c/p\u003e\n\u003cp\u003e5. Akash Agrawal (Data Curation, Methodology, Formal Analysis, writing review \u0026amp; editing)\u003c/p\u003e\n\u003cp\u003e6. Pritheesh Rajan (Methodology, writing-original draft, writing-review \u0026amp; editing, Supervision)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e7. Rohit Jain (Methodology, writing-review \u0026amp; editing, Supervision)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e8. Julie Shah (Data Curation, Methodology, Formal Analysis, writing review \u0026amp; editing)\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eA.C. and D.G. did the conceptualization, A.C. and P.R. wrote the main manuscript, A.C., A.M., A.A., J.S. did formal analysis, A.M., A.A., J.S. did data curation, A.C., A.A, A.M. prepared all the figures and videos while A.C., M.R., P.R., R.J. provided supervision, and all authors did the Methodology and writing-review \u0026amp; editing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKairaluoma MV, Kellokumpu IH. 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Intraoperative ureter visualization using a near-infrared imaging agent. \u003cem\u003eJ Biomed Opt.\u003c/em\u003e 2019;24(6):1\u0026ndash;8. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1117/1.JBO.24.6.066004\u003c/span\u003e\u003cspan address=\"10.1117/1.JBO.24.6.066004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"techniques-in-coloproctology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tcol","sideBox":"Learn more about [Techniques in Coloproctology](http://link.springer.com/journal/10151)","snPcode":"10151","submissionUrl":"https://submission.nature.com/new-submission/10151/3","title":"Techniques in Coloproctology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Rectal prolapse, extraperitoneal, anterior rectopexy, minimally invasive","lastPublishedDoi":"10.21203/rs.3.rs-7607010/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7607010/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eRectal prolapse, associated incontinence and obstruction significantly impair quality of life. Minimally invasive ventral mesh rectopexy, the current standard, being transperitoneal entails risks of vascular, bowel injury, adhesions, besides mesh and tac fixation issues. This study evaluates the feasibility, safety, and short-term outcomes of a novel \u003cb\u003etotal extraperitoneal anterior rectopexy\u003c/b\u003e that avoids peritoneal transgression and sacral fixation.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eIn this prospective single-center study conducted from July 2024 till date, 20 patients (11 males, 9 females; mean age 34.6\u0026thinsp;\u0026plusmn;\u0026thinsp;14.2 years) with complete rectal prolapse, body mass index\u0026thinsp;\u0026lt;\u0026thinsp;28 kg/m\u0026sup2;, without prior abdominal surgery underwent this procedure which involved transfascial rectal fixation to the abdominal wall with preperitoneal mesh placement. Operative variables, complications, recurrence, functional outcomes [St. Mark\u0026rsquo;s Incontinence Score (SMIS), Obstructed Defecation Syndrome (ODS) score, quality-of-life questionnaires] sigmoidoscopy, manometry, and defecography were assessed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eMean operative time was 181.2\u0026thinsp;\u0026plusmn;\u0026thinsp;41.6 minutes, blood loss 70.6\u0026thinsp;\u0026plusmn;\u0026thinsp;30.6 mL, and hospital stay 4.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7 days. During median 8-month follow-up, two patients (10%) experienced partial recurrence. There was no mortality or major complications. Four patients developed transient hematuria, resolving conservatively. Significant improvements were observed in SMIS (18.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4 to 15.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.036) and ODS scores (16.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2 to 8.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Quality-of-life improved, while manometric and defecographic parameters were not significantly altered.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eTotal extraperitoneal anterior rectopexy is feasible and safe, avoiding peritoneal entry and sacral fixation while achieving favorable early outcomes. Larger, long-term validation is needed.\u003c/p\u003e","manuscriptTitle":"Laparoscopic-Total Extraperitoneal Anterior Rectopexy (L-TEAR)-A preliminary report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-08 08:24:25","doi":"10.21203/rs.3.rs-7607010/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-21T12:38:31+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-18T21:34:13+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-22T19:26:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"88076973748713904991494687162989379488","date":"2025-10-22T09:15:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"22569055056426805669099069639749817012","date":"2025-09-25T13:02:42+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-25T08:10:07+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-21T19:52:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-17T12:30:06+00:00","index":"","fulltext":""},{"type":"submitted","content":"Techniques in Coloproctology","date":"2025-09-13T11:21:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"techniques-in-coloproctology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tcol","sideBox":"Learn more about [Techniques in Coloproctology](http://link.springer.com/journal/10151)","snPcode":"10151","submissionUrl":"https://submission.nature.com/new-submission/10151/3","title":"Techniques in Coloproctology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"e86c8c84-d4f8-4bfe-b223-68093dd3756f","owner":[],"postedDate":"October 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-09T16:10:00+00:00","versionOfRecord":{"articleIdentity":"rs-7607010","link":"https://doi.org/10.1007/s10151-025-03281-6","journal":{"identity":"techniques-in-coloproctology","isVorOnly":false,"title":"Techniques in Coloproctology"},"publishedOn":"2026-03-02 15:58:44","publishedOnDateReadable":"March 2nd, 2026"},"versionCreatedAt":"2025-10-08 08:24:25","video":"","vorDoi":"10.1007/s10151-025-03281-6","vorDoiUrl":"https://doi.org/10.1007/s10151-025-03281-6","workflowStages":[]},"version":"v1","identity":"rs-7607010","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7607010","identity":"rs-7607010","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}