Rectal Prolapse

Rectal Prolapse

Introduction to Procedure

We know that undergoing any procedure is a scary experience.  We understand the worry and anxiousness that is associated with surgeries and procedures and aim to walk the road to recovery with you every step of the way. We put this information together using the very helpful handbook, ‘Handbook of Surgical Consent” from Rajesh Nair and David J. Holroyd.  We hope that the following information will answer all your questions and help you with the preparation phase for your procedure.

Description of procedure

This is a full thickness prolapse of the rectum through the anal canal.  There are two approaches to the repair of a rectal prolapse; either a trans-abdominal or perineal.  The trans-abdominal approach can be further subdivided into the traditional open and the newer laparoscopic method.  Generally, younger patients may benefit from a trans-abdominal approach, given the lower risks of recurrence, whereas older patients may be more suitable for a perineal approach, given the higher morbidity associated with the trans-abdominal approach.

Operative techniques

Perineal rectosigmoidectomy (Altemeier’s procedure):  

Indicated in patients with external full thickness prolapse.  It is performed under regional or general anaesthesia.  The rectum is withdrawn as fully as possible and an incision is made 1.5cm proximal to the dentate line and is continued through the full thickness of the bowel wall and extended circumferentially.  The peritoneum is entered, the sigmoid colon is pulled down and the transection line determined.  In general, 15-30cm of bowel is resected and a colo-anal anastomosis is performed.

Delorme’s procedure

Transabdominal Marlex Rectopexy (Ripstein’s procedure):

Is indicated in patients with rectal prolapse without constipation and a redundant sigmoid colon.  It is performed under general anaesthesia.  A midline incision is made and the abdominal cavity is entered.  The rectum is mobilised down to the coccyx posteriorly often with division of the upper portion of the lateral ligament and the anterior cul-de-sac.  The rectum is retracted and placed under tension.  A non-absorbable Marlex (Permacol) mesh is then fixed to the presacral fascia and wrapped round and sutured to the anterior wall of the rectum to keep it in position.  

Anterior Resection

Some authors have advocated resection for patients with constipation, however, evidence is lacking.  It is performed under general anaesthesia.  A midline incision is made and the abdominal cavity is entered.  The rectum is mobilised to the level of the lateral ligaments and the redundant sigmoid colon is resected.  An anastomosis is then performed between the cut end of the colon and the proximal end of the rectum.  The colon is maintained under tension in order to prevent the prolapse recurring.

Frykman-Goldberg Operation

Advocated by some for patients with a significant degree of associated constipation.  It is performed under general anaesthesia.  A midline incision is made and the abdominal cavity is entered.  The rectum is mobilised to the coccyx posteriorly ad the cul-de-sac anteriorly.  A section of the sigmoid colon is resected with the cut end of the colon being subsequently anastomosed with the proximal end of the rectum.  The presacral fascia is then sutured either to the lateral ligament or to the rectal fascia itself thus maintaining the rectum under tension and preventing subsequent prolapse.  

Orr-Loygue Rectopexy

It is performed under general anaesthesia.  A midline incision is made and the abdominal cavity is entered.  Essentially the same as the traditional abdominal Rectopexy, the difference being that the dissection is limited to the anterior and posterior rectal wall.

Additional procedures that may become necessary
  • Abdominal or perineal drain insertion.
  • Defunctioning colostomy / ileostomy when redundant bowel is resected and anastomosed.
Benefits
  • Therapeutic: Symptomatic rectal prolapse (incontinence, bowel habit disturbances, rectal bleeding).
Alternative procedures/conservative measures
  • Conservative: Treatment involves advice regarding safe reduction of the prolapse itself and advice regarding bowel habit.
Serious/frequently occurring risks
  • Bleeding, infection, recurrence (full thickness and mucosal), incontinence, constipation, anastomotic dehiscence, incisional hernia and pelvic sepsis.
  • Perineal rectosigmoidectomy (Altemeier’s procedure): 8.6% major complications, pelvic haematomas, anastomotic dehiscence, sigmoid perforation, pararectal abscess, late anal strictures, 14% minor complications, 18% recurrence rate at 41 months.
  • Trans-abdominal suture Rectopexy:  Complication rates ranging from 9.4% to 20%, recurrence rate of 2-3.1%, postoperative incontinence of 16-26%, postoperative constipation of 31-71%.
  • Trans-abdominal Marlex Rectopexy (Ripstein procedure):  Complication rates ranging from 2.3-28%, recurrence rate of 2-14%, post-operative incontinence of 28-50%, post-operative constipation of 17-43%.Trans-abdominal Rectopexy with sigmoid resection (Frykman-Goldberg operation):  6.3%full thickness recurrence, 8.5% mucosal prolapsed, 6.3% constipation (in patients who had not pre-operatively experienced this), 12.8% patients experienced diminished continence postoperatively, 8.5% developed significant diarrhoea.
  • Trans-abdominal Rectopexy with sigmoid resection (Frykman-Goldberg operation):  6.3%full thickness recurrence, 8.5% mucosal prolapsed, 6.3% constipation (in patients who had not pre-operatively experienced this), 12.8% patients experienced diminished continence postoperatively, 8.5% developed significant diarrhoea.
  • Anterior resection:  15% morbidity, 7% recurrence at 5.5 years, 7.3% incisional hernia, 4.9% small bowel obstruction, 2.4% stroke.
  • Orr-Loygue Rectopexy:  Prolapse recurrence 4.11% (mean follow-up 27.5 months), pelvic abscess 0%, 62.5% who were preoperatively incontinent of faeces were “totally cured”.
  • Common:  Bleeding; swelling; pain; scar; prolonged wound healing; infection.
Blood transfusion necessary
  • Group and save: The process of determining the patient’s ABO blood group and screening serum for the presence of antibodies to common red cell antigens that can cause transfusion reactions in emergency situations.
  • Cross-match 2-6 units.
Type of anaesthesia/sedation
  • Regional.
  • General anaesthesia.
Follow-up or need for further procedure
  • Monitor patient in hospital until patient passes urine and faeces prior to discharge.
  • Symptomatic review in outpatient clinic.

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