Prof/ Walid Elshazly

1. Prof/ Walid Elshazly A Prof of colorectal surgery

2. Classification of rectal prolapse: • Partial: prolapse of rectal mucosa only

3. Classification of rectal prolapse: • Complete: prolapse with all layers • Grade 1: occult prolapse

4. Classification of rectal prolapse: • Complete: prolapse with all layers • Grade 2: prolapse to but not through anus

5. Classification of rectal prolapse: • Complete: prolapse with all layers • Grade 3: any protrusion through anus

6. Complications of prolapse include: • Ulceration

7. Complications of prolapse include: • Strangulation

8. Complications of prolapse include: • Urinary and fecal incontinence • Spontaneous rupture with evisceration

9. Partial Rectal Prolapse • 1-4 cms PROTRUSION of rectal mucous membrane and submucosa outside the anus. • Common in Extremes of life • Children • Elderly

10. Partial Rectal Prolapse Predisposing Factor- Infants • Underdeveloped Sacral Curve • low Anal Sore Predisposing Factor- Children • Diarrhoea • Whooping Cough • Loss of Weight Predisposing Factor- Adults • Haemorrhoids • Prolonged straining • Perineal Tears  Females • Secondary to Surgery  Damage to Sphincter

11. Investigation in Elective Case • Finding ppt. factor • At least a flexible sigmoidoscopy • Assessment of surgical risk (no effective nonoperative treatment) • Anorectal manometry, pudendal nerve test • Predicts functional outcome after surgery

12. TreatmentIn children (partial or complete) • Alleviate straining due to constipation or diarrhea (tenesmus) • Construct regular bowel habits • Strap the buttocks together after defecation after spontaneous or manual reduction • Build up the body of the child and fat reservoirs • Use sclerosant injection (phenol in almond oil for submucous injection in partial prolapse and alcohol for retrorectal injection in complete prolapse) • In case of failure one of the operations described is resorted to

13. Treatment • In partial prolapse • mucosal hemorroidectomy will often suffice to deal with the condition, • recently Longo’s procedure (PPH stapler is used to induce anal lift and refixation of the prolpased mucosa back to the rectum and anal canal)

14. Operations of prolpase • The choice of the operation depends on • Degree of prolapse present • Associated disorders (cystocele, rectocele, incontinence or constipation) • Co-morbid conditions (spinal cord lesion, mental or psychic problems or vital system problems) • The main symptoms of presentation • Goals are • Resection of redundant colon • Fixation of the rectum to the sacrum • Improving symptoms of fecal incontinence and constipation

15. Aim of treatment • Primary objective • Eradicate the prolapse • improve the quality of life • Secondary gain • Improvement in continence and bowel function

16. Elective Presentation :Operative Treatment

17. Perineal Procedures • Thiersch Procedure • Considered obsolete nowadays! • Delorme Procedure • The minimum you should do! • Altemeier Operation • (Perineal Proctosigmoidectomy)

18. Perineal Procedures :Delorme Procedure • Mortality 0-4% • Recurrence 4-38% (St Marks 12.5%) • Good for short prolapse • Can be repeated if necessary

19. Perineal Procedures :Delorme Procedure

20. Perineal Procedures :Delorme Procedure

21. Perineal Procedures :Delorme Procedure

22. Perineal Procedures :Delorme Procedure

23. Perineal Procedures :Delorme Procedure

24. Perineal Procedures :Perineal Proctosigmoidectomy(Altemeier Procedure)

25. Perineal Procedures :Perineal Proctosigmoidectomy(Altemeier Procedure) • Mortality 0-5%; • complication: pelvic sepsis, leakage Recurrence 0-16% • Best if combined with posterior levatorplasty • Ideal for incarcerated and strangulated ones • Difficult to perform for small prolapse Deen KL Br J Surg 1994:81: 302-304 Wexner, Cleveland Clinic Florida; Archieves of Surgery; Jan 2005; 140,1

26. Abdominal Procedure • Rectopexy • Sutured Rectopexy • Prosthesis or Mesh Rectopexy • Anterior ventral rectopexy • Posterior rectopexy Wells operation • Resection rectopexy (Frykman-Goldbery procedure) • Laparoscopic Vs Open

27. Sutured Rectopexy

28. Abdominal Procedure :Sutured Rectopexy • No reported mortality • Recurrence (majority 0-8%; ranges 0-27%) • Variable response to constipation • Posterior mobilization to tip of coccyx • Division of lateral ligaments on either sides

29. Anterior ventral rectopexy

30. Posterior Rectopexy Wells operation

31. Abdominal Procedure :Prosthesis or Mesh Rectopexy • Makes use foreign material to evoke more fibrous tissue reaction, examples • Anterior Sling Rectopexy • Ripstein Procedure • Posterior Mesh repair e.g. Wells Operation • Problems: Increased pelvic sepsis and rectal strict

32. Resection rectopexy (Frykman-Goldbery procedure)

33. Abdominal Procedure :Resection Rectopexy • Add 1% to mortality • Recurrence 0-5% • Majority has improved constipation

34. Abdominal Procedure :A Comparison

35. Laparoscopic Approach • Rectopexy (sutured, stapled, posterior mesh, resection) • Recurrence 0-10% • As effective as open ( no long term difference) • Benefit • Shorter post-op hospitalization • Overall reduction in cost • Earlier recovery • Less morbidity • Earlier return to work • Laparoscopic approach is desirable because of • Benign nature of the condition • Patients are often at high surgical risk for laparotomy

36. Choice of Operation :Individualized • Abdominal procedures are ideal for young fit patient and provide best chance of cure • Sutured rectopexy gives good result • Combination of a resection reduce constipation • Laparoscopic approach provides similar results with less morbidity • Perineal procedure for frail patients with extensive co-morbidity, not fit for major abdominal surgery • Perineal rectosigmoidectomy, combined with levatorplasty gives better result than Delorme’s operation