rectal prolapse n.
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Rectal Prolapse
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  1. Rectal Prolapse 8/18/2010

  2. Rectal Prolapse • A “falling down” of the rectum so that it’s out of the body • Intussusception of the rectum through the sphincters • Associated with fecal incontinence and pelvic floor abnormalities • Long history of constipation and straining • Two theories of etiology • Sliding hernia through defect in pelvic fascia • Circumferential intussusception of the rectum

  3. Rectal Prolapse • More common in women • Older age groups • Virtue of anatomy (wider pelvis) • Childbearing • Affected men tend to be younger • 20-40 yoa

  4. Patient factors that influence choice of operation • Age • Sex • Medical condition • Extent of prolapse • Bowel function • Status of fecal continence

  5. Procedure related factors that influence choice of operation • Extent of procedure • Potential morbidity • Recurrence rate • Impact on fecal continence and bowel habits • Familiarity and ease of technique

  6. Evaluation • Spontaneous prolapse may be obvious on inspection • Some patients may require straining • Best examined in sitting or squatting position • Concentric rings and grooves • Examine perianal skin for any maceration or excoriation • DRE important to detect anal path and to assess resting tone and squeeze pressure

  7. Evaluation • Colonoscopy/Flex Sig with BE • Rule out mucosal abnormalities • Defecography essential for rectoanal intussusception • Anal manometry can help assess sphincters • Longstanding prolapse may damage internal sphincter • Synchronous levatorphasty • EMG for patients with history of severe straining • Colonic transit times with severe constipation • May need colon resection (sigmoid)

  8. Surgical Options • Perineal procedures • Elderly, high-risk patients • Regional or even local anesthetic with MAC • Constipated patients • resection and rectopexy • Incontinent patients • abdominal rectopexy • perineal resection with levatorplasty

  9. Perineal Procedures • Perineal rectosigmoidectomy (Altemeier) • Morbidity 5-24% • Recurrence rates from 0-10% • Rectal mucosal sleeve resection (Delorme) • Morbidity 0-30%--hemorrhage, dehiscence, stricture, diarrhea, urinary retention • Recurrence rates 7-22% • Perineal suspension-fixation (Wyatt) • Anal encirclement (Thiersch + modification)

  10. Altemeier Procedure • Prone, lithotomy, or left lateral decub • Rectal wall injected with epi containing compound • Circumferential incision made in rectal wall 1-2 cm above dentate • Incision deepened until full thickness rectal wall is divided • Cut edge of rectum pulled down and mesorectum divided and ligated • Continue dissection until no further redundancy • Rectum divided and hand-sewn coloanalanastamosis performed • Can also use EEA stapler

  11. Delorme Procedure • Only mucosa and submucosa are excised • Submucosa infiltrated with epi solution • Mucosa incised 1cm proximal to dentate • Mucosa and submucosa dissected off underlying muscle • Continues to apex of prolapse then mucosa transected • Placating sutures are placed in the muscle • Mucosa is reapproximated

  12. Thiersch Procedure • Mechanically supplement or replace the anal sphincter and stimulate foreign body reaction in the perianal area • Radial incision made on both sides of anus about 2cm from anal verge • Tunnel created from one incision to another • above anoperineal ligament • anterior to anus • external to external sphincter

  13. Thiersch Procedure • Material brought into incision • Tunnel continued posteriorly • Encircling material then tied snugly over index finger in the anus • Nylon, Silk or Dacron • Silastic rods • Silicone • Marlex and Mersilene mesh • Fascia or tendon

  14. Transabdominal procedures • Repair of the pelvic floor • Abdominal repair of levatordiastasis • Abdominoperineallevator repair • Suspension-fixation • Sigmoidopexy (Pemberton-Stalker) • Presacralrectopexy • Lateral strip rectopexy (Orr-Loygue) • Anterior sling rectopexy (Ripstein) • Posterior sling rectopexy (Wells) • Puborectal sling (Nigro) • Resection procedures • Proctopexy with sigmoid resection • Anterior resection

  15. Abdominal Rectopexy and Sigmoidectomy • Complete mobilitzation of the rectum down to the levator musculature, leaving the lateral stalks intact • Elevation of the rectum cephalad with suture fixation of the lateral rectal stalks to the presacral fascia just below sacral promontory • Suture of the endopelvic fascia anteriorly to obliterate the cul-de-sac (most surgeons omit this now) • Sigmoid colectomy with anastamosis

  16. Abdominal Rectopexy • Used in patients without constipation or prolapse • Rectum mobilized down to levator floor preserving lateral stalks • Then secured to presacral fascia just below sacral promontory

  17. Ripstein Procedure • Anterior sling rectopexy • Rectum mobilized posteriorly down to coccyx • 5 cm piece of mesh (Marlex or Prolene) sutured to presacral fascia 5 cm below sacral promontory in midline • Rectum retracted cephalad and lateral edges wrapped around rectum and sutured to it

  18. Ivalon Sponge • Rectum is mobilized posteriorly to the levators • Also mobilized anteriorly • Ivalon then placed into pelvis and sutured to presacral fascia • Sponge is wrapped around rectum only ¾ of the way • Anterior portion left free • Pertioneum then closed over the sponge

  19. Laparoscopic Rectopexy • Largely replacing open abdominal procedures • Ease of performing rectopexy and colon resection simultaneously with shorter hospital stay • Morbidity and mortality no different than open controls • Recurrence rate lower but not statistically significant

  20. Recurrent Prolapse • Can occur in more than 50% of patients • Higher with perineal procedures • Important to evaluate patient for constipation and pelvic floor abnormalities again • Need to consider residual blood supply 

  21. Solitary Rectal Ulcer Syndrome • Rectal bleeding • Copious mucous discharge • Anorectal pain • Difficult evacuation • Usually on anterior wall just above anorectal ring • Shallow with “punched out” gray-white base surrounded by hyperemia

  22. Colitis Cystica Profunda • Mucin-filled cysts located deep to muscularis • Appear as nodules or masses on anterior rectal wall • Can be asymptomatic or complain of rectal bleeding, mucous discharge, or anorectal discomfort • Difficulty with bowel movements • Path shows mucous cysts lined by normal columnar epithelium located deep to muscularis