Rectal prolapse & its laparoscopic management - a video presentation

1. Rectal prolapse & its laparoscopic management - a video presentation Dr. BennetRajmohan, MRCS(Eng), MRCS(Ed) Consultant General & Laparoscopic Surgeon Apollo Speciality Hospital Madurai, India

2. History • 47 yrs, lady • Mass descending per rectum on straining x 15 yrs. Able to push it back in • Mucous discharge from mass, occasional leakage of liquid stool • Poor eating, avoidance of social events • No significant medical history • 3 children, sterilised

3. Clinical examination • Thinly built lady • Scar of sterilisation • Full thickness rectal prolapse on straining • Concentric mucosal folds noted • Could be pushed back inside

4. Management • Advised laparoscopic rectopexy & resection anastomosis of redundant sigmoid colon • Ultrasound abdomen – Normal • Colonoscopy – oedematous sigmoid colonic mucosa, no polyps or growths • Transrectal ultrasound – Rectal prolapse noted. Internal sphincter stretched. External sphincter contraction normal

5. Informed consent • No alternative to surgery  increasing prolapse, mucosal ulceration / gangrene / infection Risks of surgery • 1 – 10 % risk of bleeding, infection, recurrence • 1 per 1000 chance of rectal perforation – possibility of colostomy, another surgery • 1 per 1000 chance of damage to pelvic nerves – inability to sustain erection or achieve ejaculation • DVT / PE • 1-3% death rate

6. Surgery • Bowel prep for colonoscopy the day before surgery • Liquid diet 2 days pre-op • General anaesthesia • Rectal wash in OT • Inj. Cefoperazone-Sulbactum 1.5 G and Metronidazole 500 mg at induction (& 2 post-op doses only) • 14 F Foley catheter

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8. The result • Post –op DVT prophylaxis • Discharged on 5th POD, after normal passage of flatus & stools • Advised to avoid lifting heavy weights / constipation • Perenial exercises – good external sphincter tone • E.coli UTI – treated with oral antibiotics • About 2 months post-op  No prolapse • 3 to 4 bowel movements per day • No faecal incontinence

9. Rectal Prolapse or Procidentia

10. Rectal Prolapse • Protrusion of the rectum beyond the anus • Associated with faecal incontinence (>50%) &pelvic floor abnormalities • Long history of constipation & straining • Straining forces anterior wall of upper rectum into anal canal, causing a solitary rectal ulcer due to mucosal trauma • Two theories of aetiology • Sliding hernia through defect in pelvic fascia • Circumferential intussusceptionof the rectum

12. Types • Complete or Full Thickness:- Protrusion of full thickness of rectal wall through anus • Mucosal Prolapse:- Only rectal mucosa protrudes from anus • Occult prolapse or Internal intussusception:- a full thickness or a partial rectal prolapse that does not pass out of the anus • Important to distinguish full thickness prolapse from mucosal prolapse because treatment of the two conditions is very different

13. Incidence • At extremes of age • Paediatric – around 3 yrs of age, equal sex distribution • Adult – More common in women • Older age groups • Virtue of anatomy (wider pelvis) • Childbearing • Affected men tend to be younger • 20-40 yrs

14. Requirements for rectal prolapse 1) An abnormally deep Pouch of Douglas 2) Lax & atonic pelvic floor muscles & anal canal 3) Weakness of both internal & external sphincters, often with evidence of pudendal nerve neuropathy 4) Lack of normal rectal fixation, with a mobile mesorectum & lax lateral ligaments

15. Evaluation • Spontaneous prolapse obvious on inspection • Straining may be required in some patients • Best examined in sitting or squatting position • Concentric rings & grooves • Perianal skin may be macerated or excoriated • DRE important to detect anal path & to assess resting tone / squeeze pressure

16. Rectal prolapsevs Prolapsed piles Prolapsed piles –radial grooves Rectal prolapse – concentric rings

17. Investigations • Colonoscopy to rule out mucosal abnormalities (Eg: Inflammatory bowel disease, polyps, growths) • Videodefaecography • Anal manometry to assess sphincters • Longstanding prolapse may damage internal sphincter • Additional levatorplasty • Pudendal nerve EMG & colonic transit times in severe constipation (may need sigmoid resection) • Transrectal ultrasound – sphincter defects

18. Surgical Options – broad concepts • Perineal procedures • Elderly, high-risk patients • Regional or even local anesthetic with MAC • Abdominal procedures in young, fit patients • Constipation – resection & rectopexy • Incontinence – abdominal rectopexy or perineal resection with levatorplasty

19. Perineal Procedures • Perinealrectosigmoidectomy (Altemeier) • Recurrence – about 10% • Rectal mucosal sleeve resection (Delorme) • Recurrence – about 40% • Perineal suspension-fixation (Wyatt) • Anal encirclement (Thiersch + modification)

20. Perineal procedures Advantages: - • laparotomy avoided • very low morbidity • Can be done under GA, regional or occasionally local anaesthesia Disadvantages:- • Higher recurrence rate than abdominal procedures • Post-op faecal incontinence may be increased

21. Transabdominal procedures 1) Repair of the pelvic floor • Abdominal repair of levatordiastasis • Abdominoperineallevator repair 2) Suspension-fixation • Sigmoidopexy (Pemberton-Stalker) • Presacralrectopexy • Lateral strip rectopexy (Orr-Loygue) • Anterior sling rectopexy (Ripstein) • Posterior sling rectopexy (Wells) • Puborectal sling (Nigro)

22. Transabdominal procedures 3) Resection procedures • Rectopexy with sigmoid resection • Anterior resection

23. Transabdominal procedures Advantages • Lower recurrence rates • Improvement in incontinence • Preservation of rectal reservoir Disadvantages • More invasive • Risk of post-op sexual dysfunction in males

24. Abdominal Suture Rectopexy • Used in patients without constipation • Rectum mobilized down to levator floor preserving lateral stalks • Secured with sutures to presacral fascia just below sacral promontory Disadvantage: - • Redundant sigmoid colon may at least theoretically cause the onset of or exacerbate preexisting constipation

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

26. Advantages of resection rectopexy • Recurrence rates < 10 % • Better faecal continence compared to other methods • Operative morbidity comparable to rectopexy • Post-op constipation less likely • Division of lateral ligaments decrease recurrence rates but increases the incidence of post-op constipation

27. Why resect? 1 ) Resection of redundant rectosigmoid avoids torsion or volvulus 2) Achieves a straighter course of the left colon & little mobility from the phrenocolic ligament downward, which acts as yet another anchor 3) Relieves constipation

28. Lateral ligaments • Left colon & rectum receive retrograde innervation from neural efferents running through lateral ligaments • Lateral ligament division during rectopexydenervates the rectum, causing post-op constipation

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

30. Recurrent Prolapse • Can occur in 10 – 40 % of patients • Higher with perineal procedures • Important to evaluate patient for constipation and pelvic floor abnormalities again • Need to consider residual blood supply 

31. Surgery for recurrent rectal prolapse

32. Conclusion • Problem of complete rectal prolapse is formidable, with no clear predominant treatment of choice • Abdominal procedures ideal for young fit patients • Perineal procedures reserved for older frail patients with significant comorbidities • Laparoscopic rectopexy combines benefits of laparoscopy & abdominal procedures

33. Thank you • Our COO & DMS, Dr. Rohini Sridhar and Mr. Rajkumar, Manager (OT Operations) for enabling video recording facility for this procedure • Mr. Sakthivel & Mr. Saravanan, ITD dept for their help in recovering the video for editing • Dr. Periakaruppan, Consultant Radiologist for his help with Transrectalultrasonography • Dr. Subbiah, Senior Consultant Anaesthetist

34. If, you have missed the video, it is available on Youtube (www.youtube.com, search for “laparoscopic resection rectopexy video”) • If you missed the entire presentation or wish to see any of my previous presentations, visit my website, www.drbennet.com