Presented in Bir Hospital, NAMS during the pandemic of the covid

1. Dr. Kiran Pandey
MS General Surgery
Resident
National Academy of Medical
Studies(NAMS)
Rectal Prolapse
Moderator :
Dr. Pramod K.Yadav
Assistant Professor
Department of General Surgery
NAMS

2. Objective
• Rectal anatomy
• Introduction
• Presentation
• Surgical Approach
• References

3. Approximately 12–18 cm in length
Upper third: Mobile
 Peritoneal covering anteriorly and laterally;
Middle third:
 Peritoneum covers anterior and part of the lateral surfaces
Lower third:
 Lies deep in the pelvis
 surrounded by fatty mesorectum
Rectal Anatomy

4. Rectal Anatomy
 Begins at sacral promentry
 Taenia coli joins to form a continuous
outer longitudinal muscle layer
 Follows the curve of the sacrum
 Ends at the anorectal junction.
The puborectalis muscle encircles the posterior and lateral aspects of the
junction, creating th anorectal angle (normally 120°).

5. Rectal Anatomy
The rectum has three lateral curvatures:
 Upper and Lower: convex to the right
 Middle : Convex to the left.
On the luminal
 Three curves are marked by
semicircular folds(Houston’s valves)
Separated by adjacent structures by fascial layers.
 Denonvilliers’ fascia seperates from the prostate/vagina
 Waldeyer’s fascia seperates from the coccyx and lower two sacral
vertebrae
They are a barrier to malignant invasion.

6. Rectal Anatomy
Blood supply
 Superior rectal artery
 Middle rectal artery
 Inferior rectal artery
Venous drainage
 Superior rectal vein
 Middle rectal vein

7. Rectal Anatomy
Lymphatic drainage
• The lymphatics of the mucosal lining communicate with muscular layers.
• The usual flow is upwards
• Surgical clearance of malignant disease
Concentrates mainly wide resection of proximal lymph nodes.

8. Rectal Prolapse : Introduction
Defined as drooping of the rectum or Falling down of hind gut.
• First described by Papyrus in 1500 BC
• Types:
Occult (internal) rectal prolapse :
Rectal wall has prolapsed but does not protrude
through the anus.
Mucosal prolapse
only of the rectal and anal mucosa
Complete rectal prolapse or rectal procidentia:
The prolapse is delivered through the
anal canal leading to a protrusion of all
layers of rectum

9. Rectal Prolapse : Introduction
Factors associated
 Sliding hernia through a defect in the pelvic fascia
 Intussusception
 Complex, redundant rectosigmoid colon
 Deep pouch of doglus
 Loose rectal fixation
 Pelvic fascia defect, resulting in a sliding hernia.
 Constipation and difficulty in defecation,
 Pelvic floor atony
 Patulous anus,
 Excessive inhibition reflex of pelvic floor.
 Pudendal neuropathy
 Abnormal hindgut motility associated with
 Reduced high- amplitude propagated contractions,
 Increased resting colonic pressure,
 Slow colonic transit

10. Rectal Prolapse : Introduction

11. Rectal Prolapse : Introduction
Factors preventing prolapse:
Curvature of sacrum
Tilt of pelvis
Serpentine course of rectum
Levator ani muscles- fixes rectum
Puborectalis sling-Tilt and elevate lower
end of rectum

12. Rectal Prolapse : Introduction
• Bimodal distribution
– one peak occurs in children within the first 3 years of
life
– second peak occurs after the seventh decade
• In the elderly, rectal prolapse is more common in
women (80% to 90%), and the prevalence of this
abnormality increases with age
• Institutionalized patients who have neurologic or
psychiatric comorbidities (15%)

13. Clinical features
• Mass coming out of anal canal during
straining/coughing
• Mucous leakage
• Rectal bleeding
• Dull perineal pain or pressure
• Tenesmus
• Difficult defecation
• Fecal incontinence

14. Assessment
• Detailed history and examination
• Flexible Sigmoidoscope/ total colonoscopy
• Defecating Proctography
• Electromyography and measurement of the
pudendal nerve terminal motor latency

15. Treatment of Mucosal Prolapse
In infants and young children
Digital repositioning.
The parents are taught to replace the protrusion, and any underlying
causes are addressed.
Submucosal injections.
If digital repositioning fails after 6 weeks’ trial, injections of 5 per cent
phenol in almond oil are carried out under general anaesthetic.
Aseptic inflammation following these injections,
the mucous membrane becomes tethered to the muscle coat.
Surgery.
Occasionally, surgery is required and, in such cases,
The child is placed in the prone jack-knife position, the retrorectal space is
entered, and the rectum is sutured to the sacrum.

16. Treatment of Mucosal Prolapse
In Adults:
Local treatments.
Submucosal Injections of phenol
In almond oil or the application of rubber bands
Excision of the prolapsed mucosa.

17. Surgical Approach
• Surgery definitive treatment
• Therapeutic options
– narrowing of anal orifice
– obliteration of pouch of douglas
– restoration of pelvic floor
– resection of redundant bowel
– Suspension / fixation of rectum to sacrum
Garely et.al., Rectal prolapse. In: Cameron JL, Cameron AM (editors): Current surgical therapy. Elsevier Saunders: Philadelphia; 2014
Rickert et al. Laparoscopic surgery for rectal prolapse and pelvic floor disorders. World J Gastrointest Endosc 2015

18. Surgical treatment
• Perineal approach
– Thiersch
– Delorme’s
– Altemeier’s
• Abdominal approach
– Conventional laprotomy
• Well’s Repair
• Frykman and Goldberg
procedure
– Laproscopic surgery

19. Perineal Approach
Perineal procedures include
• anal encirclement (Thiersch procedure),
• mucosal sleeve resection (Delorme procedure), and
• perineal rectosigmoidectomy (Altemeier procedure).
The choice of operation depends on the
• patient’s age,
• comorbidities,
• operative risk,
• associated
• anatomic or physiologic conditions,
• history of previous surgery for prolapse.

20. Perineal Approach
Since affeccted patients are ,numerous comorbidities and
high operative risk, Perineal approach is excellent
treatment strategy.
Perineal procedures allow the
 use of spinal or locoregional anesthesia
 associated with decreased perioperative morbidity rates,
 Shorter hospital stay and recovery to normal activity,
 less pain, avoidance of peritoneal adhesions,
 lower risk of injury to the pelvic nerves, when
 compared with abdominal approaches

21. Perineal Approach
• In patients with large prolapses, perineal
rectosigmoidectomy may result in decreased
recurrence rates as compared with the
Delorme procedure.
• In small rectal prolapse, the Altemeier
procedure may be technically difficult and
inadequate mobilization of the descending
colon may lead to ischemia with high risk of
anastomotic dehiscence

22. Incarcerated and strangulated rectal
prolapse
Reduction can be
attempted under
sedation.
If successful, the
patient is referred
to elective defi
nitive treatment.
Prolapsed
bowel is
viable
Emergency perineal
rectosigmoidectomy is
required with or without
fecal diversion.
Ruptured prolapse and perineal
evisceration of small bowel is a
critical condition that requires
immediate transabdominal repair
including closure of peritoneal
defect and suture rectopexy
bowel is
not viable

23. Anal Encirclement (Thiersch Procedure)
 Avoids exteriorization of the rectum by encircling and narrowing the anal
canal.
 It was initially proposed by Thiersch using a silver wire, But prosthetic
materials such as silastic rods and polypropylene meshes have been used.
 Two small 2-cm incisions are made anteriorly and posteriorly or laterally
on both sides of the anus.
 submucosal tunnel created around the anus using a Kelly clamp,
prosthetic mesh is placed in the subcutaneous layer,
 Leading to partial closure and narrowing of the anal canal
 Placement of the mesh in the ischiorectal space may improve results.
 High recurrence rates and fecal impaction (80% of the patients.)
 Considered only for extremely high-risk patients.

24. Anal Encirclement (Thiersch Procedure)

25. Mucosal Sleeve Resection
(Delorme Procedure)
 fi rst described by Edmond Delorme in 1900 and
 Involves rectal muscle layer plication and mucosal layer resection
 relaps rates ranging from 7% to 23%
 Sphincteroplasty can be added to the Delorme procedure in patients with
fecal incontinence to improve results.
 Complications may include bleeding, leakage, stricture, fecal
incontinence, and recurrence
Incision
 Th e rectum is pulled down to the full extent of the prolapse using
Babcock clamps.
 Injection of an epinephrine solution (1:200,000) in the submucosal layer
facilitates dissection and decreases bleeding. A
 circumferential incision is made with electrocautery, 2 cm proximal to the
dentate line to preserve anorectal sensorial area, exposing the circular
muscular layer.

26. Delorme (Mucosal sleeve resection)

27. Mucosal Sleeve Resection
(Delorme Procedure)
Mucosal Sleeve Resection
Muscular Plication
• After the mucosal sleeve is stripped from the muscularis, nonabsorbable
longitudinal sutures are placed in the muscular layer to createm an
accordion eff ect.
• Th is plication begins at the proximal end of the mucosectomy and ends at
the distal edge of the internal sphincter close to the dentate line
Mucosal Anastomosis
Once muscular plication is finished, the stripped mucosa is resected and a
mucosal anastomosis is performed using 4-0 absorbable sutures,
beginning with four sutures placed in the four quadrants
Once the anastomosis is complete it usually is pulled back spontaneously into
the anal canal

28. Delorme (Mucosal sleeve resection)

29. Delorme (Mucosal sleeve resection)

30. Perineal Rectosigmoidectomy with Coloanal Anastomosis
(Altemeier Procedure)
• In 1889, Mickulicz was the first to describe perineal
rectosigmoidectomy for treating rectal procidentia,
• In a subsequent study, they also included anterior
levatorplasty and high ligation of the pouch of Douglas to
the procedure.
• Prolapse Delivery
delivered through the anus using Babcock clamps
Epinephrine solution (1:200,000) is injected circumferentially
the submucosal layer, 1.5 cm proximal to the dentate line to
minimize bleeding.

31. Perineal Rectosigmoidectomy with Coloanal Anastomosis
(Altemeier Procedure)
• Incision
• A circumferential incision is initiated at the
• posterior outer rectal wall, 1.5 to 2 cm above
• the dentate line, preserving the entire transitional zone
of the anal canal.
• The incision is made through all layers of the outer
rectal wall and deepened until the perirectal fat is
encountered and the mesorectum identifi ed.
• Care should be taken not to damage the mesorectal
vessels and to avoid simultaneous transection of the
inner rectal wall
Rectal Mobilization
• Mobilization of the rectum proceeds cranially with
careful isolation and ligation of mesorectal vessels close
to the intestinal wall.
Levatorplasty
• Posterior plication of the levator muscles is
• one modifi cation to the Altemeier procedure
• proposed to include the treatment of fecal incontinence
by restoring the angles of the pelvic floor.
Resection and Anastomosis
• Before sectioning the proximal colon, arterial
• patency is tested by dividing the terminal branches
before routinely perform in all intestinal anastomoses.
• Anastomosis can also be performed using circular
staples
• Th e anastomosis should be located above the pectinate
line, thus preservin the columns of Morgagni that play
an importan role in preserving fi ne anal continence
and decreasing the risk of postoperative stenosis.
clamping them, as we cilitate sigmoid mo-

32. Perineal Rectosigmoidectomy with Coloanal Anastomosis
(Altemeier Procedure)

33. Perineal Rectosigmoidectomy with Coloanal Anastomosis
(Altemeier Procedure)

34. Perineal Rectosigmoidectomy with Coloanal Anastomosis
(Altemeier Procedure)

35. COMPLICATIONS
Deaths related to perineal rectosigmoidectomy rare.
 In the literature vary from 0% to 32%.
 They may occur in the early or immediate
 Postoperative period and include pelvic hematomas,
 Anastomotic dehiscence, abscesses,
 and bleeding. The most frequently
 observed late postoperative complications
 are anal strictures, which may be managed
 by anal dilation.

36. Open abdominal approach
• Anterior Mesh Sling Or Ripstein Repair
• Posterior Mesh Sling Or Wells Repair
• Sigmoid Resection And Suture Proctopexy

37. BOWEL PREPARATION
 A bowel devoid of stool is easier to handle
especially if a resection is anticipated.
 At present, two sachets of oral Pico-Salax are
used the day prior to operation.
 Antibiotics are also administered preoperatively
and our current choice is
 Timentin 3.1-g i.v. within 1 hour of incision and
two postoperative doses q8h.

38. WELL’S REPAIR
Anterior mesh sling or Ripstein repair : most popular repair for rectal prolapse
Ripstein himself abandoned it, for posterior sling d/t complication
Complication reduced by half, if the sling were placed posterior to the rectum
leaving the anterior one-fourth to one third of the circumference of the
rectum free to expand, a principle expounded by Wells.
valon sponge (polyvinyl alcohol), (polypropylene) and Teflon are the most
common materials used.
Th e abdomen entered by infraumbilical transverse incision.
Care is taken to protect the ureters

39.  The retropresacral space is entered at the level of the sacral
promontory, and the rectum is gently mobilized from the sacral hollow
 Ensure that the mesorectum is anterior to the plane of dissection or
 the intestine may be devascularized and there may be annoying
bleeding.
 At the same time, one should avoid the presacral nerves.
 Dissection in the presacral plane should be performed with cautery
taking care not to injure the rectal wall.
 The rectum is fully mobilized to the level of the coccyx.
 Anterior mobilization is begun by continuing the lateral peritoneal
incisions distally until they meet in the deepest portion of the cul-de-
sac.

40. Well’s Repair

41. Well’s Repair

42. Well’s Repair

43. Postoperative Care
• Intravenous fl uids are given until the postoperative ileus has resolved,
usually in 2 or 3 days.
• Nasogastric suction is ordinarily not necessary.
• Th e Foley catheter is removed on the second day.
• ensure that the patient does not strain at defecation.
• oral intake, a bulk-forming agent in the form of a psyllium seed
preparation is given two or three times a day,
• supplemented by milk of magnesia as necessary.

44. SIGMOID RESECTION AND
SUTURE PROCTOPEXY
 Described by Frykman , performed through a transverse or midline abdominal incision.
 Foley catheter is inserted into the urinary bladder.
 The head of the operating room table is tilted down 30 to 40 degrees, depending
 on the shape of the pelvis.
 The entire small bowel is packed to the upper abdomen with moist lap pads.
Mobilization of Sigmoid Colon and Rectum
 Th e lateral peritoneal reflection of the sigmoid colon (white line of Toldt) is incised by
 The gonadal vessels and left ureter are identified and swept posteriorly.
 The peritoneal incision is continued to the left side of the rectum, about 1 cm lateral to
the rectal wall, and curves anteriorly to the rectovesical sulcus.
 Similarly, the peritoneum at the base of the sigmoid mesentery is incised by cautery and
continued to the right side of the rectum to unite with the incision on the left side

45. SIGMOID RESECTION AND
SUTURE PROCTOPEXY
 Entering the Retrorectal Space (Posterior Mobilization).
 Sweeping the Ureters and Pelvic Nerves
 Anterior Mobilization .
 Resection of the Redundant Sigmoid and Anastomosis
 Proctopexy Sutures

46. COMPLICATIONS: THEIR PREVENTION AND MANAGEMENT
 Th is review revealed a recurrence rate of 2.3%, and complications directly
related to placement of the sling occurred in 16.5% of the patients.
 The overall reoperation rate was 4.1%
 Indications for reoperation included
 fecal impaction,
 small-bowel obstruction,
 stricture,
 pelvic abscess,
 rectal erosion, and
 hemorrhage.
 Presacral bleeding may range from nuisance bleeding to hemorrhages of
terrifying proportions.
 Strictures were common, but only those that required further operation,
either division or removal of the sling or resection of the segment of
bowel, were included.

47. Frykman-Goldberg Procedure

48. Frykman-Goldberg Procedure

49. Frykman-Goldberg Procedure

50. Laparoscopic approach
Goals of surgery
 correct anatomic abnormalities associated with prolapse
 provide functional improvement of his or her symptoms.
Laparoscopic surgical options include
 rectopexy with or without mesh,
 sigmoid resection alone, or
 combination of the two.

51. Laparoscopic approach
• None operation is universal for prolapse patients
• Must be tailored to the patient and his or her individual symptoms.
A resection with rectopexy is indicated in
 sigmoid diverticular disease,
 a sigmoidocele,
 a redundant sigmoid colon,
 slow transit time, and/or constipation.

52. Laparoscopic approach
• A rectopexy relatively contraindicated in constipation
(high rates of persistence or worsening of constipation following this
procedure. )
Absolute contraindication to a laparoscopic repair
 patient’s inability to tolerate general anesthesia
Relative contraindications
 prior abdominal surgery
 irreducible prolapse

53. Preoperative Preparation
• Clear liquid diet 2 days before surgery.
• On the day prior to surgery,
 Two doses of an phosphosoda preparation.
 1 g metronidazole and 1 g neomycin at 2 p.m., 3 p.m.,
and 11 p.m.
• NPO the night before surgery.
• Preoperative antibiotics prior induction of general anesthesia.
• Positioned supine on split-leg table and sequential venous
compression stockings are placed on both lower extremities.

54. Patient Positioning and Port Placement
• Surgeon s on the patient’s right side and the assistant on the left.
• Two monitors are positioned at the foot of the bed
• The patient is then placed in steep Trendelenburg position secured with
bean bag.
Port Placement
• Either a Veress needle or the Hassan technique to access the peritoneal
cavity at or superior to the umbilicus.
• A carbon dioxide pneumoperitoneum of 15 mm Hg is created, a 30-degree
laparoscope is inserted, and the abdominal cavity is inspected.

55. Patient Positioning and Port
Placement
 5-mm port just lateral to the rectus sheath cephalad to thecamera port
 12-mm port in the right iliac fossa at the McBurney point.
(used in resection cases for the introduction of stapling devices and in
rectopexy cases for intracorporeal suturing.)
 5-mm port is placed on the left that mirrors the right upper port
location.

57. Rectopexy without Mesh
 A complete mobilization of the rectum from the sacral promontory to the coccyx
 In the course of developing this plane, the right and left ureters are identified, and
the hypogastric nerves are kept with the retroperitoneal tissue posterior to the
rectum.
 Preservation of the lateral rectal ligaments to prevent disruption of the
parasympathetic supply to the rectum,
(high rate of constipation after rectopexy alone may be caused by disruption of
these nerves.

58. Rectopexy without Mesh
 Once the rectum has been fully mobilized, the surgeon performs the rectopexy.
 Rectum is placed on cephalad tension, two or three nonabsorbable stitches are
used to secure it to the presacral fascia at the level of the sacral promontory.
 These lateral rectal stitches are placed on both sides and should include the
submucosa but not the mucosa.
 The presacral stitches should engage the fascia without piercing the presacral
venous plexus.
 After the pelvis is examined for hemostasis, the ports are removed, the
pneumoperitoneum is evacuated, and the incisions are closed

59. Rectopexy with Mesh
After rectal mobilization, sacral fixation can be achieved with
 Mesh placed anteriorly (per Ripstein) or
 Mesh placed anteriorly posteriorly (per Wells).
Ripstein procedure
 Anterior, circumferential fixation of the rectum by a piece of polypropylene mesh.
 Most surgeons have abandoned
 postoperative fibrotic reaction is often dense and leads to varying degrees of obstruction.
Wells procedure
 posterior, partial mesh wrap.
 posterior rectopexy with the creation of a T-shaped or rectangulat piece of mesh.
 The long part of the “T” is sutured with nonabsorbable suture to the presacral with junction of
“T” is at the level of the sacral promontory.
 The “arms” of the “T” are sewn to the lateral rectal walls with two or three nonabsorbable
stitches.
 Th e arms do not completely encircle the rectum, and the final product resembles a hotdog
(rectum) in a bun (mesh).

60. Sigmoid Resection with Rectopexy
 Sigmoid resections without rectopexy have been abandoned in favor of
sigmoid resection with fixation.
 After complete rectal mobilization, sigmoid colon dissected free from its
lateral attachments.
 Left ureter is identifid and a proximal margin of resection is chosen based
on the ability of the colon to easily reach the rectum (which is placed on
tension to eliminate redundancy).
 An articulating, linear, endoscopic stapler is used to divide the proximal
rectum at the distal line of resection. The distal end of the specimen is
eviscerated via a left lower quadrant muscle–splitting incision and the
proximal line of resection is divided extracorporeally.

61. Sigmoid Resection with Rectopexy
 A mesh rectopexy is not recommended
 After removing the stapler from the rectum and inspecting the
anastomotic rings for completeness, the pelvis is fi lled with irrigation
fluid, and a flexible sigmoidoscope is used to inspect the anastomosis for
hemostasis and integrity.
 If there are no air bubbles present upon insuffl ation of the rectum, the air
is evacuated and the scope is withdrawn.
 A single absorbable suture is used to close the right lower quadrant 12-
mm port site using a suture passer device.
 After a final inspection of the abdominal cavity, the 5-mm ports are
removed as the pneumoperitoneum is evacuated.
 The skin is closed.

62. Postoperative Management
• Early postoperative pain is controlled with parenteral narcotics and
parenteral NSAIDs
• On the day of surgery, patients are encouraged to ambulate and are
allowed clear liquids.
• The average length of stay for rectopexy patients is 1 to 2 days, but with
resection remain hospitalized for longer.
• Most patients begin to mobilize third-spaced fluids between postoperative
day 1 and 2 and their diet is advanced with the passage of flatus.
• The parenteral narcotics are replaced on postoperative day 2 with an oral
narcotic/acetaminophen combination.
• Most patients are discharged on postoperative day 3.
• Resolution of incontinence may take as long as 6 months, so patients may
need reassurance

63. Complications
 Lap. Rectopexy with or without mesh has been safe as open rectopexy.
 The complication rates range from 0% to 30% in most series.
 leak rates remain in the 1% to 2% range.
 Anal incontinence rates decrease by 40% to 60%, and constipation improves in
60% to 90% of patients after resection rectopexy.
 Reoperation
• bleeding (1% to 2%)
• fecal impaction (1%).
 Rectopexy alone is associated with a slightly lower reported rate in improvement
in constipation than resection rectopexy.
 Surgical treatment for Internal rectal prolapse, or rectal intussusceptio has been
ineffective (posterior rectopexy) or thought to be too risky (sigmoid resection with
anastomosis) for a condition without a clear natural history toward full, external
rectal prolapse.

64. Lap. Rectopexy Vs Rectopexy with
resection
 Resection with rectopexy has become the preferred approach for rectAal
prolapse repair,
In relatively young and healthy and suff er from constipation.
 Resection with rectopexy is as effi cacious as rectopexy alone in resolving
incontinence, but has decreased postoperative constipation rates.
 Eliminate the creation of an acute angle at the rectosigmoid junction by
removing a redundant colon,
 Preserves the rectal reservoir and avoids damage to sphincters as opposed
to the perineal approach.
Reported prolapse recurrence rates of rectopexy both with and without
resection are low and range from 0% to 7% over 2 to 10 years of follow-up.

65. Open Vs Laparoscopic Approach
 Laparoscopic procedures have been shown to be equivalent to the open
variants in terms of safety, effectiveness, and recurrence rates.
 In centers with the necessary expertise in laparoscopic pelvic surgery,
recurrences can be treated laparoscopically as well otherwise open
approach.
 Laproscopic surgical procedures have following benefits over open
• Minimal surgical stress
• Decreased lengths of stay,
• Minimal Postoperative pain
• Decreased use of narcotics
• High patient satisfaction.

66. Postoperative rates of morbidity,
mortality and recurrence
.
Hori et. al. Surgical options for full-thickness rectal prolapse: current status and institutional choice. Annals of
gastroenterology. 2018

68. Recent Advances
Robotic Modified Orr Loygue
• Involves standard ventral mesh with narrow mesh
posteriorly.
• Robotic dissection allows a long narrow tube to be
dissected posterior to rectum in between hypogastric
nerve down to rectal tube and waldeyers fascia
allowing the mesh to be tied to the rectal muscle. Not
known if it improves the outcome.
Disadvantage :cost, prolong surgery and off sight injury

69. References
Fischer’s mastery of surgery, 6th edition
Bailey and love’s short practice of surgery,
27th edition
Sabiston textbook of surgery, 20th edition
Surgical options for full-thickness rectal
prolapse: current status and institutional
choice, Hori et. al.