DR ANAS AHMAD

1. RECTAL PROLAPSE
DR ANAS AHMAD
PGR – SURGICAL UNIT 2
SHALAMAR HOSPITAL- LAHORE

2. RECTAL
PROLAPSE
FULL THICKNESS
PROLAPSE
INTERNAL
INTUSSUCEPTION
MUCOSAL
PROLAPSE

3. FULL THICKNESS PROLAPSE/ PROCIDENTIA
● Full-thickness protrusion of the rectum through
the anal sphincters
● Protrussion consists of all layers of rectal wall
● 4-15 cm in length
● More common in females. Female to male ratio
6:1
● Commonly associated with prolapse of uterus
● A “falling down” of the rectum so that it’s out
of the body

4. INTERNAL PROLAPSE/INTUSSUSCEPTION
● Occult rectoanal
intussusception
● Prolapse does not protude
from the anus

5. MUCOSAL PROLAPSE
 Protusion of the rectoanal mucosa

6. MUCOSAL VS FULL RECTAL PROLAPSE

7. MUCOSAL VS FULL RECTAL PROLAPSE

8. Difference Between Rectal Prolapse and
Hemorrhoids
Rectal Prolapse Hemorroids
Tissue Folds Circumferential Radial
Abnormality on
Palpation
Double Rectal
Wall
Hemorrhoidal
Plexus
Resting and
Squeeze
Pressures
Decreased Normal

9. Difference Between Rectal Prolapse
and Hemorrhoids

10. PATHOPHYSIOLOGY
 INFANTS
 Undeveloped sacral curve
 CHILDREN
 Attack of diarrhoea
 ADULTS
 Constipation (component of colonic dysmotility)
 Weakening/malfunctioning of pelvic floor/sphincters
 Anismus – spastic pelvic floor
 Pudendal neuropathy (obstetric injuries, aging)
 Sphincter dysfunction (trauma, aging)

11. Clinical Features
♦ Mucus Discharge
♦ Rectal Bleeding
♦ Soilage
♦ Feeling of incomplete evacuation
♦ Diarrhea
♦ Itching

12. Clinical Features
♦ Children: first three years (male=female)
● Cystic fibrosis, malnutrition, diarrhea, severe cough,
parasites
♦ Adults: majority are eldery female
● Females >50 – 6 times more likely than males
● 2/3 are multiparous
● Mental illness (depression, autism)
● Neurologic disorder
● Connective tissue disorder
● Constipation and straining

13. Clinical Features
♦ Constipation is associated with prolapse in 30%-70% of pts
♦ Chronic straining, sensation of anorectal blockage, need of digital
evacation
♦ 60% have coexisting incontinence
● Stretching of anal sphincters
● Impaired rectal compliance
♦ 20-35% have associated urinary incontinence

14. NON OPERATIVE MANAGMENT
 Treat constipation
 Fiber supplements
 Stool softeners
 Digital repositioning in infants and young children
 Sub mucosal injection of 5% phenol in almond oil
 Reduce incarcerated rectal prolapse
 Table sugar

15. Surgical Treatment
♦ Mainstay in treatment of rectal prolapse
♦ Over 100 procedures
♦ In infants and young children rectum is sutured to sacrum in prone jack-knife
position.
♦ In adults with unilateral prolapse, redundant mucosa is excised or, if
circumferential, an endoluminal stapling technique can be used.
Full thickness prolapse:
♦ Perineal procedures
● Resection, reefing, and encirclement
♦ Abdominal procedures
● Fixation, colon resection or combination of both

16. Choosing Type of Surgery
♦ Abdominal
● Recurrence low
(<10%)
● ↑ constipation 50%
● Higher M & M esp.
with anastomosis
● Mesh placement –
stricture, migration,
erosion, infection
♦ Perineal
● Recurrence (20%)
● Constipation rate
unchanged
● Persistent incontinence
worse rate due to removal
of rectal resevoir
● Correction of
associated abnormalities
(rectoceole, sphincter)
● No pelvic dissection –
preserves sexual function

17. Perineal Procedures
♦ Perineal Proctosigmoidectomy – Altemeier
♦ Mucosal Sleeve Resection - Delorme
♦ Anal Encirclement - Thiersch Wire Technique
♦ Perineal suspension/fixation - Wyatt

18. Altemeier Procedure

19. Delorme Procedure

20. Delorme Procedure

21. Delorme Procedure

22. Thiersch Procedure

23. Abdominal Procedures
♦ Anterior rectopexy or Ripstein procedure/ sutured rectopexy
● Anterior wrapping of the rectum and fixation to sacrum
♦ Goldberg rectopexy/ resection rectopexy:
(Ant rectopexy+sigmoid resection)
♦ Posterior rectopexy - Wells procedure
● Synthetic mesh
● Sutures alone
♦ Sigmoid colectomy with sutured rectopexy
● Low recurrence
● Low morbidity
● Improves constipation

24. Ripstein Procedure

25. Ripstein Procedure

26. 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

27. Lap ventral mesh Rectopexy
 Purpose of surgery : to correct prolapse, protect or restore
continence and avoid constipation
 Correct middle compartment prolapse too

28. Dissection from sacral promontory
avoiding nerves

29. Deep part of fold of Douglas retracted
and incised

30. Polypropylene mesh sutured
to anterior aspect of rectum and
fixed to sacral promontory
(Loosely)

31. Posterior vaginal suture

32. Further rectal sutures

33. Closure of peritoneum

34. Rectopexy +/- Resection
♦ Rectopexy with resection - Multiple papers
● Improvement in continence and constipation
● Mortality – 0-6.7%
● Recurrence – 0-5%
♦ Rectopexy without resection - Wilson et. Al
● 9% recurrence at 48 month f/u
● 17% severe constipation managed by laxatives

35. Conclusions
♦ Consider surgery when conservative therapy fails
♦ Careful pt selection is crucial to satisfactory outcome
♦ Tailor surgery to the specific pt
♦ Laparoscopic rectopexy allows for quicker recovery
and shorter LOS but similar recurrence
♦ Regardless of material used, correct suture and tack
placements are crucial
♦ If severely constipated, perform sigmoidectomy
♦ Pts care as much about continence and constipation

36. Any questions??

37. THANK YOU