education purpose only.

1. Rectal Prolapse –
Pathophysiology and
management
Chairpersons :
Prof. U. Bhattacharya
Dr. D. Bhanja Chowdhury Speaker : Raju Mitra

2. Falling down the hindgut/ procidentia
Types of presentation :
1. Complete or full thickness Involvement Of bowel
2. Partial or Incomplete type involving prolapse of mucosa
only

3. Stability of rectum
• Role of Levator ani 💪
• Puborectalis sling
• Pelvic floor

4. Multifactorial etiology and pathogenesis
• Altered pelvic anatomy
• Patulous anus
• Neurologic diseases
• Pelvic floor muscles weaknesses
• Congenital anomaly
• Colorectal intussusception
• Female gender
• Parity
• Psychological

5. (1) anterior perineal hernia through the
urogenital diaphragm
(2 ) posterior perineal hernia through
the levator ani muscle
(3 ) posterior perineal hernia between
the levator ani and coccygeus muscles.

6. Differential Diagnosis
• prolapsed hemorrhoids
• Rectal polypoid lesion
• (difference between full thickness or partial thickness prolapse)

7. Clinical Features
• Prolapse
• Lump in the perineum
• Constipation
• Fecal incontinence
• Bleeding per rectum
• Ano rectal or pelvic pain

8. In Younger Patients
• pronounced functional dis-turbance of defecation :
fre-quent visits to the bathroom
long periods spent there on each occasion
the patient may be spending several hours in the bathroom straining
psychiatric symptoms

9. Anorectal Assessment
• Inspection
• Assessment of the tone and contractility
• Degree of prolapse
• Colonoscopy
• Evacuation proctography
• Pudendal nerve terminal motor latency (PNTML) studies

10. • Anasthesia
• Decreased edema
• Emergency resection
Management of acute, incarcerated (i.e.,
irreducible) rectal prolapse

11. Nonoperative Treatment of Rectal Prolapse
• Adhesive strapping of buttocks
• Manual anal support during defecation
• Correction of constipation
• Establishment of workable time and method of defecation
• Perineal strengthening exercises
• Electronic stimulation
• Injection of sclerosing agent
• Rubber ring ligation
• Infrared coagulation

12. Surgical Therapy for Rectal Prolapse
• Narrowing of the anal orifice
• Obliteration of the peritoneal pouch of Douglas
• Restoration of the pelvic floor
• Resection of bowel
Transabdominal
Perineal
Transsacral
• Suspension or fixation of the rectum
To sacrum
To pubis
To other structures

13. Perineal Procedure
• Simple, safer
• High rate of reccurent
• Advised for older, frailer patients

14. Perianal procedure
• 1. Thiersch Repair:
Historical importants only
Can be carried out under local anesthesia
Silver wire was placed into the peri-anal space to encircle and narrow
the anus.
Other materials such as nylon, Mersilene, Dacron, polypropylene mesh
(i.e., Marlex), Tef-lon, fascia lata, silicone rubber, Silastic, and Dacron-
impreg-nated Silastic mesh have been used for the same purpose

15. Thiersch-Type Repairs

16. Other Thiersch-Type Repairs
• Lomas and Cooperman-Marlex mesh has been employed(wound infection
rate 33%)
• Notaras used a ribbon of Mersilene (approximately 4 cm wide)
• Sainio and colleagues -underwent anal encirclement with polypropylene
mesh.
• Labow and associates-use of an elastic fabric sling, a Dacron-impregnated
Silas-tic sheet
• Hunt and colleagues-implanting Silastic rods
• Swerdlow-He describes a helical rod (the Encircler)—a single loop having a
diameter of 6 cm with an extension beyond 360 degrees—the end of which
is adapted to accept varying tips

17. Altemeier’s Operation
• Position lithotomy stirrups or prone jackknife position

18. Altemeier’s Operation

19. Altemeier’s Operation

20. Altemeier’s Operation

21. Delorme’s Procedure
• This is a submucosal dissection with a mucosal stripping
• Using electrocautery, the mucosa is stripped to the apex of the
protruding bowel
• The redundant mucosa is excised, and the denuded muscularis
propria is pleated longitudinally
• collapsing the bowel like an accordion the edges of the mucosa are
then sutured
• Complications from this operation are common and include
hemorrhage, hematoma, suture line dehiscence, stricture,
incontinence, and, of course, recurrence.

22. Delorme’s Procedure

23. Abdominal Procedures
• Teflon or Marlex Sling Repair:

24. Complications of Teflon Sling operation
• Difficulty in regular bowl function
• Incontinence
• Laxative dependence
• Fecal Impaction
• Mortality
• Recurrence
• Mesh infection
• Rectal stricture

25. Rectopexy – currently used procedure

26. Laparoscopic Rectopexy

27. Rectopexy with Sigmoid Resection

28. INTERNAL RECTAL PROLAPSE (PREPROLAPSE,
RECTAL INTUSSUSCEPTION)

29. Internal rectal prolapse
• Assessment :
Digital rectal examination
Rigid rectoscopy
Proctoscopy
Proctography(gold standard)
Rectal Examination Under Anesthesia (accurate way)
Diagnostic Laparoscopy

30. Internal Rectal prolapse
Treatment:
laxatives, dietary advice and biofeedback, or pelvic floor retraining
Surgical:
Posterior Rectopexy with or without Resection
Laparoscopic Ventral Rectopexy
STARR Procedure