Acs0536 Procedures For Rectal Prolapse 2004

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Acs0536 Procedures For Rectal Prolapse 2004

  1. 1. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 36 Procedures for Rectal Prolapse — 1 36 PROCEDURES FOR RECTAL PROLAPSE Steven D.Wexner, M.D., F.A.C.S., F.A.S.C.R.S., and Susan M. Cera, M.D. Rectal prolapse is an intussusception of the rectum, which may be or may develop into a chronic condition. Chronic prolapse results in categorized as occult (internal), mucosal, or complete. Occult rectal the development of a patulous anus and incontinence.The inconti- prolapse does not extend beyond the anal canal and often is not as- nence may derive from direct sphincteric stretching, from traction sociated with any symptoms; it may be a precursor to complete pro- injury of the pudendal nerves caused by straining, or from continu- lapse. Mucosal prolapse involves protrusion of the mucosa only, ous stimulation of the rectoinhibitory reflex by the intussusception, with the muscular layers of the rectum remaining in place. Com- which results in chronic reflexive relaxation of the internal anal plete rectal prolapse, or rectal procidentia, involves full-thickness sphincter and inappropriate leakage of stool and mucus. protrusion of the rectum through the anus [see Figure 1]. The anatomic abnormalities resulting from rectal prolapse in- Whereas the exact pathophysiology of rectal prolapse remains clude a deep cul-de-sac, a redundant rectosigmoid, an elongated unclear, several factors have been associated with its development, mesorectum, diastasis of the levator ani, perineal descent, a patu- including constipation, female sex, postmenopausal status, and pre- lous anus, and loss of support of the uterus and the bladder [see vious anorectal surgical procedures. The constipation frequently Table 1]. Rectal prolapse also is frequently associated with other arises from conditions such as colonic inertia, neurologic disease, anatomic defects of the pelvic floor, such as rectoceles, enteroceles, psychiatric illness, and obstructed defecation. Obstructed defeca- cystoceles, and uterine and vaginal prolapse. Recognition of how tion is also referred to as anismus, spastic pelvic floor, and paradox- the functional pathology of the pelvic floor results in the anatomic ical or nonrelaxing puborectalis syndrome. Patients with this condi- abnormalities seen with rectal prolapse is essential to understanding tion experience significant pain and have difficulty passing stool; the various operative approaches and determining appropriate digital compression or any of a variety of perineal maneuvers may long-term management. Patients with rectal prolapse, like most pa- be necessary to relieve the functional obstruction. tients with pelvic floor dysfunction, frequently require postoperative Chronic constipation and straining are thought to lead to her- bowel retraining with fiber therapy, laxatives, or biofeedback to ad- niation of the rectum through the muscular aperture of the pelvic dress the functional component of this disease and thereby prevent floor, much as occurs with a hiatal or ventral hernia. As hernia- recurrence once the prolapse has been surgically corrected. tion progresses, the mesorectum lengthens and the lateral and More than 120 operations for treating rectal prolapse have rectosigmoid attachments stretch.Weakened pelvic floor muscles been described. A detailed description of all available options is (from aging and the postmenopausal state) contribute to the her- clearly beyond the scope of this chapter. Instead, we focus on a niation process, as do sphincter defects and pudendal neuropathy few key procedures that currently are freqently employed and from previous anorectal operations or obstetric injuries. enjoy widespread acceptance. For present purposes, we have Initially, prolapse occurs only with straining; later in the course of excluded a number of procedures that, though popular in certain the disease, it occurs with any increase in intra-abdominal pressure regions of the world, are not universally accepted. a b Peritoneum Longitudinal Mucosa Submucosa Muscle Circular Muscle Mucosa Figure 1 In mucosal prolapse (a), only the mucosa protrudes, whereas in complete rectal prolapse (b), the full thickness of the rectal wall protrudes.
  2. 2. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 36 Procedures for Rectal Prolapse — 2 sonography, manometry, electromyography, and pudendal nerve terminal motor latency testing are indicated to help guide the Table 1 Anatomic Abnormalities Associated choice of surgical procedure to treat the prolapse. with Rectal Prolapse Deep cul-de-sac Herniation of pelvic organs Operative Planning Redundant rectosigmoid colon through pelvic funnel Elongated mesorectum Patulous anus CHOICE OF PROCEDURE Diastasis of levator ani Loss of support of uterus and Because the etiology and pathophysiology of rectal prolapse bladder Perineal descent are not well understood and appear to vary, it has not proved possible to identify any individual procedure as the optimal sur- gical approach to this condition. The current focus in the litera- Preoperative Evaluation ture is on developing criteria by which specific patients can be Because of the protrusion of tissue through the anus and the fre- matched to the specific operations that are most appropriate for quent bloody discharge, most patients initially mistake rectal pro- them.The choice of operation is determined by the patient’s age, lapse for hemorrhoids [see Table 2]. Such patients often present with sex, level of operative risk, associated pelvic floor defects, degree a complaint of “persistent hemorrhoids” after a recent hemorrhoid of incontinence, and history of constipation, as well as by the sur- operation. Similarly, many patients mistake incarcerated rectal pro- geon’s experience. The goal is to correct the greatest number of lapse for thrombosed hemorrhoids. Consequently, a high level of anatomic problems (including the prolapse and any associated suspicion and careful physical examination are required to differen- functional disorders) safely and efficiently while minimizing both tiate hemorrhoids from rectal procidentia [see Table 3]. perioperative morbidity and postoperative recurrence. The diagnosis is most easily made with the patient straining The procedures performed for repair of rectal prolapse may be while seated on the toilet. If the prolapse cannot be reproduced divided into two broad categories: perineal and abdominal [see in the office setting, administration of a phosphate enema may Table 4]. The perineal operations include anal encirclement (the reveal it. The appearance of circumferential, concentric folds of Thiersch wire procedure), mucosal sleeve resection (the Delorme rectal mucosa serves to differentiate rectal prolapse from hemor- procedure), and perineal rectosigmoidectomy (the Altemeier pro- rhoids, in which the folds (sulci) occur in a radial pattern, yield- cedure). In the original description of the Thiersch wire procedure, ing three discrete anatomic bundles [see Figure 2]. In addition, silver wire was placed in the subcutaneous tissues surrounding the close inspection of a full-thickness rectal prolapse reveals a cir- anus through two small incisions, then tied around the assistant’s cumferential sulcus between the anus and rectum, and palpation finger to narrow the anal aperture.5 It was believed that this opera- reveals a double rectal wall. The prolapse should be easily tion controlled the prolapse by reinforcing the anal sphincter and reducible unless incarcerated. fixing the rectum to surrounding structures through induction of Chronic prolapse leads to inflammation, edema, and ulcera- tissue reaction to the foreign material.The simplicity of the opera- tion of the rectal mucosa. Biopsy of these areas should be under- tion was offset by many problems, including breakage of the wire, taken to determine whether there is a neoplastic lesion acting as sloughing of the overlying skin, perineal sepsis, and fecal im- the source of the intussusception. In addition, complete colonos- paction. Various other, more compliant materials (e.g., Marlex copy is performed to search for lesions elsewhere in the colon, mesh and Silastic rods) have since been used in place of the silver which may affect the surgical approach to the proplapse. Occa- sionally, a solitary rectal ulcer in the anterior rectum is seen in a patient with obstructed defecation caused by ischemia of the rec- tal wall from chronic straining. Barium enemas may induce stran- Table 2 Symptoms of Rectal Prolapse gulation and thus should be avoided; however, water-soluble Sensation of protrusion of tissue Incontinence contrast enemas may be of some use in identifying pathologic through anus Incomplete evacuation conditions in the remainder of the colon. Defecography is useful “Persistent hemorrhoids” Perineal pressure when occult intussusception or mucosal prolapse is suspected or Mucoid or bloody discharge Excoriation of perianal skin when the patient has a history of prolapse but is unable to repro- duce the prolapse in the office. If the prolapse is associated with Constipation conditions arising from pelvic floor defects (e.g., urinary inconti- Straining nence, rectocele, enterocele, cystocele, and uterine and vaginal prolapse), consultation with a gynecology team for combined surgical intervention is warranted.1,2 About 50% of patients with prolapse have a history of consti- Table 3 Differences between Rectal Prolapse pation.1,3 Possible causes of the underlying constipation—such and Hemorrhoids as electrolyte (calcium) imbalance, hormonal (thyroid) dysfunc- tion, obstructed defecation, and colonic inertia—should be in- Rectal Prolapse Hemorrhoids vestigated. Surface electromyography may be used to diagnose paradoxical contraction of the puborectalis muscle. In patients Tissue folds Circumferential Radial with severe constipation, a colonic transit study using ingested Sulcus between prolapse and radiopaque markers aids in diagnosing colonic inertia, which Circumferential None rectum may necessitate inclusion of subtotal colectomy as part of surgi- Hemorrhoidal cal management. Abnormality on palpation Double rectal wall plexus Fecal incontinence is a presenting symptom in 30% to 80% of patients with rectal prolapse.3,4 For these patients, anal ultra- Resting and squeeze pressure Decreased Normal
  3. 3. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 36 Procedures for Rectal Prolapse — 3 a b Figure 2 Rectal prolapse can be differentiated from hemorrhoids on the basis of physical appearance. (a) Rectal prolapse is distinguished by concentric mucosal folds. (b) Hemorrhoids are distinguished by radial sulci and discrete hemorrhoidal bundles. wire, but none of these modifications have proved successful. In ad- formed. The rectopexy sutures are placed by means of an open dition, better anesthetic techniques and improved perioperative technique, and the anastomosis is created with a transanally placed medical management have made it possible to employ other per- circular stapler. Laparoscopic suture rectopexy without resection is ineal or abdominal procedures safely in most patients. Consequent- performed entirely laparoscopically, with intracorporeal mobiliza- ly, anal encirclement remains an option only for those patients who tion and suture placement. would be at unacceptably high risk with other types of procedures. Mucosal sleeve resection, as described by Delorme in 1900, involves stripping the mucosa from the redundant rectum and Perineal Procedures plicating the denuded rectal wall with sutures to create bulk and MUCOSAL SLEEVE RESECTION (DELORME PROCEDURE) thus prevent future prolapse.6 Perineal rectosigmoidectomy, orig- inally described by Mikulicz7 and subsequently modified by Both mucosal sleeve resection and perineal rectosigmoidecto- Altemeier,8 involves transanal amputation of the prolapsed rec- my may be performed with the patient under either general or tum coupled with a coloanal anastomosis. spinal anesthesia. Preoperatively, the patient undergoes mechani- The various abdominal operations may be performed as either cal and antibiotic bowel preparation. Such preparation consists of open or laparoscopic procedures, and they differ with respect to oral administration of 45 ml of sodium phosphate solution, fol- how far rectal mobilization extends, whether the lateral ligaments lowed by three 8 oz glasses of water, at 4 P.M. and 9 P.M., and are divided, whether the rectum is fixed anteriorly or posteriorly, administration of 1 g of neomycin with 500 mg of metronidazole what fixation material is used (sutures, mesh, or sponge), and at 7 P.M. and 11 P.M. Before the procedure, the patient receives whether sigmoid resection is included. At present, the operation prophylactic antibiotics, and subcutaneous heparin is used in most commonly performed to treat rectal prolapse in the United conjunction with sequential compression devices to prevent States is suture rectopexy, with sigmoid resection added (the venous thromboembolism. Frykman-Goldberg procedure) if constipation is a significant pre- senting complaint.The various posterior rectopexies with sutures or mesh are more popular than the procedures involving anterior fixation with mesh or posterior placement of a polyvinyl alcohol Table 4 Operations Performed to Treat (Ivalon) sponge. Anterior fixation of the rectum using a sling was Rectal Prolapse proposed by Ripstein and Lantern as a way of restoring the nat- ural contour of the rectum and preventing intussusception.9 Anal encirclement (Thiersch wire procedure) Originally, fascia lata was used for the sling; subsequently, various Perineal procedures Mucosal sleeve resection (Delorme procedure) artificial materials (e.g., Teflon, Marlex, and Gore-Tex mesh) Perineal rectosigmoidectomy (Altemeier procedure) came to be used instead. The Ivalon sponge operation (the Wells Rectopexy procedure) entails placement of the sponge posterior to the rec- Suture tum to create an inflammatory reaction and a consequent rec- Anterior sling (Ripstein procedure) topexy.10 Because of the risks imposed by the foreign materials Ivalon sponge (posterior rectopexy) (including infection, erosion, and stenosis), few surgeons now Posterior sling (modified Ripstein procedure) Transabdominal Resection perform either anterior fixation or foreign body placement. procedures Suture rectopexy with resection (Frykman- Laparoscopic resection rectopexy involves a laparoscopic-assisted Goldberg procedure) approach with intracorporeal mobilization of the sigmoid colon and Laparoscopic repairs the rectum, division of the mesenteric vessels, and distal transection Resection rectopexy of the bowel.The bowel is then exteriorized through a small incision Suture rectopexy Rectopexy with mesh (often, a Pfannenstiel incision), and the proximal transection is per-
  4. 4. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 36 Procedures for Rectal Prolapse — 4 a b Figure 3 Mucosal sleeve resection. (a) With the rectum everted, the mucosa is incised and dissected away from the muscular tube. (b) The muscu- lar tube is plicated with sutures to form a muscular pessary. (c) A mucosa-to-mucosa anas- tomosis is fashioned. (d) The anastomosis spontaneously reduces into its anatomic position. c d After induction of anesthesia or administration of intravenous Step 4: dissection of mucosa from muscle Gentle trac- sedation, a bladder catheter is inserted, and the patient is placed tion is placed on the clamps, and the mucosa is dissected away in the prone jackknife position with a Kraske roll beneath the hips from the muscle with the electrocautery. A finger is placed inside and the buttocks abducted with tape. A self-retaining retractor the muscular tube to facilitate traction and help prevent full- may be used to evert the anus. The muscular stripping can be thickness injury. Resection of the mucosal sleeve is continued undertaken with the prolapse either everted or reduced. Our pref- until resistance prevents further dissection. A tube of redundant erence is to evert the prolapse, and the following technical muscular tissue then remains. description embodies that preference. Step 5: plication of rectal muscle The muscular tube is pli- Operative Technique cated by placing eight reefing sutures circumferentially in the wall. Step 1: eversion of rectum The rectal prolapse is everted by placing gentle traction on the rectal wall with Babcock tissue Step 6: resection of mucosa and anastomosis The forceps passed through the anus. As the prolapsed tissue emerges, excess mucosa is transected in a superior-to-inferior direction, the Babcock forceps are repositioned more proximally on the rec- and the two cut edges of mucosa are approximated with sutures. tal wall to provide a better grasp and facilitate delivery of the pro- Transection is continued on one side for a quarter of the circum- lapse through the anus and into the operative field. ference, at which point a second suture is placed. With traction applied to these two sutures, two additional sutures are placed at Step 2: submucosal injection of anesthetic Once the rec- 90° intervals to establish four quadrants.Transection and anasto- tum has been everted, a local anesthetic solution containing mosis are serially performed in each of the four quadrants until 0.25% bupivacaine, 0.5% lidocaine, and epinephrine (in a the mucosa is completely excised and the anastomosis has been 1:400,000 dilution) is circumferentially injected 1 to 1.5 cm completed. With the removal of the retractor, the anastomosis above the dentate line to minimize bleeding. should spontaneously reduce into its anatomic position. Step 3: circumferential incision of mucosa The rectal Postoperative care Because the patients are often elderly, 1 mucosa is incised at this level with a conventional diathermy, and to 3 days of observation may be indicated. The bladder catheter four clamps are placed on the proximal mucosal edge for traction is removed on the following morning, and the patient is advanced [see Figure 3]. to a regular diet as soon as he or she can tolerate it. The patient
  5. 5. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 36 Procedures for Rectal Prolapse— 5 is sent home on a regimen of fiber supplementation and sitz baths rectal wall, with the inner tube consisting of rectum attached to as soon as medical stability is ensured and appropriate social cir- the sigmoid and the outer tube consisting of rectum attached to cumstances arranged. the dentate line. The mucosa is circumferentially scored with a standard diathermy 1 to 1.5 cm cephalad to the dentate line [see Troubleshooting Figure 4]. The incision should be made at the top of the anal The Delorme procedure prevents rectal intussusception by columns to preserve the entire transition zone, which is important resecting redundant mucosa and by removing laxity in the rectal for nocturnal continence. The incision is deepened through all wall through plication of the muscular redundancy. The key to layers of the outer rectal tube until perirectal fat is encountered success is to continue the sleeve resection until some resistance is and the mesorectum is identified on the superior aspect of the met and the dissection cannot proceed further. Sometimes, the prolapse with the patient prone. anterior wall is longer than the posterior wall or vice versa, but such discrepancies should not affect the repair. The anastomosis Step 4: mobilization of rectum and division of mesen- is performed one quadrant at a time to prevent retraction of the tery Rectal mobilization is accomplished by clamping, ligating, transected mucosa into the proximal bowel. and dividing the vessels of the mesorectum. As the mesorectum is divided, tension on the rectum delivers more of the prolapse PERINEAL RECTOSIGMOIDECTOMY into the operative field. Division of the mesorectum is continued close to the bowel wall until no more bowel can be delivered. Operative Technique During this phase, the sliding hernia of peritoneum (cul-de-sac) Anesthesia and positioning are the same for perineal rectosig- anterior to the rectum (on the inferior aspect of the prolapse with moidectomy as for mucosal sleeve resection. the patient prone) may be opened to allow palpation of the intraperitoneal contents and determination of whether the colon Steps 1 and 2 Steps 1 and 2 of this procedure are the same is straight in the pelvis. as steps 1 and 2 of mucosal sleeve resection (see above). A finger may be inserted into the pelvis alongside the rectum to facilitate assessment of the redundancy of or the tension on the Step 3: circumferential incision through rectal wall remaining rectum and sigmoid. If redundancy is still encoun- With the rectum everted, the prolapse consists of two tubes of tered, more mesorectum is divided to allow further mobilization a b c d e f Figure 4 Perineal rectosigmoidectomy. (a) The rectum is everted. (b) The anesthetic is injected submucos- ally. (c) A circumferential incision is made and deepened through the outer rectal tube until perirectal fat is encountered. (d) The rectum and the sigmoid are mobilized with division of the mesentery; levatorplasty is then done. (e) The first suture of the anastomosis is placed. (f) The remaining sutures are placed.
  6. 6. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 36 Procedures for Rectal Prolapse — 6 of the bowel through the anus. Careful control of the mesentery short segment of prolapse is produced or the patient is found to with ligatures is advised to prevent retraction of bleeding vessels have only a mucosal prolapse, a Delorme operation may be per- into the pelvis. formed instead. COMPLICATIONS Step 5: ligation of hernia sac Once the redundant rectum and sigmoid have been adequately mobilized, the hernia sac of peri- Partial separation of the mucosal anastomosis after mucosal toneum is sutured closed. Care is taken to resect any redundant sleeve resection is not uncommon and usually does not warrant hernia sac to prevent future anterior intussusception; this step is intervention. After perineal rectosigmoid resection, anastomotic similar to the high ligation performed for other types of hernias. separation may lead to leakage and pelvic sepsis, which must be treated with bowel rest and antibiotics or, in extreme cases, with Step 6: levatorplasty Levatorplasty is then performed to debridement, repair, and stoma formation. restore the appropriate angles of the pelvic floor muscles, to aid Early postoperative bleeding from the mucosal edges or, in the in treatment of incontinence, and to narrow the aperture through case of the perineal rectosigmoidectomy, from the presacral space which herniation occurs and thereby prevent recurrence. It can may be observed. Late postoperative bleeding may result from be performed anterior to the rectum, posterior to the rectum, or tearing of the sutures through the mucosa or from separation of both. A narrow retractor is employed to expose the outer tube of the anastomosis. All significant bleeding should be evaluated and rectum and uncover the levator muscles. Interrupted 2-0 nonab- controlled in the OR, with the source of the bleeding dictating the sorbable sutures are placed through the levator muscles on each type of repair required. side and secured loosely enough to allow a finger to be inserted Anastomotic strictures may occur after either mucosal sleeve alongside the rectum. resection or perineal rectosigmoidectomy. They are treated with serial dilations either at home or in the OR. Step 7: proximal transection of rectum and anastomosis OUTCOME EVALUATION The point at which the redundant rectum is to be transected is identified at the level at which the mesorectum is divided.The bow- The advantages of the perineal procedures include (1) the el wall is circumferentially cleared of appendages in preparation for option to use spinal anesthesia, (2) avoidance of peritoneal adhe- transection and anastomosis. Transection is begun by dividing a sions, (3) short hospital stays (1 to 4 days), (4) a lower risk of small area of the bowel wall superiorly and placing a suture through injury to the pelvic nerves, (5) reduced pain, and (6) the oppor- the edge of the outer tube of rectum and the newly transected prox- tunity for concomitant repair of other anorectal problems (e.g., imal edge of the bowel.Transection is continued inferiorly on one sphincter defects, hemorrhoids, rectoceles, cystoceles, and vagi- side for a quarter of the circumference, and a second suture is nal prolapse). The disadvantages include (1) a higher recurrence placed.With traction on these two sutures, two additional sutures rate and (2) reduced improvement of any fecal incontinence. are placed around the remaining circumference to mark four Reported recurrence rates for the perineal approaches range quadrants. Transection and anastomosis are serially performed in from 5% to 21%11-13 and are higher than those for the abdominal each of the four quadrants until the rectum is completely transect- approaches; however, the perineal repairs can be performed multi- ed. When the anastomosis is complete, it retracts into the pelvis, ple times in the same patient as necessary.14 Because they are less where it may be inspected with a bivalve retractor. invasive, perineal procedures generally carry a lower morbidity than abdominal procedures do, with the majority of the complications Postoperative care Patients are often observed in the hos- being medical in nature.11,12 Whereas constipation is neither exacer- pital for 1 to 3 days. Their diet is advanced as tolerated, and the bated nor alleviated by the perineal procedures, continence is signi- bladder catheter is removed on postoperative day 1. Patients are ficantly improved, though not as much as it is improved by the ab- sent home on a regimen of fiber supplementation and sitz baths. dominal procedures.15,16 The improvement in continence seen after both abdominal and perineal procedures for rectal prolapse is relat- Troubleshooting ed to cessation of rectoanal inhibition and recovery of sphincter Perineal rectosigmoidectomy involves a combination of repairs function with reduction of the prolapse.The lesser improvement re- of anatomic abnormalities associated with rectal prolapse. Rectal ported after perineal procedures may be related to sphincter mobilization yields a rectopexy from scarring; resection removes stretching or, in the case of perineal rectosigmoidectomy, to loss of redundant bowel; ligation of the enterocele obliterates the hernia the rectal reservoir. A comparison of various perineal procedures— sac; and levatorplasty provides reconstruction of the pelvic floor. including the Delorme procedure, perineal rectosigmoidectomy, Each step requires that attention be paid to appropriate planes of and rectosigmoidectomy with levatorplasty—found that the addi- dissection and that meticulous hemostasis be maintained. For tion of a levatorplasty yielded the greatest improvement in conti- example, transection of the outer rectal wall may lead to inadver- nence, the least morbidity, and the lowest recurrence rate.16 tent division of the mesentery before vascular control is obtained; Because the incidence of rectal prolapse peaks in the sixth and if this occurs, traction should be placed on the inner wall to seventh decades of life, patients undergoing these procedures fre- expose the proximal mesentery and allow the surgeon to regain quently are elderly and have significant comorbid conditions.17 vascular control. In addition, transection of the outer rectal wall The perineal procedures are economically and physiologically may lead to inadvertent simultaneous transection of both walls; if advantageous in the short term and are therefore ideal for elder- this occurs, clamps should be placed on the inner wall to prevent ly patients or for any patients with multiple comorbid conditions, retraction into the pelvis and to facilitate rectal mobilization and as well as for those who are at high operative risk or who need division of the mesorectum [see Step 4, above]. combined intervention from various pelvic surgical specialists. In To help prevent recurrence, all redundant bowel should be these patients, who generally have limited life expectancies, the resected once mobilization of the rectum and division of the high risk of recurrence associated with the perineal procedures mesentery are complete. If, at the start of the procedure, only a may be irrelevant. Perineal operations may also be indicated for
  7. 7. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 36 Procedures for Rectal Prolapse — 7 a b Figure 5 Open resection rectopexy. (a) The redundant sigmoid is mobilized through the abdominal wound. (b) The proximal sigmoid is transected, and the sigmoid mesentery is clamped, ligated, and divided. patients who have undergone multiple previous abdominal oper- point of transection is chosen by finding an area of colon that eas- ations and are likely to have dense adhesions, as well as for young ily falls into the pelvis but includes all of the redundant sigmoid men who do not wish to risk impairment of sexual function. colon. This level of the colon, the sigmoid-descending portion, is circumferentially cleaned of surrounding tissue. A straight clamp is placed proximally and an adjacent bowel clamp distally. The Abdominal Procedures bowel is divided with a knife along the straight clamp. The straight clamp is released, and three Babcock forceps are placed OPEN RECTOPEXY to hold open the lumen. A purse-string suture of 2-0 Prolene is placed, and the head of a 33 mm circular stapler is secured in the Resection Rectopexy (Frykman-Goldberg Procedure) lumen. Alternatively, a purse-string clamp may be used. Just as with perineal procedures, patients undergo mechanical and antibiotic bowel preparation on the day before surgery. Step 4: division of sigmoid mesentery. The mesentery of the sig- Before operation, parenteral antibiotics and subcutaneous moid is clamped, ligated, and divided close to the colon [see heparin are administered, and sequential compression devices Figure 5b]. The superior rectal vessels are carefully preserved. are placed on the legs. After induction of general anesthesia, the patient is placed in the Step 5: mobilization of rectum and division of lateral ligaments. A modified lithotomy position with the legs in padded stirrups. If Babcock clamp is placed on the rectal stump and lifted upward. there is a history of one or more previous pelvic operations, bilater- The avascular plane of areolar tissue between the mesorectum al ureteral stents are placed by a urologist, and a urinary catheter is and the presacral fascia is identified and divided with the elec- inserted. The rectum is irrigated with saline through a transanally trocautery. A St. Mark’s retractor is placed behind the rectum to placed mushroom catheter until the effluent is clear, after which provide traction, then advanced with dissection distally along the point additional irrigation is undertaken with a povidone-iodine rectum to the level of the coccyx. solution.The catheter is left in place for the initial portion of the pro- Dissection of the right side of the rectum is performed with the cedure, and the extra effluent is allowed to drain into a plastic bag surgeon standing to the patient’s left. The left hand places trac- secured to the catheter.The surgeon stands on the patient’s left side. tion on the rectum, while the right hand uses the electrocautery to divide the lateral stalk in a posterior-to-anterior direction.The Operative technique Step 1: initial incision and exploration. St. Mark’s retractor is used to retract the tissues of the sidewall A low midline or Pfannenstiel incision is made, the pelvis is away from the rectum. explored, a Balfour or Buchwalter retractor is placed, and the Dissection of the left side of the rectum is performed with the small bowel is packed into the upper abdomen. surgeon on the patient’s right. Again, the left hand places traction on the rectum, while the right hand performs the dissection in a Step 2: mobilization of sigmoid. The sigmoid colon is mobi- posterior-to-anterior direction. lized away from the left lateral wall by incising the lateral peri- Dissection anterior to the rectum is performed by using the toneal reflection [see Figure 5a]. The gonadal vessels and the retractor to place traction on either the uterus (in women) or the ureter are identified and swept posteriorly. The peritoneal inci- bladder (in men), then proceeding anterior to the rectum down sion is continued to the left of the rectum, curving anteriorly in to the level of the lower third of the vagina (in women) or below the rectouterine or rectovesical sulcus. The peritoneum at the the seminal vesicles (in men). The lower one third to one half of base of the sigmoid mesentery on the right is also incised, and the lateral stalks may be preserved, though the overlying peri- this incision is continued to the right of the rectum to unite with toneum should be incised. the previous incision at the anterior rectum. Step 6: placement of sutures for rectopexy. With upward traction Step 3: proximal transection of sigmoid colon and placement of sta- applied to the rectal stump, horizontal mattress sutures of 2-0 pler anvil. Once the entire sigmoid is mobilized, the proximal Prolene are placed to perform the rectopexy. Starting on one
  8. 8. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 36 Procedures for Rectal Prolapse — 8 side, a suture is placed through the peritoneum and the endopelvic fascia adjacent to the rectum, with care taken not to penetrate the rectal wall. The suture is guided through the pre- sacral fascia and the periosteum to the side of the midline and approximately 1 cm below the level of the sacral promontory. It is then completed by passing it back through the peritoneum and the endopelvic fascia. One or two sutures are placed on each side; they are left untied and are tagged with hemostats. 10 mm 10 mm Step 7: transection of bowel at upper rectum. The rectosigmoid junction is identified on the basis of the splaying of the taeniae coli, the absence of appendices epiploicae, and the proximity to the sacral promontory. This junction marks the site of distal transection. Proctoscopic examination is helpful for determining the appropriate 10 mm location.Transection may be performed with a stapler, a purse-string suture clamp, or a knife followed by a handsewn purse-string suture. Step 8: completion of colorectal anastomosis. The circular stapler is advanced through the anus to the rectal stump. Under the man- Figure 6 Laparoscopic resection rectopexy. Shown is the ual and visual guidance of the abdominal and perineal operating recommended port placement. A 10 mm trocar is placed in surgeons, the trocar is advanced and the anvil engaged. The cir- the periumbilical region by means of an open technique. cular stapler is closed and fired. The stapler is then gently Two 10 mm trocars are then placed in the right abdomen. removed, and the “doughnuts” are checked for integrity. The anastomosis is tested for leaks by filling the pelvis with irrigant, Complications Presacral bleeding may result from place- clamping the colon proximal to the anastomosis, and insufflating ment of sutures in the presacral fascia and consequent injury to air into the rectum. Air bubbles from the anastomosis indicate a the presacral veins. It may be controlled by tying down the leak that requires suture reinforcement.The rectopexy sutures are secured snugly to complete the procedure, and the abdomen is sutures and applying direct manual pressure. For persistent irrigated and closed in the usual fashion. bleeding, thumbtacks may be required. An alternative approach to this step is to perform endoscopic Injury to the pelvic nerves and consequent impotence are pos- visualization of the anastomosis while simultaneously insufflating sibilities with any procedure in which the rectum is mobilized. air through either the rigid proctoscope or the flexible sigmoido- Performing the dissection close to the bowel wall minimizes the scope. This method allows reliable confirmation of mucosal via- chances that these complications will occur. bility and anastomotic integrity. Moreover, if any supplemental Suturing the rectum too close to the sacrum may compress the anastomotic reinforcement sutures are needed, they can be lumen. This problem may be corrected by removing and replac- placed much more easily at this time than after the rectopexy ing the sutures. Any uncertainty about rectal compression can be sutures have been secured. Sheets of sodium hyaluronate–based resolved by means of intraoperative proctoscopy. bioresorbable membrane are placed before closure of the fascia to The incidence of abdominal sepsis from an anastomotic leak help minimize postoperative adhesion formation; at our institu- can be minimized by ensuring a well-vascularized and tension- tion, these sheets are routinely used during most laparotomies.18 free anastomosis. The abdominal incision is closed in the usual fashion. LAPAROSCOPIC RECTOPEXY Postoperative care. After operation, the patient is started on a Laparoscopic Resection Rectopexy clear liquid diet, then advanced to a regular diet when bowel function returns. The bladder catheter is removed on postopera- Preoperative management includes full mechanical bowel tive day 1, when ambulation also begins. preparation and both oral and parenteral antibiotic preparation. In addition, cefotetan, 2 g I.V., is administered along with hep- Troubleshooting Either suture rectopexy or sigmoid resec- arin, 5,000 units subcutaneously, at the start of the operation. tion can be performed alone by following some of the steps just After the induction of general anesthesia, the patient is placed outlined (see above). Circumferential mobilization of the rectum in the modified lithotomy position with the legs in pneumatic to the level of the coccyx posteriorly and the upper third of the compression stockings and padded stirrups.The arms are tucked vagina anteriorly, with division of the lateral ligaments, is advo- at the sides, and extra care is taken to secure the patient to the bed cated to minimize recurrence. Division of the lateral ligaments because of the rotation and tilting required during operation.Two increases the risk of postoperative constipation; however, inade- or more monitors are placed on opposite sides of the operating quate distal mobilization or posterior mobilization performed table. The rectum is irrigated with saline through a transanally without lateral ligament division results in laxity of the rectum placed mushroom catheter until the effluent is clear, at which and the attachments below the level of sacral fixation, which point additional irrigation is initiated with a povidone-iodine increases the risk of early recurrence. During the sigmoid resec- solution. The catheter is left in place for the initial portion of the tion, it is important to remove all redundant bowel; however, it is procedure, and the extra effluent is allowed to drain into a plastic equally important to ensure that the anastomosis is tension free bag secured to the catheter. If requested, lateral ureteral stents are and well vascularized. During both rectal mobilization and sig- placed by a urologist, and a urinary catheter and an orogastric moid resection, careful attention should be paid to preserving the tube are inserted. The abdomen is shaved, prepared with superior rectal artery and the sacral nerves. povodone-iodine solution, and appropriately draped.
  9. 9. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 36 Procedures for Rectal Prolapse — 9 Operative technique Step 1: placement of ports. A 10 mm Step 5: extracorporeal transection of proximal bowel. A small (4 trocar is placed infraumbilically or supraumbilically (depending to 5 cm) Pfannenstiel incision is made, a wound protector drape on patient size) by means of the open Hasson technique; this port is inserted, and the sigmoid is delivered through the wound. will be used for the camera. Pneumoperitoneum is established, Transection of the proximal bowel is performed in an area of the and two additional 10 mm trocars are placed along the lateral colon that easily reaches the sacral promontory without redun- edge of the rectus abdominis in the right midabdomen and the dancy. A purse-string suture is placed in the edge of the proximal right iliac fossa [see Figure 6]. If necessary, one or two additional bowel, and the anvil of a 33 mm circular stapler is inserted and trocars may be placed laterally on the left of the abdomen to secured. The bowel is then placed back into the abdomen. assist with sigmoid retraction. Step 6: placement of rectopexy sutures. Via the Pfannenstiel inci- Step 2: mobilization of sigmoid and rectum. The operating table sion, mattress sutures of nonabsorbable material are passed is tilted to the patient’s right to facilitate medial retraction of the through the peritoneum and fascia on the lateral rectum, through left colon, which is gently grasped with a Babcock forceps. An the presacral fascia just off the midline and 1 cm below the sacral ultrasonic scalpel is placed through the right lower port and used promontory, and back through the lateral tissue. One or two to mobilize the sigmoid colon and the descending colon away sutures are placed on each side but are not secured until the anas- from the left lateral side wall. Early identification of retroperi- tomosis has been created. toneal structures, including the left ureter and the gonadal and iliac vessels, is achieved. The extent of mobilization is limited Step 7: creation of anastomosis. The circular stapler is inserted because the goal is to resect only the redundant portion of the transanally to the level of the rectal stump, and its trocar is care- colon. Laparoscopic resection rectopexy is the only type of left- fully advanced. The anvil is engaged on the trocar, the surgeon side resection in which the splenic flexure is deliberately not confirms that there is no inclusion of extraneous tissue and no mobilized in order to prevent redundancy and therefore recur- rotation of the bowel or its mesentery, and the stapler is closed. rence of the prolapse. Dissection is extended into the pelvis, and The locations of the ureters and the vagina are reconfirmed to the upper lateral rectal attachments are divided. With cephalad ensure that these structures are not incorporated into the staple traction applied to the rectum, the mesorectum is circumferen- line.The stapler is fired, and the tissue doughnuts are inspected to tially divided to the level of the coccyx. verify circumferential integrity.The anastomosis should be tension free and well vascularized. Its integrity is tested by insufflating air Step 3: division of mesenteric vessels. The peritoneum of the left into the rectum with the anastomosis submerged in fluid, and any mesocolon is scored to permit identification and preparation of leaks identified are reinforced with sutures. As with open rec- the vessels for transection. A 30 mm linear vascular cutting sta- topexy, endoscopic visualization can be a useful alternative; this is pler is inserted through the right iliac fossa port, and the vessels in fact our preferred approach for all circular stapled anastomoses. are individually transected. The use of endoscopic hemostatic Insufflation of air during visualization completes the assessment. clips or endoscopic vessel loops is the most expedient option for Finally, the rectopexy sutures are tied and the abdominal and port site incisions closed. managing imperfections of hemostasis.The location of the ureter is reconfirmed before each application of the stapler. Postoperative care. Patients are immediately started on a clear liquid diet and advanced to a solid diet when bowel function Step 4: intracorporeal transection of rectum at rectosigmoid junction. returns. The bladder catheter is removed on postoperative day 1. At the point where the taeniae coli coalesce, the rectosigmoid junction is divided with a laparoscopic linear stapler passed Laparoscopic Suture or Mesh Rectopexy through the right lower quadrant port. Patient preparation, positioning, and placement of ureteral stents are the same for laparoscopic suture or mesh rectopexy as for laparoscopic resection rectopexy. Operative technique Step 1: placement of ports. An infraumbilical or supraumbilical port is placed, followed by two additional ports in the lower abdomen (one in each quadrant), positioned so that the camera and the needle holders can be exchanged to afford access to both sides of the rectum [see Figure 7]. The surgeon stands to the patient’s left. 10 mm Step 2: mobilization of rectum. Two bowel graspers are used to retract the rectosigmoid junction and the midrectum upwards. An 10 mm ultrasonic scalpel is employed to perform the presacral dissection 10 mm and to divide the upper half to two thirds of the lateral ligaments. Step 3: intracorporeal placement of sutures or mesh. With upward traction applied to the rectum, sutures are passed through the lateral rectal fascia and peritoneum, through the pre- sacral fascia just off the midline and 1 cm below the sacral pro- Figure 7 Laparoscopic suture or mesh rectopexy. A 10 mm montory, and back through the lateral tissue. Two sutures are trocar is placed in the periumbilical region. Two additional placed on each side and tied with the laparoscopic needle hold- 10 mm trocars are then placed, one in each lower quadrant. ers. The port sites are closed in the usual fashion.
  10. 10. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 36 Procedures for Rectal Prolapse — 10 a Presacral Space b Rectum 0-Silk Suture Grasper Tied Suture Polypropylene Mesh Rectum Sacral Laparoscopic Promontory Needle Holder Figure 8 Laparoscopic mesh rectopexy. (a) A piece of mesh is inserted into the abdomen through a port, then stapled to the sacrum. (b) The lateral edges of the mesh are wrapped around three quarters of the rectal circumference and sutured to the rectal wall. Alternatively, a piece of mesh is rolled up and inserted through a incidence of ureteral injury can be minimized by early identifica- port.The mesh is tacked to the sacrum with a laparoscopic stapler, tion of these structures, which may be facilitated by the use of and the lateral edges of wrapped mesh are secured to the rectal wall ureteral catheters. with sutures [see Figure 8].This type of posterior mesh sling proce- Vascular injury can occur at several different points of the opera- dure is also known as the modified Ripstein procedure. tion. Injury to the epigastric vessels during port placement is usual- ly avoided by transilluminating the abdominal wall with the camera Postoperative care. The patient is started on a clear liquid diet to identify the vessels. The iliac and gonadal vessels are retroperi- and advanced to a regular diet on the morning of postoperative toneal structures, which, like the ureter, can be avoided with careful day 1. The bladder catheter is also removed at this time. dissection and identification.The mesenteric vessels must be prop- erly identified and controlled with graspers before the mesocolon is Troubleshooting transected.The use of endoscopic clips as the sole means of vascular Laparoscopic repair of rectal prolapse follows the same basic control before transection is discouraged; the calcified vessels com- principles as open repair. There are multiple variant forms of monly encountered in this mainly elderly population lead to clip laparoscopic rectopexy, differing not only with respect to technical slippage and incomplete hemostasis. details (e.g., resection versus no resection and suture versus mesh) The incidence of anastomotic leakage can be minimized by but also with respect to whether the procedure contains an open ensuring a tension-free, nonrotated, airtight connection with a component or is fully laparoscopic. The essential steps, however, good blood supply and by making sure not to incorporate diver- are the same in all of the variants and include adequate mobiliza- ticula into the suture line. tion of the rectum, careful placement of sutures, and appropriate Surgical site infections are a common complication of all col- resection with healthy anastomosis of the segments. For example, orectal resections. Their incidence can be minimized by perform- in the approach to laparoscopic resection rectopexy we describe ing appropriate bowel preparation, providing I.V. antibiotic pro- (see above), most of the mobilization is performed laparoscopical- phylaxis before operation, and, possibly, employing a plastic wound ly, with resection, anastomosis, and suture placement performed protector at the site of colon extraction. Copious wound irrigation in an open fashion, whereas in laparoscopic rectopexy performed before closure at the end of the procedure is also helpful. without resection, sutures are placed and tied (or mesh secured) MESH AND SPONGE REPAIRS intracorporeally.The modified Ripstein procedure (see above) can be performed in a totally laparoscopic fashion if desired. Ripstein Procedure Complications Preoperative care and patient positioning are the same for the Intraoperative complications of laparoscopic rectopexy include Ripstein procedure as for open resection rectopexy. inadvertent enterotomy or colotomy, ureteral injury, and organ injury from trocar placement. Most of these injuries are associat- Operative technique Step 1: initial incision and exploration. ed with the presence of adhesions and can usually be prevented Step 1 in the Ripstein procedure is identical to step 1 in resection by careful intra-abdominal dissection in appropriate planes. The rectopexy.
  11. 11. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 36 Procedures for Rectal Prolapse — 11 a b Figure 9 Ripstein procedure. (a) With the rectum under tension, a piece of mesh is sutured to the presacral fascia on one side, then sutured to the muscularis of the anterior rectum. (b) The rectum is then secured to the presacral fascia on the other side to form a sling. Step 2: mobilization of rectum. The lateral peritoneal folds of below the promontory [see Figure 9a]. The rectum is pulled taut the rectum in the pelvis are incised from the rectosigmoid junc- with upward traction, partial-thickness nonabsorbable sutures tion to the anterior midline on each side. With the St. Mark’s are placed in rows along the anterior rectum to hold the mesh in retractor used to supply traction, the rectum is dissected away place, and the mesh is sutured to the presacral fascia on the other from the sacrum with the electrocautery down to the level of the side [see Figure 9b].The sling is left loose enough to allow two fin- coccyx. Anterior dissection separates the rectum from the vagina gers to pass between the bowel and the sac. or the seminal vesicles. The upper one third to two thirds of the Because of the high risk of constipation and even obstipation lateral stalks are divided to facilitate mesh placement. after anterior mesh encirclement, a modified version of the Ripstein procedure was developed that involved posterior fixation Step 3: placement of mesh. A 5 cm rectangle of mesh is placed of mesh to the sacrum, leaving the anterior rectal wall free of any around the anterior rectum at the level of the peritoneal reflec- potential constriction. In this modified approach, the mesh is tion and firmly sutured to the presacral fascia on one side, 5 cm tacked to the sacrum first.The lateral edges of the mesh are then wrapped around three quarters of the circumference of the rec- tum and sutured anterolaterally to the rectal wall. Intraoperative rigid proctoscopy may be helpful for ensuring that the position- ing of the mesh does not result in obstruction. Step 4: closure of peritoneum. The peritoneal reflection is closed so that the mesh is excluded from the peritoneal cavity and the small bowel is prevented from migrating into the pelvis on top of the mesh. The abdomen is irrigated and closed in the usual fashion. Postoperative care. The patient is started on a clear liquid diet and advanced to a solid diet with resumption of bowel function. The bladder catheter is removed 2 days after operation. Ivalon Sponge Repair (Wells Procedure) Preoperative care and positioning are the same for the Wells procedure as for open resection rectopexy. Operative technique Steps 1 and 2. Steps 1 and 2 are the same as in the Ripstein procedure. Step 3: placement of sponge. A rectangular piece of sterilized and moistened Ivalon sponge is secured in place with mattress sutures passed through the sponge, through the presacral fascia, and back through the sponge. Careful hemostasis is ensured to prevent purulent collections in the area of the sponge. The rec- Figure 10 Ivalon sponge repair (Wells procedure). The sponge is tum is retracted cephalad, and the lateral edges of the sponge are anchored to the sacrum. With the rectum under tension, the edges folded around it for approximately three fourths of its circumfer- of the sponge are brought around three quarters of the rectal cir- ence.The edges are secured to the anterior portion of the rectum cumference and sutured to the muscularis of the anterior rectum. with seromuscular sutures [see Figure 10].
  12. 12. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 36 Procedures for Rectal Prolapse — 12 Step 4: closure of peritoneum. The pelvic peritoneum is closed half of each lateral stalk in an attempt to balance functional out- to exclude the small bowel from the pelvis and thus prevent it come against cure of the prolapse. from coming in contact with the sponge. The constipation produced by rectopexy and lateral ligament division may be overcome by adding sigmoid resection to the pro- Postoperative care. Postoperative care is the same for the Wells cedure. Several prospective randomized trials revealed a reduc- procedure as for the Ripstein procedure. tion in postoperative constipation when resection was added to rectopexy in patients with preoperative constipation.28,29 Recur- Complications rence rates after resection rectopexy were comparable to those Fecal impaction may result from making the sling too tight or after rectopexy alone, and although the resection imposed addi- from severe constipation caused by leaving a redundant rectosig- tional risks (i.e., anastomotic leakage and wound infection), mor- moid colon above the level of the repair. bidity rates were comparable as well. Continence rates are im- Presacral bleeding may result from placement of sutures in the proved with resection rectopexy because the rectal reservoir is presacral fascia and consequent injury to the veins. If bleeding oc- maintained (by limiting resection to the portion of the large bowel curs, the sutures should be immediately secured and manual pres- above the peritoneal reflection). Because of the risk of pelvic sep- sure applied. If these measures fail, thumbtacks may be required. sis, resection is only combined with suture rectopexy, not with Strictures may result at the site of the sling and may be diag- Ivalon sponge or mesh repairs. nosed by means of barium enema or sigmoidoscopy. If the mesh Isolated resection of the sigmoid colon is an effective method is wrapped anteriorly, revision may involve laterally transecting of preventing recurrence permanently; limiting the length of the the mesh where it is not fused to the rectum, removing the mesh, bowel definitively inhibits the mobility of the rectum.30 or resecting the portion of the rectum where stricture occurs. To Recurrence rates are the same for this procedure as for other minimize the risk of this complication, either the mesh should be abdominal procedures, and morbidity is determined by the level placed posteriorly (see above) without a circumferential wrap or, of the anastomosis. Patients with constipation secondary to if an anteriorly based sling is employed, care should be taken not colonic inertia associated with rectal procidentia may require an to encircle the rectum too tightly. extended resection that includes subtotal colectomy with ileorec- Sepsis may result when placement of full-thickness sutures or tal anastomosis.31 erosion into the bowel wall leads to mesh or sponge infection. Disadvantages of the open abdominal procedures for rectal Pelvic abscesses and fistulas are treated by removing the mesh or prolapse include a significant incidence of peritoneal adhesions, sponge and, in some circumstances, by performing a diverting the need for general anesthesia, a longer hospital stay, greater colostomy. Preventive measures include giving perioperative morbidity, and possible compromise of sexual function. Certain antibiotics, placing seromuscular sutures, and ensuring that the disadvantages (e.g., more extensive intra-abdominal invasion, synthetic material is not too tightly wrapped. scarring, and longer recovery time) are reduced when the laparo- Adhesions to the mesh may be associated with small bowel scopic approach is employed. Controlled studies of laparoscopic obstruction.This complication can be prevented by reperitoneal- rectopexy revealed recurrence rates and morbidity comparable to izing the pelvis to prevent migration of the small bowel onto the foreign substances. Placement of Seprafilm beneath the fascial those of open approaches.32,33 A subsequent study comparing closure helps reduce adhesions. laparoscopic resection rectopexy with the corresponding open approach found that with the former, though longer operating OUTCOME EVALUATION times were noted, less time was required for return of bowel func- Overall, abdominal operations yield better results than perineal tion, toleration of a regular diet, and hospital stay.34 Another study operations with respect to recurrence rates (which range from 0% found that continence improved to a significant extent after to 8%) and functional outcome.19 The abdominal approach laparoscopic rectopexy without significant changes in postopera- allows the rectum to be maximally mobilized and fixed to the tive constipation.35 sacrum. In addition, transabdominal procedures can be tailored to the presence or absence of functional disorders (e.g., constipa- Special Situations tion or incontinence) through the addition or omission of sigmoid resection. Morbidity, however, is greater with abdominal proce- INCARCERATION, STRANGULATION, AND GANGRENE dures than with perineal procedures. In planning surgical treat- ment of rectal prolapse, therefore, it is essential to consider risk On rare occasions, a rectal prolapse becomes incarcerated. If factors for complications in addition to likelihood of cure. the bowel is viable, sedation and gentle manual reduction in the For many surgeons, posterior rectopexy is the procedure of emergency department usually suffice. Sprinkling table sugar on choice because of its low morbidity and recurrence rates.13,20,21 the prolapse helps reduce edema.36 If such measures are unsuc- Some 50% to 88% of patients show improved continence,22-24 but cessful, paralyzing the perianal muscles with an anal block or gen- as many as 53% experience either new-onset constipation or exac- eral anesthesia in the OR may help resolve the problem. If the erbation of preexisting constipation.22 The constipation is thought incarceration is irreducible or the viability of the bowel is ques- to be attributable to rectal denervation resulting from division of the tionable, emergency perineal rectosigmoidectomy should be per- lateral ligaments; however, preservation of these ligaments is associ- formed, with or without fecal diversion.37 ated with a significantly higher (> 50%) recurrence rate.25,26 The RUPTURED PROLAPSE type of material used to perform the rectopexy has no effect on re- currence: recurrence rates are the same for suture repairs as for Rupture of the prolapse usually involves opening of the hernia mesh repairs.27 Suture repairs, however, carry a lower risk of associ- sac and exposure of the small bowel to the perineum. Emergency ated pelvic sepsis and luminal constriction, especially when com- transabdominal repair is indicated, with closure of the peritoneal pared with repairs involving mesh wrapped around the anterior rec- hernia sac and suture rectopexy constituting the safest and most tum. Our practice, therefore, is to resect the upper one third to one efficient repair.
  13. 13. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 36 Procedures for Rectal Prolapse — 13 PROLAPSE IN MALE PATIENTS agement. Some authorities advocate an abdominal procedure for Prolapse in male patients, though relatively rare, may occur at the second operation, regardless of what the initial operation was, any age. Rectal mobilization should be modified so as to preserve because of the superior rates of success with such procedures39; the presacral nerves, keep from damaging Denonvillier’s fascia, however, care must be taken in performing repeat resectional pro- and avoid division of one of the lateral ligaments.38 Lateral cedures (e.g., anterior resection after perineal rectosigmoidectomy, pararectal tissues carry parasympathetic fibers and are important or vice versa) because of the risk of bowel ischemia between the two anastomoses. In our view, unless the previous anastomosis can be in normal ejaculatory function. Consideration should be given to resected in the second procedure, repeat resectional procedures taking a perineal approach or performing resection alone. should be avoided.39,40 Perineal rectosigmoidectomies are an excep- RECURRENT PROLAPSE tion to this broad rule: they can be safely repeated because the re- current prolapse contains the previous anastomosis.41 Recurrence Rectal prolapse is the anatomic consequence of an underlying rates and morbidity after operative treatment of recurrent rectal functional disorder of the colon and the rectum. Although surgi- prolapse are essentially the same as those after operative treatment cal intervention corrects the anatomic abnormalities present, the of primary rectal prolapse.42 functional disorder often persists, resulting in a tendency for the prolapse to recur.39 Recurrence rates differ among the various RECTAL PROLAPSE WITH SOLITARY RECTAL ULCER SYNDROME types of procedures but are generally higher with the perineal As many as 80% of patients with solitary rectal ulcer syndrome operations than with the abdominal operations. In most cases, (SRUS) have an associated rectal prolapse,43,44 a finding that indi- the cause of the recurrence cannot be identified, though early cates a close relationship between these two entities. In cases of recurrences (those occurring less than 2 years after operation) are symptomatic SRUS associated with asymptomatic prolapse, a trial thought to be related to technical factors associated with the orig- of medical therapy is warranted45; if such therapy fails, surgical in- inal procedure.39 tervention with procedures used for rectal prolapse should be con- The initial operation for rectal prolapse is chosen on the basis of sidered.46 In cases of symptomatic prolapse associated with asymp- several different factors, but the choice of operation for recurrent tomatic SRUS, healing of the ulcer can be demonstrated in one prolapse is based primarily on the procedure chosen for initial man- third of patients undergoing operation for the prolapse.46 References 1. Madden MV, Kamm MA, Nicholls RJ, et al: 11. Johanson OB, Wexner SD, Daniel N, et al: Peri- 21. Madoff RD, Mellgren A: One hundred years of Abdominal rectopexy for rectal prolapse: neal rectosigmoidectomy in the elderly. Dis Colon rectal prolapse surgery. Dis Colon Rectum prospective study evaluating changes in symp- Rectum 36:767, 1993 42:441, 1999 toms and anorectal function. Dis Colon Rectum 12. Lechaux JP, Lechaux D, Perez M: Results of the 22. Aitola PT, Hiltunen KM, Matikainen MJ: Func- 35:48, 1992 Delorme procedure for rectal prolapse: advan- tional results of operative treatment of rectal pro- 2. Boutsis C, Ellis H:The Ivalon-sponge wrap oper- tage of a modified technique. Dis Colon Rectum lapse over an 11 year period: emphasis of the ation for rectal prolapse: an experience with 26 38:301, 1995 transabdominal approach. Dis Colon Rectum patients. Dis Colon Rectum 17:21, 1974 13. Ripstein CB: Surgical treatment of rectal pro- 42:655, 1999 3. Madoff RD, Williams JG, Wong WD, et al: Long lapse. Pac Med Surg 75:329, 1967 23. Madden MV, Kamm MA, Nicholls RJ: Abdo- term functional results of colon resection and 14. Fengler SA, Pearl RK, Prasad ML, et al: Man- minal rectopexy for complete rectal prolapse: rectopexy for overt rectal prolapse. Am J agement of recurrent rectal prolapse. Dis Colon prospective study evaluating changes in symp- Gastroenterol 87:101, 1992 Rectum 40:832, 1997 toms and anorectal function. Dis Colon Rectum 4. Keighley MR, Shouler PJ: Abnormalities of 35:48, 1992 15. Williams JG, Rothenberger DA, Madoff RD, et colonic function in patients with rectal prolapse al: Treatment of rectal prolapse in the elderly by 24. McCue IL, Thompson JPS: Clinical and func- and fecal incontinence. Br J Surg 71:892, 1984 perineal rectosigmoidectomy. Dis Colon Rectum tional results of abdominal rectopexy for com- 5. Goldman J: Concerning prolapse of the rectum 35:830, 1992 plete rectal prolapse. Br J Surg 78:921, 1991 with special emphasis on the operation by 16. Agachan F, Reissman P, Pfeifer J, et al: Compar- 25. Scaglia M, Fasth S, Hallgren T, et al: Abdominal Thiersch. Dis Colon Rectum 31:154, 1988 ison of three perineal procedures for the treat- rectopexy for rectal prolapse: influence of surgi- 6. Classic articles in colonic and rectal surgery. ment of rectal prolapse. South Med J 90:925, cal technique on functional outcome. Dis Colon Edmond Delorme 1847–1929. On the treatment 1992 Rectum 37:805, 1994 of total prolapse of the rectum by excision of the 17. Agachan F, Daniel N, Wexner SD: The outcome 26. Speakman CT, Madden MV, Nicholls RJ, et al: rectal mucous membranes or recto-colic. Dis of rectal prolapse surgery in the elderly. Is long- Lateral ligament division during rectopexy caus- Colon Rectum 28:544, 1985 term follow up possible? Coloproctology 18:41, es constipation but prevents recurrence: results 7. Mikulicz J: Zur operativen Behandlung des pro- 1996 of a prospective randomized study. Br J Surg lapsus recti et coli invaginati. Verhandlung der 78:1431, 1991 18. 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