This document discusses rectal prolapse, including its definition, anatomy, risk factors, diagnosis, and management options. Rectal prolapse is a protrusion of the rectum through the anus. It is more common in women, the elderly, and those with conditions causing chronic straining. Diagnosis involves history, examination, and imaging tests. Treatment includes non-operative options like fiber supplements, as well as surgical procedures like the Delorme procedure, Altemeier procedure, and abdominal approaches involving rectopexy. Perineal procedures are less invasive but abdominal approaches have lower recurrence rates. The optimal treatment depends on the individual patient's characteristics and risk factors.

1. RECTAL PROLAPSE
DR SETH JOTHAM (GS, PG-2)
CUHAS

2. At the end o this presentation
• Concept of rectal prolapse
• Surgical anatomy and physiology
• Etiology/predisposing factors and classification (altehmer vs beahrs)
• Reaching the diagnosis
• Updates on the management

3. Rectal prolapse
• Rectal prolapse is a protrusion of the rectum or part of it through the
anus.

4. Historical view
Egyptian honey suppository 460 B.C Hippocrite 400 B.C

5. Anatomy-physiology

6. Ddx1

7. ddx2

8. .

9. .

10. Mucosal or full thickness (Radial vs circular folds)

11. Epidemiology Risk factors
• Children under 3 yrs
• 4th and 7th decades
• Women more 85%
• Chronic straining (constipation)
• COPD
• Previous surgery
• Diarrhea
• Cystic fibrosis
• Connective tissue disorders
• Neurogenic (multiple sclerosis,
lumber sacral disorders and
injury)

12. Diagnosis Further diagnostics
• History
• Inspection
• DRE
• Proctoscopy
• Colonoscopy
• Defecography (MRI/X-RAY)
• Transit time measuring
• Anal monometry
• Endo anal ultrasound

13. Management
NON OPERATIVE MX
• Treat constipation
- Fibers supplement
- Stool softeners
• Reduce incarcerated rectal
prolapse
- Table sugar
- Cold packs
• Others
- Sclerotherapy

14. OPERATIVE MX
PERINEAL APPROACH
• Delorme
• Altemeier
• STARR (stapled trans anorectal
resection)
• Thiersch (T-Stitch)
ABDOMINAL APPROACH
• Without resection
- Suture rectopexy (Sudeck)
- Mesh rectopexy (ripstein)
- Ant.mesh rectopexy (D Hoore)
• With resection
- Frykman-Goldberg procedure

15. Delorme procedure: Mucosal sleeve resection
• Done for elderly risk patients
with co-morbidities
• Usefully in mucosal prolapse
• Risk
Hemorrhage
Dehiscence
Stricture

16. Altemeier procedure (Perineal Recto-sigmoidectomy)
• Useful in full thickness prolapse
• Relatively safe and effective in
frail older patient
• Low post op morbidity.

17. STARR (stapled trans anorectal resection)

18. Thiersch (T-Stitch)
• In high risk patient with rectal
prolapse
• Considered a palliative
procedure
• Can be used in children for
temporary relief until the base
pathology is managed

19. General advantages of perineal procedures
• Regional anesthesia possible if
general anesthesia not possible
• Shorter operating time
• Less invasive
• Reduce perioperative risks
• For the old and frailty with
comorbidities
No laparotomy, no longer stays

20. .
ABDOMINAL APPROACHES

21. Suture Rectopexy(sudeck)
• Rectum mobilized then sutured
to the pre sacral fascia

22. Mesh rectopexy (Ripstein)

23. Ventral mesh rectopexy (D Hoore)

24. Frykman-Goldberg procedure
• Rectopexy and sigmoid colectomy
• Part of the rectum or sigmoid is resected, make anastomosis and
suture part of the rectum posteriorly to the pre sacral fascia
• Recurrence 2%
Anastomotic leak?

25. Advantages of abdominal vs perineal
approach
• Less recurrence rate
• Improvement of incontinence
But …
Need general anaesthesia
More invasive
Nerve injury?....sacral plexus

26. .

27. .
“When an internal organ persists in an endeavor to become
an external organ, it generally causes a great deal of
trouble”
W. Ernest Miles, 1993

28. References
I. Shwartz’s principle of surgery 10thEd
II. Sabistontextbook of surgery 15thand 20thEd
III. PROSPER trial on rectal prolapse: 2001-2008, published 2013.
IV. The Cochrane review: Surgery for complete rectal prolapse in
adults, published 24th November 2015