This document discusses rectal prolapse and various surgical treatments. It provides details on:
1) Types of rectal prolapse including full thickness, mucosal, and internal prolapse.
2) Common anatomical abnormalities that can cause rectal prolapse like a deep pouch of Douglas or lax muscles.
3) Investigations used to evaluate rectal prolapse like imaging, sigmoidoscopy, and manometry.
4) Goals of treatment include controlling the prolapse, restoring bowel function and continence, and preventing recurrence.
5) Numerous surgical procedures are described ranging from perineal to abdominal approaches, with recurrence rates varying from 0-38% depending on the
Rectal prolapse (Surgical anatomy of rectum, pathology and management0sunil kumar daha
Please find the powerpoint on Rectal prolapse. I tried present it on understandable way and all the contents are reviewed by experts and from very reliable references.
Rectal prolapse: Do we really have a perfect surgical solution? pptx copyDr Amit Dangi
Ventral rectopexy has gained worldwide acceptance for surgical correction of rectal prolapse and high-grade internal rectal intussusception. The technique is based on correcting the descent of the posterior and middle compartments combined with reinforcement of the vaginal septum and elevation of the pelvic floor. anterior mobilization of the distal rectum and mesh suspension performed during VR can correct full-thickness rectal prolapse, rectoceles, and internal rec- tal prolapse and can be combined with vaginal prolapse procedures, such as sacrocolpopexy, in patients with multicompartment pelvic floor defects.
Rectal prolapse (Surgical anatomy of rectum, pathology and management0sunil kumar daha
Please find the powerpoint on Rectal prolapse. I tried present it on understandable way and all the contents are reviewed by experts and from very reliable references.
Rectal prolapse: Do we really have a perfect surgical solution? pptx copyDr Amit Dangi
Ventral rectopexy has gained worldwide acceptance for surgical correction of rectal prolapse and high-grade internal rectal intussusception. The technique is based on correcting the descent of the posterior and middle compartments combined with reinforcement of the vaginal septum and elevation of the pelvic floor. anterior mobilization of the distal rectum and mesh suspension performed during VR can correct full-thickness rectal prolapse, rectoceles, and internal rec- tal prolapse and can be combined with vaginal prolapse procedures, such as sacrocolpopexy, in patients with multicompartment pelvic floor defects.
Rectal Prolapse - Cedars Sinai Medical Center - Medicine Resident TalkTheSurgeryGroupofLA
Presentation by Yossef Nasseri, M.D.
Yosef Nasseri, M.D., is a founding member of The Surgery Group of Los Angeles, a Los Angeles based physician group providing a comprehensive approach to surgical care through advanced technology, long-term patient follow-up, and direct physician access. Dr. Nasseri is double board-certified in general and colorectal surgery and specializes in cutting-edge robotic and minimally invasive techniques for the treatment of colon and rectal cancers, inflammatory bowel disease, benign anorectal diseases, a variety of hernias, and general surgery.
Extended totally extraperitoneal repair (eTEP) is a novel technique that was first introduced by Jorge Daes in 2012 to address difficult inguinal hernias.
Component separation technique for a very large abdominal wall herniaSanjiv Haribhakti
Component separation technique is an excellent technique for large ventral central defects which can allow a medial shift of approx. For More information visit at Gisurgery.info
LAPAROSCOPIC INGUINAL HERNIA REPAIR- OPERATIVE SURGERY
#surgicaleducator #operativesurgery #laparascopicinguinalherniarepair #usmle #babysurgeon #surgicaltutor
Dear viewers,
• Greetings from “Surgical Educator”
• Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries.
• I have already uploaded videos on open and Laparoscopic Appendicectomy, Thyroidectomy, Modified Radical Mastectomy and open and
Laparoscopic Cholecystectomy and Open inguinal hernia repair
• In this video today, I have discussed Laparoscopic Inguinal Hernia Repair- both TAPP and TEP approaches.
• However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery.
• Along with these videos, I recommend you to watch real operative surgery videos as well and I will give a link for each surgery in the end of the video as end-cards, which I think will be very useful.
• This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch the video in the following links:
• surgicaleducator.blogspot.com
• youtube.com/c/surgicaleducator
• Thank you for watching the videos.
Rectal Prolapse - Cedars Sinai Medical Center - Medicine Resident TalkTheSurgeryGroupofLA
Presentation by Yossef Nasseri, M.D.
Yosef Nasseri, M.D., is a founding member of The Surgery Group of Los Angeles, a Los Angeles based physician group providing a comprehensive approach to surgical care through advanced technology, long-term patient follow-up, and direct physician access. Dr. Nasseri is double board-certified in general and colorectal surgery and specializes in cutting-edge robotic and minimally invasive techniques for the treatment of colon and rectal cancers, inflammatory bowel disease, benign anorectal diseases, a variety of hernias, and general surgery.
Extended totally extraperitoneal repair (eTEP) is a novel technique that was first introduced by Jorge Daes in 2012 to address difficult inguinal hernias.
Component separation technique for a very large abdominal wall herniaSanjiv Haribhakti
Component separation technique is an excellent technique for large ventral central defects which can allow a medial shift of approx. For More information visit at Gisurgery.info
LAPAROSCOPIC INGUINAL HERNIA REPAIR- OPERATIVE SURGERY
#surgicaleducator #operativesurgery #laparascopicinguinalherniarepair #usmle #babysurgeon #surgicaltutor
Dear viewers,
• Greetings from “Surgical Educator”
• Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries.
• I have already uploaded videos on open and Laparoscopic Appendicectomy, Thyroidectomy, Modified Radical Mastectomy and open and
Laparoscopic Cholecystectomy and Open inguinal hernia repair
• In this video today, I have discussed Laparoscopic Inguinal Hernia Repair- both TAPP and TEP approaches.
• However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery.
• Along with these videos, I recommend you to watch real operative surgery videos as well and I will give a link for each surgery in the end of the video as end-cards, which I think will be very useful.
• This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch the video in the following links:
• surgicaleducator.blogspot.com
• youtube.com/c/surgicaleducator
• Thank you for watching the videos.
2. What is rectal prolapse?
• Full-Thickness rectal prolapse describes the entire
rectum protruding through the anus
• Mucosal prolapse describes only the rectal mucosa
(not the entire wall) prolapsing
• Internal intussusception where the rectum collapses
but does not exit the anus.
3. Anatomical abnormality
• Abnormally deep pouch of
Douglas
• Lax/atonic muscles of pelvic
floor and anus
• Weakness of sphincters (often
with pudendal neuropathy)
• Lack of normal fixation of
rectum with mobile
mesorectum and lax lateral
ligaments
4. Cause of rectal prolapse
• Rectal prolapse may be associated with the following conditions:
– advanced age,
– long term constipation,
– long term straining during defecation,
– receiving anal sex,
– long term diarrhoea,
– pregnancy and stresses of childbirth,
– previous surgery,
6. How common?
• Rectal prolapse is uncommon; however, the true
incidence is unknown because of underreporting,
especially in the elderly population.
• Age – under 3 years old and after the 5th decade
• 80-90% patients are women.
• Associated features: 50% incontinence, 15%-65%
constipation
• The condition is often concurrent with pelvic floor
descent and prolapse of other pelvic floor organs,
such as the uterus or the bladder.
• 35% of patients are nulliparous.
10. Investigations
• Colonic imaging – to exclude neoplasm
• Sigmoidoscopy - ? SRUS
• Defecography
• Anal rectal manometry is sometimes used to evaluate
the anal sphincter muscles.
• Marker study
11. Aims of treatment
• Control prolapse and prevent recurrence
• Restore normal bowel function
– Restore continence
– Prevent constipation/ impaired evacuation
EITHER resection/plication of redundant bowel
OR fixation of the rectum to the sacrum
12. Incarceration
• An incarcerated rectal prolapse is rare.
– Sugar!!
– Emergency resection is required if the prolapse
cannot be reduced and the viability of the bowel is
in question.
13. Many ways to skin a cat!
• 1959 – Charles Wells
– ‘ I have traced in the literature between 30 and 50
operations for prolapse of the rectum and would
like to add still one more’
– Over 100 procedures now described!
14. Delormes’ Operation
• First described in 1900
• A circumferential incision is made through the mucosa of the
prolapsed rectum near the dentate line
• Using electrocautery, the mucosa is stripped from the rectum to
the apex of the prolapse and excised.
• The denuded prolapsed muscle is then plicated with a suture
and is reefed up like an accordion.
• The transected edges of the mucosa are then sutured together.
• Low morbidity- can be done under spinal
16. Altemeier
• First used by Miles in 1933, Altemeier in 1971
• Full-thickness circumferential incision is made in the prolapsed
rectum at about 1-2 cm from the dentate line
• The hernia sac is then entered, and the prolapse is delivered.
• The mesentery of the prolapsed bowel is serially ligated until no
further redundant bowel can be pulled down.
• The bowel is transected and hand sewn to the distal anal canal
or stapled using a circular stapler.
• Before anastomosis, some surgeons plicate the levator ani
muscles anteriorly, which may help improve continence
19. Perineal stapled prolapse (PSP) – stapled
altemeier
• Pulling out the prolapse completely
• At 3 and 9 o’clock, in lithotomy position — axially
cutting it open with a linear stapler
20. PSP
• Resection performed using a
curved Contour Transtar
stapler.
• 32 patients (30 female:2
male)
• Median age 80 years (range
26-93)
• Median operation time was
30 minutes (range 15-65)
• Median hospital stay was 5
days
• 6 cartridges (range 4-12)
21. Functional outcome after PSP for
external rectal prolapse
• The median follow-up was 6 months (4-22)
• Before surgery twelve (39%) patients complained of
constipation, 10 (31%) reported a continuation of their
symptoms after surgery.
BMC Surgery 2010, 10:9
23. Perineal approach
• Low morbidity
• Possibly high recurrence rates
• Avoids abdominal surgery and pelvic dissection
• ‘cutting off an upturned sock – not fixing it’
25. Posterior suture rectopexy
First described by Cutait in 1959
Mobilisation an upward fixation by fibrosis and suturing
Recurrence 0-9%
26. Mobilisation alone may cause
adequate fibrosis to treat prolapse
• Suggested by John Goligher
• 643 patients (1979-2001)
– 46 mobilisation only
– 130 resection -pexy
– 467 pexy only
• No significant difference in recurrence rates
• 1,5 and 10 year recurrence rates were 1.06%, 6.61%,
and 28.9 %
Raftopoulos et al, DCR 2005 ;48:1200-6
27. Randomised controlled trial of
rectopexy vs no rectopexy
• 252 patients in 41 centres randomised
• Sigmoid resection was allowed in presence of
constipation (more frequently in no rectopexy group)
• No significant difference in complication rates
• 5 year recurrence 8.6% vs 1.5% (p=0.003)
Karas et al., DCR 2011:54:29
28. Posterior mesh rectopexy
To create more fibrosis – Sponge used by Wells in 1959
Also a variety of absorbable and non absorbable meshes
29. Posterior mesh rectopexy
• Low recurrence and low mortality
• Pelvic sepsis – 2-16%
• Haematoma should be avoided by draining pelvis (esp
if considerable ooze)
• Incontinence improved but constipation made worse
30. Resection rectopexy
• Resection of redundant rectosigmoid
• Straight course of left colon – more fixation
• Relief of constipation
32. Lap vs Open
• Simple procedure
• Reduced pain
• Reduced hospital stay
• Studies show lap as effective as open
– No difference in incontinence, constipation or
recurrence
Sajid et al, Colorectal Dis 2010:12:515-25
35. Long term results
• 10 year period – 1994-2004
– 321 patients treated by 4 colorectal surgeons
– 128 perineal procedures
• 99 Delormes’
• 29 Altemeier
– 193 abdominal procedures
• 126 laparoscopic rectopexies
• 46 open rectopexies
• 21 resection rectopexies
Byrne et al DCR 2008: 51:1597
36. Lap rectopexy method
• Full circumferential mobilisation to pelvic floor
• ‘lateral ligaments’ divided
• Polypropylene mesh secured to sacrum and lateral
rectum (with protacker)
• Audit
• Low numbers interviewed re functional results
• Poor definition of recurrence
37. Long term results (lap rectopexy)
• 17 patients thought they had a recurrence at median of 5 years
of follow up
• 5 confirmed full thickness recurrence (126) – 4%
• 7 had banding for mucosal prolapse
• Others had no evidence of FTRP
• Incontinence scores improved - 6.6 to 3.4
• Constipation scores no change – 4.2 to 4.3
39. Summary of results
Recurrence
•Delormes 0-38%
•Altemeier 0-16%
•Posterior suture rectopexy 0-9%
•Mesh posterior rectopexy 0-6%
•Resection rectopexy 0-5%
•Post operative constipation in up to 50% of rectopexy
patients
40. Why constipation associated with
rectopexy?
Full mobilisation of rectum
Autonomic nerve injury
Dysmotility and impaired evacuation
41. Lap ventral mesh rectopexy
• Purpose of surgery for rectal prolapse to correct
prolapse, protect or restore continence and avoid
constipation
• Correct middle compartment prolapse too
• D’Hoore and Penninckx 2004
• 42 patients with total rectal prolapse
D’Hoore et al: BJS 2004:91:1500
48. By 2006
• 109 patients (From 1995 – 2004)
• Mean age 49.3 years
• Hospital stay 5 days
• Minor morbidity – 7%
• 3 recurrences – detachment at sacral promontory
• No mesh erosions
D’Hoore and Penninckx Surg Endosc 2006:20:1919
49. Lap ventral mesh rectopexy
• Systematic review in
2010 of 12 non
randomised studies -728
patients
• Recurrence of 3.4%
• Improvement in
incontinence of 45%
• Improvement in
constipation of 24%
50. Complications
• Complications of 1.4 – 47%
– 1 death from septicaemia from mesh infection
– 1 mesh erosion of posterior vaginal wall
– 2 mesh detachments
– 3 deaths – MI, PE and CVA
– 6 post – operative bleeds
• Less constipation
• Short follow up in some patients
• Mixed reasons for VMR
Samaranavake CB et al. Colorectal Dis 2009
51. Lap Ventral Mesh Rectopexy
-Oxford results
• 65 patients with external prolapse
• 93% female
• Median age 72 years (range 16-93)
• Median follow up 19 months
Boons et al Colorectal Dis 2010: 12:526-32
52. Lap VMR results
• Median operating time 140 mins
• Length of stay 2 days
• 1 recurrence – delormes and 2 mucosal prolapse –
banding
• No mortality
• 5 surgical re-interventions – 1 portsite haematoma
and 4 port site hernias
54. Lap VMR -? Treats prolapse with low recurrence
and improves constipation without resection
55. Warning
• In 2008, the FDA released a warning to healthcare
professionals outlining complications linked to the
use of surgical mesh in treating pelvic organ prolapse
(and stress urinary incontinence).
• To date, FDA has received almost 4000 reports of
adverse events linked to the surgical mesh.
• The agency issued a second warning July 13, 2011, as
a result of a spike in reports of serious adverse events
associated with mesh.
56. US Litigation
• On July 13, 2011, the FDA announced that patients
undergoing pelvic organ prolapse repair with a
surgical mesh may be at a greater risk for mesh
complications than women pursuing other surgical
treatments.
• Because the manufacturers of trans vaginal meshes
failed to warn patients and doctors about this
increased risk, women suffering mesh complications
may be able to file a claim seeking compensation for
medical bills, pain and suffering and other damages.
57.
58. Incidence of complications with mesh
for vaginal prolapse repair – systematic review
1950-2010
110 studies overall synthetic biological
• Mesh erosion 10.3% 10.3% 10.1%
• Wound granulation 7.8% 6.8% 9.1%
• Dyspareunia 9.1% 8.9% 9.6%
• Treatment – removal required in >50%
Abed et al Int Urogynecol J 2011:22:789
59. Vaginal mesh contraction with
polypropylene meshes
• Shown by ultrasound- progressive and linear
relationship
– 30% contraction at 3 years
– 65% contraction at 6 years
– 85% contraction at 8 years
• Presents with
– Pain
– Dyspareunia
– Erosion
– Discharge Feiner and Maher: Obs and Gyne 2010:115:325
61. Erosion rates for gynaecologists
273 patients
Erosion rates
• Abdominal sacrocolpopexy 3.2%
• Abdominal sacro colpo perineopexy 4.5%
• Transvaginal 16%
• Time to mesh erosion 6 weeks to 6 years – mean of
21 months
Visco et al: Am J Ob Gyn 2001:184:297
62. Lap VMR – is it a time bomb?
• Contraction
• Erosion
63. Lap VMR – cure?
• An excellent cure rate and improvement in
incontinence and constipation for full thickness rectal
prolapse
• Good long term results and no reports of mesh
erosion in colorectal literature
64. Lap VMR – or not?
• Mesh may continue to shrink with time
• Worrying and increasing numbers of vaginal erosions
in gynaecological procedures
• Erosion – difficult to treat
65. What procedure?
• Role for perineal procedure in elderly unfit patients
– Low morbidity and high recurrence
• Role for rectopexy – preferably laparoscopic in
patients fit for anaesthetic
– Posterior suture rectopexy as good as posterior
mesh (avoid taking the lateral ligaments)
– Ventral mesh rectopexy adds a mesh but is
superior if perineal descent and other organ
prolapse, avoids new constipation – MESH!
66. Is perineal approach really safer?
• 1469 patients identified from American College of
Surgeons National Surgical Quality improvement data
(2008-9)
• Age
• ASA class
• Approach
Fang et al DCR 2012:55:1167
68. Conclusion
• Tailor the procedure to the patients fitness and
anaesthetic risks
• Tell the patient the risks vs the recurrence rates
• VMR in women with any evidence of middle
compartment prolapse
– Mesh
– Longer op time
– Potential mesh compications
– Remember 10% are men