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Similar to rectal prolapse. SYED OBAID PROFESSOR OF SURGERY
rectal prolapse. SYED OBAID PROFESSOR OF SURGERY
- 1. RECTAL PROLAPSE DR SYEDUBAID Associate professor of surgery
- 2. RECTAL PROLAPSE FULL THICKNESSPROLAPSE INTERNAL INTUSSUCEPTION MUCOSAL PROLAPSE
- 3. FULL THICKNESS PROLAPSE/PROCIDENTIA Full-thickness protrusion of the rectum through the anal sphincters ● Protrussion consists of all layers of rectal wall ● 4-15 cm in length ● More common in females. Female to male ratio 6:1 ● Commonly associated with prolapse of uterus ● A “falling down” of the rectum so that it’s out of the body
- 4. FULL THICKNESS PROLAPSE/PROCIDENTIA
- 5. FULL THICKNESS PROLAPSE/PROCIDENTIA
- 6. INTERNAL PROLAPSE/INTUSSUSCEPTION ● Occultrectoanal intussusception ● Prolapse does not protude from the anus
- 7. MUCOSAL PROLAPSE –Protusion ofthe rectoanal mucosa
- 8. MUCOSAL VS FULLRECTAL PROLAPSE
- 9. MUCOSAL VS FULLRECTAL PROLAPSE
- 10. Difference Between RectalProlapse and Hemorrhoids Rectal Prolapse Hemorroids Tissue Folds Circumferential Radial Abnormality on Palpation Double Rectal Wall Hemorrhoidal Plexus Resting and Squeeze Pressures Decreased Normal
- 11. Difference Between RectalProlapse and Hemorrhoids
- 13. Rectal prolapse canbe distinguished from prolapsed incarcerated internal hemorroids by the characteristic concentric folds of rectal prolapse and by the painless reduction if not incarcerated.
- 14. PATHOPHYSIOLOGY • INFANTS • Undevelopedsacral curve • CHILDREN • Attack of diarrhoea • ADULTS – Constipation (component of colonic dysmotility) – Weakening/malfunctioning of pelvic floor/sphincters – spastic pelvic floor – Pudendal neuropathy (obstetric injuries, aging) – Sphincter dysfunction (trauma, aging)
- 15. Clinical Features ♦ MucusDischarge ♦ Rectal Bleeding ♦ Soilage ♦ Feeling of incomplete evacuation ♦ Diarrhea ♦ Itching
- 16. Clinical Features ♦ Children:first three years (male=female) ● Cystic fibrosis, malnutrition, diarrhea, severe cough, parasites ♦ Adults: majority are eldery female ● Females >50 – 6 times more likely than males ● 2/3 are multiparous ● Mental illness (depression, autism) ● Neurologic disorder ● Connective tissue disorder ● Constipation and straining
- 17. Clinical Features ♦ Constipationis associated with prolapse in 30%-70% of pts ♦ Chronic straining, sensation of anorectal blockage, need of digital evacation ♦ 60% have coexisting incontinence ● Stretching of anal sphincters ● Impaired rectal compliance ♦ 20-35% have associated urinary incontinence
- 18. NON OPERATIVE MANAGMENT •Treat constipation • Fiber supplements • Stool softeners • Digital repositioning in infants and young children • Sub mucosal injection of 5% phenol in almond oil • Reduce incarcerated rectal prolapse • Table sugar
- 19. Surgical Treatment ♦ Mainstayin treatment of rectal prolapse ♦ Over 100 procedures ♦ In infants and young children rectum is sutured to sacrum in prone jack- knife position. ♦ In adults with unilateral prolapse, redundant mucosa is excised or, if circumferential, an endoluminal stapling technique can be used. Full thickness prolapse: ♦ Perineal procedures ● Resection, reefing, and encirclement ♦ Abdominal procedures ● Fixation, colon resection or combination of both
- 20. Choosing Type ofSurgery ♦ Abdominal ● Recurrence low (<10%) ● ↑ constipation 50% ● Higher M & M esp. with anastomosis ● Mesh placement – stricture, migration, erosion, infection ♦ Perineal ● Recurrence (20%) ● Constipation rate unchanged ● Persistent incontinence worse rate due to removal of rectal resevoir ● Correction of associated abnormalities (rectoceole, sphincter) ● No pelvic dissection – preserves sexual function
- 21. Perineal Procedures ♦ PerinealProctosigmoidectomy – Altemeier ♦ Mucosal Sleeve Resection - Delorme ♦ Anal Encirclement - Thiersch Wire Technique ♦ Perineal suspension/fixation - Wyatt
- 22.
- 23. Delorme’s procedure Onlymucosa and submucosa are excised Submucosa infiltrated with epine. solution Mucosa incised 1cm proximal to dentate Mucosa and submucosa dissected off underlying muscle Continues to apex of prolapse then mucosa transected Placating sutures are placed in the muscle Mucosa is re-approximated
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- 26. Delorme –dissected offmucosa
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- 29. Delorme-reduced prolapse within thepelvis as a bulbous plug
- 30. Complications • Hemorrhage • Hematoma •Wound dehiscence • Sepsis • Stricture
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- 35. Abdominal Procedures ♦ Anteriorrectopexy or Ripstein procedure/ sutured rectopexy ● Anterior wrapping of the rectum and fixation to sacrum ♦ Goldberg rectopexy/ resection rectopexy: (Ant rectopexy+sigmoid resection) ♦ Posterior rectopexy - Wells procedure ● Synthetic mesh ● Sutures alone ♦ Sigmoid colectomy with sutured rectopexy ● Low recurrence ● Low morbidity ● Improves constipation
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- 38. Laparoscopic Rectopexy ♦ Largelyreplacing open abdominal procedures ♦ Ease of performing rectopexy and colon resection simultaneously with shorter hospital stay ♦ Morbidity and mortality no different than open controls ♦ Recurrence rate lower but not statistically significant
- 39. Lap ventral meshRectopexy • Purpose of surgery : to correct prolapse, protect or restore continence and avoid constipation • Correct middle compartment prolapse too
- 40. Dissection from sacralpromontory avoiding nerves
- 41. Deep part offold of Douglas retracted and incised
- 42. Polypropylene mesh sutured toanterior aspect of rectum and fixed to sacral promontory (Loosely)
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- 46. Rectopexy +/- Resection ♦Rectopexy with resection - Multiple papers ● Improvement in continence and constipation ● Mortality – 0-6.7% ● Recurrence – 0-5% ♦ Rectopexy without resection - Wilson et. Al ● 9% recurrence at 48 month f/u ● 17% severe constipation managed by laxatives
- 47. Conclusions ♦ Consider surgerywhen conservative therapy fails ♦ Careful pt selection is crucial to satisfactory outcome ♦ Tailor surgery to the specific pt ♦ Laparoscopic rectopexy allows for quicker recovery and shorter LOS but similar recurrence ♦ Regardless of material used, correct suture and tack placements are crucial ♦ If severely constipated, perform sigmoidectomy ♦ Pts care as much about continence and constipation
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Editor's Notes
- #20 This perhaps sheds some light on etiology of hemorrhoidal disease and opens doors to future research into prevention and treatment of hemorrhoids.
- #21 This perhaps sheds some light on etiology of hemorrhoidal disease and opens doors to future research into prevention and treatment of hemorrhoids.
- #31 This perhaps sheds some light on etiology of hemorrhoidal disease and opens doors to future research into prevention and treatment of hemorrhoids.
- #32 This perhaps sheds some light on etiology of hemorrhoidal disease and opens doors to future research into prevention and treatment of hemorrhoids.
- #33 This perhaps sheds some light on etiology of hemorrhoidal disease and opens doors to future research into prevention and treatment of hemorrhoids.
- #34 This perhaps sheds some light on etiology of hemorrhoidal disease and opens doors to future research into prevention and treatment of hemorrhoids.
- #35 This perhaps sheds some light on etiology of hemorrhoidal disease and opens doors to future research into prevention and treatment of hemorrhoids.
- #36 This perhaps sheds some light on etiology of hemorrhoidal disease and opens doors to future research into prevention and treatment of hemorrhoids.
- #37 This perhaps sheds some light on etiology of hemorrhoidal disease and opens doors to future research into prevention and treatment of hemorrhoids.
- #38 This perhaps sheds some light on etiology of hemorrhoidal disease and opens doors to future research into prevention and treatment of hemorrhoids.
- #46 This perhaps sheds some light on etiology of hemorrhoidal disease and opens doors to future research into prevention and treatment of hemorrhoids.