Rectal Prolapse

Question 1

Rectal prolapse defined as

Answer 1

a prolapse of either the full or partial thickness rectal wall through the anus beyond the anal verge.

Question 2

RF

Answer 2

-Women
-Multiparity
-Constipation
-Straining
-Old Age

Question 3

Some indications of the etiology

Answer 3

Men and Nulliparity
> constipation and/ or straining due to disordered defecation.

Multiparity
> Pelvic Floor Weakness

Question 4

When Prolapse becomes Recurrent and Chronic

Answer 4

Recurrent
> can act as a mechanical obstruction

Chronic
> can cause fecal incontinence and with time can be permanent damage to sphincter

Question 5

Important Qs in Hx

Answer 5

-onset
-bowel habits
-prior obstetrical history
-prior anorectal surgery
-pelvic organ symptoms
(urinary incontinence, frequency, prolapse, rectocele, etc.)
-colonoscopy history.

Question 6

Physical Exam

Answer 6

• left lateral or prone jack-knife position.
• fecal smearing, mucus drainage, skin irritation or breakdown from moisture, a patulous anus, and presence of any prolapsed tissue at rest.
• patient is then asked to bear down.
• If the prolapse cannot be elicited with Valsalva in the left lateral or prone jack-knife positions > Valsalva in a seated position on the commode > still cannot > photographs of the prolapse
  -Check anal Tone
  -Any other prolapse Such as Vagina

Question 7

If Still Prolapse cant be elicited

Answer 7

defecography can be pursued.

Question 8

Rectal prolapse Vs Hemorrhoids

Answer 8

Full thickness rectal prolapse :
Concentric rings/ circles as the rectum telescopes out of the anus

hemorrhoidal prolapse :
creates radial lines from the center of the anus

Question 9

Temporizing measures to reduce it in case no ischemia

Answer 9

• applying sugar to the mucosa of the prolapsed segment of rectum can be used in cases where the bowel is edematous but not ischemic.
• If the bowel still will not reduce after application of sugar, then urgent surgical repair

Question 10

In the setting of acute incarceration that cannot be reduced, What Procedure to Do ?

Answer 10

• Perineal rectosigmoidectomy is most prudent
• it ensures that all compromised rectum is excised.

Question 11

When to use abdominal Approach ?

Answer 11

If Ischemia not Present and rectum reduces with induction of ansthesia

Question 12

Approaches to Rectal prolapse

Answer 12

see

Question 13

Delorme procedure.

Answer 13

Perineal Approach For
- Partial thickness prolapse
- Also short segment (< 5 cm) full thickness prolapse.

Question 14

How it is Done

Answer 14

1- saline mixed with epinephrine is injected into the submucosal layer > lift it off of the underlying muscular layers + aid with hemostasis.

2- A circular incision is created just proximal to the dentate line > down to this submucosal layer.

3- full thickness > plicating sutures would then be placed through the muscularis > placed in four quadrants

4- The redundant mucosa is then amputated, and the remaining mucosa is sutured back to the proximal resection point.

Question 15

What approach for elderly or frail individuals

Answer 15

perineal approach

Question 16

What is Perineal rectosigmoidectomy, or Altemeier procedure

Answer 16

Full thickness resection and coloanal anastomosis.

Question 17

How it is Done

Answer 17

1- rectum is prolapsed its maximum
2- full thickness incision through the rectal wall about 1 to 2 cm proximal to the dentate line.
3 - carried circumferentially
4- pelvis entered anteriorly between the rectum and vagina/ prostate > dividing the peritoneal attachments
5- The lateral ligaments divided using an energy device
6- The rectum and sigmoid colon are then prolapsed out > Dividing posterior attachments and vessels of the mesorectum and mesocolon until the colon cannot be prolapsed any further.
7- place anchoring, full thickness sutures to colon wall
8- if the patient had preoperative incontinence and wide levator hiatus > posterior levatorplasty > interrupted sutures to narrow the levators.
9- also performed anteriorly if wide defect
10- Coloanal anastomosis performed in a handsewn or stapled fashion

Question 18

Some surgeons advocate for ? in regards incontinence

Answer 18

• Small colonic J-pouch to act as a reservoir
• Straight coloanal anastomosis with levatorplasty is an option as well

Question 19

The Two main abdominal procedures for rectal prolapse:

Answer 19

• Rectopexy or Resection rectopexy

Question 20

Suture Rectopexy

Answer 20

• fully mobilize the rectum down to the levator muscles
• restore its anatomic position by suturing it to the sacral promontory

Question 21

Steps

Answer 21

1- The rectum is fully mobilized
2- Incising the peritoneum at the sacral promontory
3- dissection is carried down to the levator muscles posteriorly
4- DONT divide lateral stalks of the rectum close to the rectal wall but rather leave peritoneal “wings” to suture back to the sacral promontory.
5- Care must be taken to avoid injury to the hypogastric nerves when performing this posterior dissection.
6- suture rectum to the sacral promontory on both sides with nonabsorbable suture or tacks
8- Sutures placed lateral to the hypogastric nerves and medial to the ureter
9- Dont narrow the rectum or place it at a sharp angle, which will make evacuation difficult postoperatively.

Question 22

Potential areas for concern postoperatively

Answer 22

• Increased constipation due to division of lateral stalks and compromise of nervous innervation running within them
• Sexual dysfunction in men due to the extensive posterior mobilization with increased risk of nerve damage.

Many surgeons advocate for a perineal approach to full thickness prolapse in men to avoid these areas of potential nerve damage altogether.

Question 23

Ventral Mesh Rectopexy

Answer 23

Either as a material to fix the rectum to or as a sling/ wrap to return the rectum to its usual position in pelvis

Question 24

Advantages of ventral mesh rectopexy

Answer 24

• Avoids the posterior dissection and division of the lateral stalks that are worrisome in a suture rectopexy and relies on an anterior fixation.

Question 25

Steps

Answer 25

• Peritoneum is incised over the sacral promontory
• Avoid the hypogastric nerves and iliac bifurcation
• performed on one side of the rectum typically the right
• dissection down laterally and into the rectovaginal septum
• complete dissection anteriorly to the pelvic floor
• A strip of mesh is cut and placed into the space between the rectum and vagina
• sutured to the anterolateral rectal wall on either side of the rectum + incorporating a small amount of pelvic floor musculature into sutures.
• The mesh is then stretched to the sacral promontory and tacked or sutured to the right side
• peritoneum that has been incised laterally is usually then sutured back to itself to cover the mesh if possible.

Question 26

Advantages to ventral mesh rectopexy

Answer 26

• Lack of a posterior mobilization and potential autonomic nerve injury
• Ability to address multicompartmental prolapse

Question 27

Potential complications

Answer 27

mesh erosion and/ or infection, which has motivated some surgeons to use biologic mesh

Question 28

suture rectopexy versus ventral mesh rectopexy

Answer 28

no statistically significant difference in recurrence