Rectal Prolapse Flashcards
Rectal prolapse defined as
a prolapse of either the full or partial thickness rectal wall through the anus beyond the anal verge.
RF
-Women
-Multiparity
-Constipation
-Straining
-Old Age
Some indications of the etiology
Men and Nulliparity
> constipation and/ or straining due to disordered defecation.
Multiparity
> Pelvic Floor Weakness
When Prolapse becomes Recurrent and Chronic
Recurrent
> can act as a mechanical obstruction
Chronic
> can cause fecal incontinence and with time can be permanent damage to sphincter
Important Qs in Hx
-onset
-bowel habits
-prior obstetrical history
-prior anorectal surgery
-pelvic organ symptoms
(urinary incontinence, frequency, prolapse, rectocele, etc.)
-colonoscopy history.
Physical Exam
- 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
If Still Prolapse cant be elicited
defecography can be pursued.
Rectal prolapse Vs Hemorrhoids
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
Temporizing measures to reduce it in case no ischemia
- 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
In the setting of acute incarceration that cannot be reduced, What Procedure to Do ?
- Perineal rectosigmoidectomy is most prudent
- it ensures that all compromised rectum is excised.
When to use abdominal Approach ?
If Ischemia not Present and rectum reduces with induction of ansthesia
Approaches to Rectal prolapse
see
Delorme procedure.
Perineal Approach For
- Partial thickness prolapse
- Also short segment (< 5 cm) full thickness prolapse.
How it is Done
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.
What approach for elderly or frail individuals
perineal approach
What is Perineal rectosigmoidectomy, or Altemeier procedure
Full thickness resection and coloanal anastomosis.
How it is Done
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
Some surgeons advocate for ? in regards incontinence
- Small colonic J-pouch to act as a reservoir
- Straight coloanal anastomosis with levatorplasty is an option as well
The Two main abdominal procedures for rectal prolapse:
- Rectopexy or Resection rectopexy
Suture Rectopexy
- fully mobilize the rectum down to the levator muscles
- restore its anatomic position by suturing it to the sacral promontory
Steps
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.
Potential areas for concern postoperatively
- 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.
Ventral Mesh Rectopexy
Either as a material to fix the rectum to or as a sling/ wrap to return the rectum to its usual position in pelvis
Advantages of ventral mesh rectopexy
- Avoids the posterior dissection and division of the lateral stalks that are worrisome in a suture rectopexy and relies on an anterior fixation.
Steps
- 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.
Advantages to ventral mesh rectopexy
- Lack of a posterior mobilization and potential autonomic nerve injury
- Ability to address multicompartmental prolapse
Potential complications
mesh erosion and/ or infection, which has motivated some surgeons to use biologic mesh
suture rectopexy versus ventral mesh rectopexy
no statistically significant difference in recurrence
