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Rectal Prolapse . 8/18/2010. Rectal Prolapse . A “falling down” of the rectum so that it’s out of the body Intussusception of the rectum through the sphincters Associated with fecal incontinence and pelvic floor abnormalities Long history of constipation and straining
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Rectal Prolapse 8/18/2010
Rectal Prolapse • A “falling down” of the rectum so that it’s out of the body • Intussusception of the rectum through the sphincters • Associated with fecal incontinence and pelvic floor abnormalities • Long history of constipation and straining • Two theories of etiology • Sliding hernia through defect in pelvic fascia • Circumferential intussusception of the rectum
Rectal Prolapse • More common in women • Older age groups • Virtue of anatomy (wider pelvis) • Childbearing • Affected men tend to be younger • 20-40 yoa
Patient factors that influence choice of operation • Age • Sex • Medical condition • Extent of prolapse • Bowel function • Status of fecal continence
Procedure related factors that influence choice of operation • Extent of procedure • Potential morbidity • Recurrence rate • Impact on fecal continence and bowel habits • Familiarity and ease of technique
Evaluation • Spontaneous prolapse may be obvious on inspection • Some patients may require straining • Best examined in sitting or squatting position • Concentric rings and grooves • Examine perianal skin for any maceration or excoriation • DRE important to detect anal path and to assess resting tone and squeeze pressure
Evaluation • Colonoscopy/Flex Sig with BE • Rule out mucosal abnormalities • Defecography essential for rectoanal intussusception • Anal manometry can help assess sphincters • Longstanding prolapse may damage internal sphincter • Synchronous levatorphasty • EMG for patients with history of severe straining • Colonic transit times with severe constipation • May need colon resection (sigmoid)
Surgical Options • Perineal procedures • Elderly, high-risk patients • Regional or even local anesthetic with MAC • Constipated patients • resection and rectopexy • Incontinent patients • abdominal rectopexy • perineal resection with levatorplasty
Perineal Procedures • Perineal rectosigmoidectomy (Altemeier) • Morbidity 5-24% • Recurrence rates from 0-10% • Rectal mucosal sleeve resection (Delorme) • Morbidity 0-30%--hemorrhage, dehiscence, stricture, diarrhea, urinary retention • Recurrence rates 7-22% • Perineal suspension-fixation (Wyatt) • Anal encirclement (Thiersch + modification)
Altemeier Procedure • Prone, lithotomy, or left lateral decub • Rectal wall injected with epi containing compound • Circumferential incision made in rectal wall 1-2 cm above dentate • Incision deepened until full thickness rectal wall is divided • Cut edge of rectum pulled down and mesorectum divided and ligated • Continue dissection until no further redundancy • Rectum divided and hand-sewn coloanalanastamosis performed • Can also use EEA stapler
Delorme Procedure • Only mucosa and submucosa are excised • Submucosa infiltrated with epi 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 reapproximated
Thiersch Procedure • Mechanically supplement or replace the anal sphincter and stimulate foreign body reaction in the perianal area • Radial incision made on both sides of anus about 2cm from anal verge • Tunnel created from one incision to another • above anoperineal ligament • anterior to anus • external to external sphincter
Thiersch Procedure • Material brought into incision • Tunnel continued posteriorly • Encircling material then tied snugly over index finger in the anus • Nylon, Silk or Dacron • Silastic rods • Silicone • Marlex and Mersilene mesh • Fascia or tendon
Transabdominal procedures • Repair of the pelvic floor • Abdominal repair of levatordiastasis • Abdominoperineallevator repair • Suspension-fixation • Sigmoidopexy (Pemberton-Stalker) • Presacralrectopexy • Lateral strip rectopexy (Orr-Loygue) • Anterior sling rectopexy (Ripstein) • Posterior sling rectopexy (Wells) • Puborectal sling (Nigro) • Resection procedures • Proctopexy with sigmoid resection • Anterior resection
Abdominal Rectopexy and Sigmoidectomy • Complete mobilitzation of the rectum down to the levator musculature, leaving the lateral stalks intact • Elevation of the rectum cephalad with suture fixation of the lateral rectal stalks to the presacral fascia just below sacral promontory • Suture of the endopelvic fascia anteriorly to obliterate the cul-de-sac (most surgeons omit this now) • Sigmoid colectomy with anastamosis
Abdominal Rectopexy • Used in patients without constipation or prolapse • Rectum mobilized down to levator floor preserving lateral stalks • Then secured to presacral fascia just below sacral promontory
Ripstein Procedure • Anterior sling rectopexy • Rectum mobilized posteriorly down to coccyx • 5 cm piece of mesh (Marlex or Prolene) sutured to presacral fascia 5 cm below sacral promontory in midline • Rectum retracted cephalad and lateral edges wrapped around rectum and sutured to it
Ivalon Sponge • Rectum is mobilized posteriorly to the levators • Also mobilized anteriorly • Ivalon then placed into pelvis and sutured to presacral fascia • Sponge is wrapped around rectum only ¾ of the way • Anterior portion left free • Pertioneum then closed over the sponge
Laparoscopic Rectopexy • Largely replacing 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
Recurrent Prolapse • Can occur in more than 50% of patients • Higher with perineal procedures • Important to evaluate patient for constipation and pelvic floor abnormalities again • Need to consider residual blood supply
Solitary Rectal Ulcer Syndrome • Rectal bleeding • Copious mucous discharge • Anorectal pain • Difficult evacuation • Usually on anterior wall just above anorectal ring • Shallow with “punched out” gray-white base surrounded by hyperemia
Colitis Cystica Profunda • Mucin-filled cysts located deep to muscularis • Appear as nodules or masses on anterior rectal wall • Can be asymptomatic or complain of rectal bleeding, mucous discharge, or anorectal discomfort • Difficulty with bowel movements • Path shows mucous cysts lined by normal columnar epithelium located deep to muscularis