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Open Approaches for Rectal Prolapse

Open Approaches for Rectal Prolapse. John Hartley Academic Surgical Unit University of Hull. Open procedures for rectal prolapse. Open operations for rectal prolapse. Perineal operations inferior to abdominal procedures, but definite role

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Open Approaches for Rectal Prolapse

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  1. Open Approaches for Rectal Prolapse John Hartley Academic Surgical Unit University of Hull

  2. Open procedures for rectal prolapse

  3. Open operations for rectal prolapse • Perineal operations inferior to abdominal procedures, but definite role • Delorme’s procedure – simple but high recurrence rate, can be repeated • Perineal rectosigmoidectomy – more complex but lower recurrence rate • “If the patient is fit enough and life expectancy > 5yrs abdominal approach preferred” Keighley and Williams 2nd Edition 2001

  4. Open operations for rectal prolapse The realities – Yorkshire colon and rectal surgery

  5. Open operations for rectal prolapse A range of possibilities: • Exclusion procedures • Pelvic floor repair • Anterior or posterior rectopexy • Resection – alone or with rectopexy

  6. Open operations for rectal prolapse Sigmoid exclusion procedure (Lahaut’s operation) • Rectum fully mobilised in pelvis • Rectosigmoid sutured to posterior rectus sheath • Sigmoid extra-peritonealised behind rectus muscle

  7. Open operations for rectal prolapse Lahaut’s operation • 33 pts • 1 death (3%) • No recurrences • 11 of 12 pts improved continence • One faecal fistula (?ischaemic) • One obstruction Mortensen et al Ann R Coll Surg Engl 1984:66:17 18

  8. Open operations for rectal prolapse Pelvic floor repair via the abdomen • Full anterior and posterior mobilisation of the rectum • Repair of pelvic floor posterior (originally ant and post) to rectum • Difficult access • Pelvic floor thin and attenuated • Largely replaced by rectopexy

  9. Pelvic floor repair for prolapse

  10. Results of abdominal pelvic floor repair for prolapse From Keighley and Williams 2001

  11. Open procedures for rectal prolapse Rectopexy • Probably the operation of choice • Recurrence rates approx. 2% • Continence restored in 60-80% with rectopexy alone • How should rectum be fixed? • When should resection be added?

  12. Open operations for rectal prolapse Anterior rectopexy (Ripstein procedure) • Full mobilisation of rectum • Fixation to sacral promontary by sling (polypropylene, teflon or fascia) • Principle complication – fibrous stricture

  13. Anterior rectopexy

  14. Anterior rectopexy From Keighley and Williams 2001

  15. Open operations for rectal prolapse Posterior rectopexy • Posterior aspect of fully mobilised rectum attached to sacrum • Lateral peritoneum divided, posterior mobilisation to tip of coccyx, division of lateral ligaments • No anterior restriction, distensible rectum • Mesh to sacrum and lateral aspects rectum

  16. Posterior rectopexy

  17. Posterior rectopexy Method of fixation • Teflon • Polypropylene (marlex) • Polyvinyl alcohol sponge (Well’s procedure) - infection (recurrence) • Vicryl • Gore-Tex • SIMPLE SUTURES

  18. Sutured posterior rectopexy

  19. Posterior rectopexy (suture only) From Keighley and Williams 2001

  20. Prosthetic vs suture posterior rectopexy (no resection) Novell et al. Br J Surg 1994;81:904-906.

  21. Division of lateral ligaments in mesh posterior rectopexy Speakman et al. Br J Surg 1991;78:1431-1433

  22. Open operations for rectal prolapse Resection alone • Sigmoid or partial rectal resection (n=113) • Incontinence: - Improved 23 (20%) - Same 13 (11%) - Worse 10 (9%) • Sepsis morbidity: 52% after “low” and 19% after high anastomosis • Recurrence at 10 yrs 14% after “high” and 9% after “low” resections Schlinkert et al Dis Colon Rectum 1985:28:409-412

  23. Resection Rectopexy

  24. Resection Rectopexy • Aims to achieve low recurrence rates and avoid long term constipation University of Minnesota series • 138 pts • Anastomotic leaks in 5 (4%) • Recurrent prolapse in 2 (1.4%) • Continence improved in all but 1 pt • Constipation improved in 56% same in 35% worse in 9% Watts et al. Dis Colon Rectum 1985;28:96-102.

  25. Rectopexy +/- Resection Sayfan et al. Br J Surg 1990;77:143-145.

  26. Rectopexy +/- Resection Tjandra et al. Dis Colon Rectum 1993:36;501-507

  27. Open Approaches for Rectal Prolapse Summary • Lower recurrence rates but higher morbidity than perineal procedures • Fixation superior to pelvic floor repair, or resection alone • Posterior fixation superior results • Sutures alone comparable to mesh fixation • Less constipation with concomitant resection

  28. Open Approaches for Rectal Prolapse Conclusions Sigmoid resection with sutured rectopexy offers: • Low risk of recurrence • The long term avoidance of constipation • PROCEDURE OF CHOICE • (why not laparoscopically?)

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