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Chapter 14 • Perineal Proctectomy for Prolapse (Altmeier/Prassad Technique) 255
Anococcygeal
ligament
Ischiorectal
fossa
External anal
sphincter muscle
Ischial tuberosity
Figure 14-3
Coccyx
Lines of dissection
Anus
Levator ani muscle
Perineal body
Vagina
AB
Levator ani muscle
External anal
sphincter muscle
Ischiorectal fossa
CD
256 Chapter 14 • Perineal Proctectomy for Prolapse (Altmeier/Prassad Technique)
at the base of the Morgagni columns, which are interdigitating lines of squamous epithelium
into the cuboidal and columnar epithelium of the distal rectum. The anal transition zone is the
most highly innervated section of the rectum and anal canal containing nerve fibers sensing
temperature, vibration, electrical stimulation, pressure, liquid, solid, and gas. The dentate line
lies approximately halfway along the surgical anal canal, which extends from the palpable anal
verge all the way up to the anorectal ring palpated at the puborectalis sling posteriorly. The
anoderm within the anal canal, cephalad to the anal verge, has no hair follicles.
Step 2: Preoperative Considerations
Colonoscopy should be performed before the operation. Testing to determine sphincter function
and anatomy can also be performed to evaluate potential for sphincter function recovery after
the operation. All patients should undergo a full mechanical bowel preparation. Patients should
receive preoperative antibiotics and deep vein thrombosis chemical prophylaxis and sequential
compression devices. A bladder catheter should be placed.
Step 3: Operative Steps
u
The patient is placed in the prone-flexed position (Figure 14-4). The perineum is prepared
and draped in the standard sterile fashion. A self-retaining retractor is used for retraction
(Figure 14-5).
u
The redundant distal rectum is prolapsed through the anal canal (Figure 14-6). The rectal
wall is circumferentially infiltrated with local anesthetic containing epinephrine approximately 1 cm proximal to the dentate line (Figure 14-6).
u
A full-thickness circumferential incision is made in the rectum until the perirectal fat is
reached. It is helpful to score the mucosa initially before the full-thickness incision to maintain
a consistent rectal cuff distance. Four quadrant stay sutures are placed in the anal cuff (Figure
14-7).
u
Rectal dissection is performed in the areolar tissue plane proximally until the bowel cannot
be easily prolapsed further. The anterior peritoneum at the cul-de-sac is encountered at this
time. The apex of the peritoneum anteriorly is tagged with sutures to facilitate closure of the
peritoneum later in the procedure (Figure 14-8).
Chapter 14 • Perineal Proctectomy for Prolapse (Altmeier/Prassad Technique) 257
Mesentery
Sigmoid colon
Figure 14-4
Figure 14-6A
Figure 14-5
Figure 14-6B
Figure 14-7
Figure 14-8
258 Chapter 14 • Perineal Proctectomy for Prolapse (Altmeier/Prassad Technique)
u
Attention is given to careful ligation of the posterior mesorectal and sigmoid vessels all the
way up to the sacral promontory (Figure 14-9).
u
The point of proximal colon transection is usually at the left colon–sigmoid junction (Figure
14-10). The resection is performed at the limit of adequate blood supply and at the extent
of mobilization of the proximal segment, which allows a left colon-to-anal canal anastomosis
under slight tension. The anastomosis should spontaneously return to the pelvis at the level
of the puborectalis muscle (Figure 14-11).
u
Reefing of the levator muscles may be performed anterior or posterior to the rectum to make
the anorectal angle more acute and to reduce the opening of the pelvic floor outlet. It should
be just loose enough to allow admittance of a finger (Figures 14-12 and 14-13).
Chapter 14 • Perineal Proctectomy for Prolapse (Altmeier/Prassad Technique) 259
Figure 14-9
Figure 14-11
Figure 14-10
Figure 14-12
Figure 14-13
260 Chapter 14 • Perineal Proctectomy for Prolapse (Altmeier/Prassad Technique)
u
The left colon is sequentially resected at the level of the anal canal as sutures are placed full-
thickness through the bowel using the four previously placed anal cuff quadrant sutures
(Figures 14-14 and 14-15). The intervening spaces are filled with full-thickness sutures until
a complete coloanal anastomosis is obtained (Figure 14-16).
Step 4: Postoperative Care
Pain is usually minimal. Diet may be resumed after 2 days of bowel rest. The patient may be
discharged after return of bowel function.
Step 5: Pearls and Pitfalls
Careful attention must be given to ligation or energy sealing of the posterior mesorectal and
sigmoid vessels because these may retract into the pelvis before establishing hemostasis. Also,
care must be taken to avoid too-proximal ligation of the mesentery, which causes a shortened
length of proximal bowel and tension at the anastomosis. Resection of the proximal bowel and
suture placement should be performed in segments to prevent retraction of the proximal bowel
into the pelvis.
Selected Readings
Glasgow SC, Birnbaum EH, Kodner IJ, et al. Recurrence and quality of life following perineal proctectomy for rectal prolapse. J Gastrointest
Surg 2008;12:1446–51.
Riansuwan W, Hull TL, Bast J, et al. Comparison of perineal operations with abdominal operations for full-thickness rectal prolapse. World
J Surg 2010;34:1116–22.
Chapter 14 • Perineal Proctectomy for Prolapse (Altmeier/Prassad Technique) 261
Figure 14-14
Figure 14-15
Figure 14-16
Step 1: Clinical Anatomy
C H A P T E R
15
Open Resection Rectopexy
for Rectal Prolapse
Elisa H. Birnbaum
The left colon is adherent to the retroperitoneum along the left gutter via an avascular filmy
tissue plane. The left colon and its mesentery attach to the posterior retroperitoneum where the
ureter and gonadal vessels are found. There is also an avascular peritoneal surface attaching the
left colon to the left and posterior abdominal wall from the splenic flexure to the sigmoid colon.
The peritoneal attachments along the left gutter suspend the left colon from the left side of the
abdomen from the pelvic rim all the way up to the splenic flexure. At the pelvic rim, the colon
becomes free from pelvic side wall attachments and assumes a sigmoid shape and at this point
is known as the sigmoid colon. The sigmoid colon lies free within the abdominal cavity and
pelvis attached posteriorly to its vascular pedicle arising from the aorta. It is common to see a
redundant sigmoid colon with a narrow vascular pedicle. The sigmoid colon continues distally
into the pelvis where at the level of the sacral promontory the three taenia coalesce and become
the top of the rectum. The upper portion of the rectum is intraperitoneal. The exact limits of
the rectum are controversial. The rectosigmoid junction is considered to be at the level of S3
by anatomists, but most surgeons regard the sacral promontory as the landmark for the upper
rectum (Figure 15-1
taenia at the epiploic appendices and diverticulum. The mesentery can be ill-defined, and the
posterior aspect of the rectum is extraperitoneal and closely adherent to the sacral hollow. This
peritonealized mesorectum becomes elongated in patients with prolapse. This posterior tissue
is perirectal areolar tissue containing the terminal branches of the inferior mesenteric artery
(IMA). The upper third of the rectum is intraperitoneal, exposed to the peritoneum anteriorly
and laterally. The middle third of the rectum is exposed to the peritoneum in its anterior aspect
only, and the lower one third of the rectum is entirely extraperitoneal. The anterior peritoneal
reflection can be variable but generally occurs at 7 to 9 cm from the anal verge in men and
5 to 7.5 cm from the anal verge in women.
). The rectum is approximately 12 to 15 cm long. There is an absence of
262
Pancreas
Spleen
Chapter 15 • Open Resection Rectopexy for Rectal Prolapse 263
Left kidney
Transverse
colon
Splenic
flexure
Duodenum
Figure 15-1
IMV
IMA
Left ureter
Left colon
264 Chapter 15 • Open Resection Rectopexy for Rectal Prolapse
Step 2: Preoperative Considerations
Resection rectopexy is indicated for young patients with full rectal prolapse and occasionally
patients with significant internal intussusception. A mechanical bowel preparation is typically
performed, and prophylactic antibiotics appropriate for colectomy are given within 1 hour of
the incision to reduce the risk of wound infection. Patients require routine deep vein thrombosis
prophylaxis. Preoperative counseling should include the risk of rectal prolapse recurrence and
the possibility of persistent fecal incontinence. Patients with normal sphincter tone are better
candidates for abdominal rectopexy because perineal proctectomy requires the anal sphincter
to be lax and completely everted during prolapse.
Step 3: Operative Steps
u
General endotracheal anesthesia is required. An oral gastric tube helps decompress the
stomach during the procedure. The patient is placed in the lithotomy position. Sequential
compression devices and deep vein thrombosis chemical prophylaxis are applied, and a
bladder catheter is placed.
u
A Pfannenstiel incision is used for exposure into the pelvis. Alternatively, a lower midline
incision can be made from the umbilicus to the pubis. A body wall retractor is placed for
abdominal wall retraction.
u
The patient is placed in the Trendelenburg position, and the small bowel is packed out of
the pelvis allowing access to the redundant rectosigmoid junction (Figure 15-2).
u
A peritoneal incision is made from the lateral ligaments to the sacral promontory along the
left peritoneal reflection, and a similar incision is made along the right peritoneal reflection
(Figure 15-3).