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10 Continent Ileostomy
167
Fig. 10.11 Conversion of the failed pelvic pouch to continent ileostomy. ( a ) Cross-section of the pelvis with the failed pouch present. ( b ) Segment
of bowel to be used to create the continent ileostomy with 15 cm needed for the nipple valve. ( c ) Completed continent ileostomy
There are three options that most readily come to mind for
patients with a failing pelvic pouch: (1) it may simply be
defunctionalized by a covering ileostomy, (2) revisional surgery may be done, and (3) the pouch may be excised. Clearly,
the fi rst option is mostly aimed to be just a temporary intervention. Refashioning of the pouch and/or the ileoanal anastomosis, which may well be tried, is often associated with an
unsuccessful result. According to reports in the literature,
pouch excision with construction of a conventional ileostomy appears to be the most common measure—even in spe-
mended (Fig. 10.11 ). Recent reports [ 61 , 62 ] from
well- known colorectal centres confi rm that such a conversion is a viable option with encouraging long-term results.
Apart from patients with a problematic conventional ileostomy and those unsuitable for a restorative proctocolectomy, candidates for a continent ileostomy are also the
growing number of patients with a failed ileal pouch-anal
anastomosis. It seems reasonable therefore to assume that
there may well be a great revival of interest in the continent
ileostomy technique in the future.
cialized clinics. This is a very unfortunate decision, however,
as such an operation will inevitably be associated with loss
of a signifi cant length of terminal ileum. Apart from the
Summary Pearls
practical problems of a “high-fl ow” ileostomy, salt-water
imbalance and malabsorbtion of bile acids and vitamin B12
will develop. Given the shortcomings of pouch excision or
infi nite diversion, conversion of a failed pouch to a continent
ileostomy as suggested by Kusunoki et al. [ 53 ] and Hultén
and associates [
54 , 56 ] should be a reasonable alternative.
The terminal ileum is preserved and malabsorbtion consequences are avoided. For carefully informed and strongly
motivated patients, conversion of the failed ileal pouch-anal
anastomosis to a continent ileostomy should be recom-
In summary, the low-pressure intestinal reservoir developed
by N. G. Kock is the basis for modern pouch surgery, from
continent ileostomy to ileal pouch-anal anastomosis, and
remains a viable alternative for select patients to this day.
Candidates for a continent ileostomy are patients with poorly
functioning conventional ileostomy, patients with ulcerative
colitis or familial adenomatous polyposis not suitable for
restorative proctocolectomy, or patients with personal preference. A failed pelvic pouch or one that cannot be constructed
168
L. Hultén and H.E. Myrvold
during the operation can also be converted to a continent
ileostomy. When performing the procedure, stabilization of
the nipple valve and anchoring it to the reservoir wall are the
key points in the successful construction of the continent
ileostomy. Surgeons caring for these patients should be
aware of the early and late complications including ischemic
necrosis of the outlet, intra-abdominal abscess, fi stulas, and
slippage of the nipple valve resulting in incontinence.
Salvage procedures of nipple valve dysfunction and fi stulas
are technically demanding and include either rotating the
reservoir with construction of a new nipple valve on the former inlet or creating a new nipple valve on a transposed ileal
segment. Having a thorough understanding of these concepts
will provide valuable insight when faced with the diffi cult
clinical situations that these unique patients may pose.
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Part III
The Pelvis
Rectal Prolapse: Current Evaluation, Management, and Treatment of a Historically Recurring Disorder
Dana M. Hayden and Steven D. Wexner
Key Points
• Rectal prolapse is a surgical disorder for which there
are a multitude of treatment options; however, conclusive evidence does not support any one operation
as a panacea.
• Symptomology, comorbidities, and previous surgeries will guide the selection of the appropriate
operation for prolapse.
• If a patient is medically fi t, the transabdominal
approach should be attempted for both initial and
recurrent rectal prolapse, regardless of the initial
operation.
Etiology and Epidemiology of Prolapse
Key Concept: Rectal prolapse affects both men and women
and may be associated with constipation or fecal incontinence. Several anatomic conditions are commonly found
with rectal prolapse.
Although an uncommon disorder, full-thickness rectal
prolapse can drastically impair the quality of life. It was
described as early as 1500 BC, depicting the protrusion of all
layers of the rectum through the anal canal into the external
environment (Fig. 11.1 ) [ 1 ]. Rectal prolapse can lead to
1 1
several problems including fecal incontinence, obstructed
defecation, bleeding, mucosal ulceration, mucous per rectum, and, rarely, bowel necrosis from strangulation [ 2 , 3 ].
This disorder is more common in females, especially in the
elderly population, although it affects both genders and
patients of all ages, with an overall incidence of 4 per 1,000
[ 3 ]. Although prolapse is commonly thought to be associated
with multiparty, one-third of females with rectal prolapse are
nulliparous [ 4 ]. The peak incidence occurs in the seventh
decade for women; interestingly for males with prolapse, it
occurs at age 40 years or younger [ 4 ]. Although the exact
etiology of prolapse remains unclear, it has been attributed to
distal intussusception of the rectum and a combination of
associated anatomic factors, including relaxation of the rectal suspensory ligaments, chronic straining, altered bowel
transit, diastasis of the levator ani, increased width of the
retrorectal space, an abnormally deep pouch of Douglas with
an associated sliding hernia, and patulous anal sphincter
[ 1 , 4 – 6 ]. Surgical intervention is the only means of treatment;
however, the type of operation still remains controversial, as
illustrated by more than 100 different operations.
D. M. Hayden , MD, MPH
Department of General Surgery , Loyola University
Medical Center , 2160 South First Avenue ,
Maywood , IL 60153 , USA
e-mail: dhayden21@gmail.com
S. D. Wexner , MD, PhD (Hon), FACS, FRCS, FRCS(Ed) (
Department of Colorectal Surgery ,
Cleveland Clinic Florida , 2950 Cleveland
Clinic Blvd. , Weston , FL 33331 , USA
e-mail: wexners@ccf.org
S.R. Steele et al. (eds.), Complexities in Colorectal Surgery,
DOI 10.1007/978-1-4614-9022-7_11, © Springer Science+Business Media New York 2014
*)
Fig. 11.1 Rectal prolapse
173
174
D.M. Hayden and S.D. Wexner
Evacuatory dysfunction frequently occurs with rectal
prolapse and fecal incontinence has been found in approximately 50–75 % of patients with rectal prolapse [
Several factors may contribute to this association: traumatic stretch of the sphincter complex by the protruding
rectum or continuous stimulation of the rectoanal inhibitory refl ex by the prolapse resulting in chronic low internal
anal sphincter pressures and the presence of a direct conduit bypassing the sphincter mechanism [ 1 , 4 ]. Interestingly,
constipation is also a commonly associated feature of rectal
prolapse, reported by 25–50 % of patients [ 4 ]. Although the
mechanism is not clear, it appears to be related to diffi culty
with defecation due to an obstructing rectal intussusception, paradoxical puborectalis contraction, or colonic dysmotility [ 1 , 4 ].
1 , 4 ].
Diagnosis and Evaluation
Key Concept: Rectal prolapse is a clinical diagnosis.
Underlying symptoms and risk factors should guide the
evaluation.
History and physical examination are the key components
to the diagnosis of full-thickness rectal prolapse. History
and symptoms including persistent or spontaneous prolapse,
prolapse with straining, and other symptoms including rectal pain, bleeding, mucous secretion, fecal incontinence, and
constipation should be ascertained. Previous surgical history
including colon resections or anorectal surgery and anorectal congenital anomalies repaired during childhood must be
documented, as well as medical comorbidities. During the
physical examination, reproduction of the prolapse with
Valsalva should be performed; status of the anal sphincters, perineal descent, and associated pelvic organ prolapse
should also be documented. If the prolapse is not reproduced
in the lateral decubitus or prone positions in the offi ce, the
patient should sit on a commode and strain.
Adjunctive imaging and testing are not always necessary,
but may be helpful. If the prolapse cannot be detected in the
offi ce, defecography should be performed. This procedure
will also identify some associated pelvic fl oor disorders or
defects that may require treatment as well [ 4 ]. A lifelong his-
tory of severe constipation should be investigated with
colonic transit study and defecography to evaluate for
colonic inertia or puborectalis dysfunction; these fi ndings
may change the planned operation (total abdominal colectomy with rectopexy) or aid in postoperative planning for
biofeedback. Colonoscopy should be undertaken before
operative intervention according to guidelines for colorectal
cancer screening and surveillance as well as to exclude any
fi ndings that may change the surgical approach (incidental
colon cancer or a tumor serving as lead point for rectal
intussusception) [
4 ]. Anorectal physiology testing may not be
helpful since studies have shown that these tests do not reliably predict postoperative function after prolapse repair [
4 ].
Types of Operative Repair
Key Concept: Understanding the risks, benefi ts, and technical details of the various approaches for rectal prolapse
repair will aid in proper selection of operative repair and
help optimize outcomes. In general, functional improvements
for both constipation and fecal incontinence occur following
both perineal and abdominal repair.
Perineal Operations
Key Concept: Perineal approaches are a second resort, normally to be used only in patients with medical comorbidities
that prevent abdominal approaches. Your preferred choice is
almost always to perform an Altemeier outside of mucosal or
limited full-thickness prolapse where a Delorme may be
useful.
Two main perineal operations are currently performed: the
Altemeier (perineal rectosigmoidectomy) with or without
levatorplasty and with or without colonic J pouch and the
Delorme. Anal encirclement procedures, including the
Thiersch operation, have for the most part been abandoned
due to high complication rates (infection, erosion, breakage)
and high recurrence rates [
described in 1900, is performed most commonly for mucosal
prolapse or short full-thickness rectal prolapse [ 1 , 4 ]. This
operation involves circumferential mucosal sleeve resection of
redundant mucosa with imbrication of the muscularis layer
and then mucosal anastomosis [ 4 ]. The complete bowel wall is
not resected. This perineal operation has been shown to
improve incontinence when performed with or without a
sphincteroplasty [ 1 ]. It may be technically more challenging
than the Altemeier and has been reported to have higher recurrence rates as well [ 1 ]. Although complications are thought to
occur less frequently than with the abdominal approach, urinary retention, infection, bleeding, and fecal impaction have
been reported in 4–12 % [ 4 ]. Patients will usually have postop-
erative improvement of their fecal incontinence (25–70 %)
and constipation (13–100 %); however, urgency and tenesmus
may occur in a small percentage of patients [ 4 ].
Auffret in France fi rst described perineal rectosigmoidectomy in 1882; a series of six cases were published by
Mikulicz in 1889 [ 7 ]. Miles popularized the technique in
1933, although it was named after Altemeier, who described
the technique with an associated levatorplasty in 1971,
reporting a recurrence rate of only 2.8 % [ 2 ]. This operation
involves transanal full-thickness resection of the rectum and
sigmoid colon (Figs.
1 ]. The Delorme procedure, fi rst
11.2 and 11.3 ). A coloanal anastomosis
11 Rectal Prolapse : Current Evaluation, Management, and Treatment of a Historically Recurring Disorder
175
Fig. 11.2 Rectal prolapse during perineal repair
Fig. 11.4 Hand-sewn coloanal anastomosis during perineal
proctosigmoidectomy
of the levatorplasty appears to decrease short-term recurrence rates and prolong the recurrence-free interval [
1 ]. The
addition of the colonic J pouch may also improve postoperative function. The senor author fi rst described it and routinely
employs it [ 8 ]. Some surgeons report low recurrence and
morbidity rates with the perineal approach and advocate the
Altemeier as the fi rst-line treatment for patients of all ages.
Fig. 11.3 Extraction of rectum and sigmoid during perineal
proctosigmoidectomy
is then created with sutures or staples [ 4 ] (Fig. 11.4 ). Some
surgeons reserve this perineal repair for older patients with
comorbidities since major complications are reported to
occur less often than after abdominal operations; the procedure can be performed without general anesthesia, and hospital stay is shorter [ 4 ]. Complications do occur, including
pelvic bleeding, anastomotic leak, abscess, stricture, and
bleeding from the anastomosis, but rates are typically less
than 12 % [ 1 , 4 ]. In addition, complications related to
abdominal operations and pelvic dissection, such as sexual
dysfunction, small bowel obstructions, wound infections,
and incisional hernias, are avoided with the perineal approach
[ 7 ]. Most studies show improvement in continence after peri-
neal proctosigmoidectomy with levatorplasty similar to that
seen after abdominal operations (20–90 %) [
1 ]. Functional
improvement in constipation is reported in a smaller number
of series, with rates ranging from 61 to 100 %. The addition
Abdominal Operations
Key Concept: An abdominal operation, through either an
open or minimally invasive approach, is the preferred operation for full-thickness rectal prolapse if the patient’s risk profi le permits. Regardless of the method chosen, adequate
mobilization and fi xation at the sacral promontory are
required for optimal outcomes.
A variety of abdominal operations are performed to treat
rectal prolapse based on the general principles of rectal mobilization and suspension of the rectum out of the pelvis. The
operations vary by surgical technique (mobilization only,
mobilization-rectopexy, mobilization-resection- rectopexy),
means of access (laparoscopic or open) and method of fi xation (suture or mesh) [ 9 ]. The extent of dissection, division
of the lateral stalks, need for concomitant sigmoid resection,
and method of rectal fi xation are variable and remain points
of controversy, as no single method has been shown to be
more successful than the others and all have associated failures. Laparoscopy has been increasingly used for a variety of
the prolapse repairs (including mesh or suture rectopexy and/
or sigmoid resection) with similar recurrence and postoperative incontinence and constipation rates when compared to
open surgery. Studies evaluating the laparoscopic approach
indicate longer operative times but shorter hospital stays and
lower overall costs [
1 ].
176
D.M. Hayden and S.D. Wexner
Fig. 11.5 Rectal mobilization during laparoscopic rectopexy
Mobilization of the rectum should extend caudally to the
level of the pelvic fl oor musculature, specifi cally to the levator ani muscles, while the extent of lateral mobilization
remains controversial (Fig. 11.5 ). In a small study performed
by Speakman et al., division of the lateral stalks appeared to
be associated with a high rate of postoperative constipation;
however, division of the stalks was also found to be associated with decreased recurrence [ 1 , 4 ]. Other studies have
shown higher rates of constipation with stalk preservation
[ 4 ]. Currently, most surgeons preserve the lateral stalks or
may divide one lateral ligament.
The method of fi xation of the rectum is also controversial,
manifesting in the multitude of techniques available. Suture
rectopexy is commonly performed with the advantage of
avoiding the use of a prosthetic mesh, hopefully allowing
good fi xation with very little risk of infection or erosion,
especially if a resection is performed concomitantly. Fixation
with tacks has also been used. Rectopexy with mesh has
been described with anterior or posterior placement [ 4 ]. The
Ripstein repair and its variations involve placing a synthetic
mesh around the mobilized rectum, attaching the mesh to the
presacral fascia below the sacral promontory. Studies have
shown low recurrence rates as well as improved incontinence
in 20–60 % of patients [ 4 ]. Erosion and defecation problems
have been noted with the anterior repair, and, accordingly,
alternative approaches (attachment to the lateral mesorectum
or variety of mesh types) have been used. The Wells mesh
rectopexy originally used an Ivalon sponge (polyvinyl alcohol) with division of the lateral ligaments. The sponge is no
longer used due to increased complications and postoperative constipation; however, this technique continues to be
used with synthetic mesh [
4 ]. Ventral mesh rectopexy (ante-
rior mobilization of rectum) has also been described by
D’Hoore et al., in order to decrease postoperative constipation. Orr- Loygue mesh rectopexy mobilizes both the anterior
Fig. 11.6 Laparoscopic suture rectopexy
and posterior rectum before fi xation with mesh. Studies
show low recurrence rates (3.4 %) and decreased postoperative constipation with ventral rectopexy; however, the rate of
new- onset constipation has been reported at approximately
14 % [
4 ]. To date, no randomized trials have compared suture
rectopexy to mesh fi xation.
Concomitant sigmoid resection performed with suture
rectopexy was fi rst described by Frykman and Goldberg in
1969 [ 1 ]. The addition of the resection has decreased rates of
postoperative constipation, but it does not appear to affect
recurrence rates. The addition of a resection to the operation
increases the potential risks associated with the transection
of bowel and creation of an anastomosis, including anastomotic leak, abscess, and wound infection.
Laparoscopy and Rectal Prolapse Repair
Key Concept: A minimally invasive approach provides similar outcomes as open surgery, given experience and technical profi ciency, and is increasingly being performed via
laparoscopic and robotic means.
The fi rst laparoscopic repair of rectal prolapse (rectopexy)
was performed in 1992 [ 4 ]. Since that time, several studies
have demonstrated that laparoscopy is safe and feasible for
the treatment of prolapse (Figs. 11.6 and 11.7 ). Although
these studies are small, they have shown similar recurrence
and morbidity rates (4–8 % and 10–33 %, respectively) when
compared to the open approach [ 4 ]. The benefi ts of laparos-
copy have been reported in several studies. One small randomized trial by Solomon et al. found laparoscopy to be
associated with less postoperative pain, faster return of bowel
function, and shorter hospital stays, although operative times
were longer [ 4 , 10 ]. A meta-analysis performed in 2005 com-
pared open to laparoscopic abdominal rectopexy [
3 ]. This
11 Rectal Prolapse : Current Evaluation, Management, and Treatment of a Historically Recurring Disorder
177
Fig. 11.7 Suture placement during robotically-assisted suture
rectopexy
group found that operative time was longer for laparoscopy,
but length of stay was shorter. However, overall recurrence
was found to be similar between open and laparoscopic
abdominal rectopexy with a mean follow-up time of 12–31
months for the included studies [
3 ]. Byrne et al. investi-
gated long-term functional outcomes between laparoscopic
rectopexy and open and resection-rectopexy. They found
that the recurrence rate remains low (7 % at 5 years and
11 % at 10 years follow-up) and that improvement of postoperative incontinence and constipation is similar when
compared to the other operations; the majority of patients
felt as if their constipation improved after surgery, and
incontinence scores had improved [ 11 ]. The rate of wound
complications also appeared to be lower in the laparoscopic
group [ 4 ].
Robotic surgery has also been applied to the treatment of
rectal prolapse (Fig. 11.7 ). There have been only a few
series with small numbers reported. One small nonrandomized trial reported longer operating time and higher costs,
but robotic-assisted mesh rectopexy was found to be safe
and feasible [ 12 ]. Nonetheless, the visualization and ease of
suturing during robotic surgery appears improved compared
to conventional laparoscopy [ 4 , 12 ]. Non-resectional recto-
pexy may be one of the better indications for robotic surgery
as the procedure requires only a single docking of the robot
and no incision is necessary for specimen retrieval.
Moreover, unlike using laparoscopic instruments to suture
the rectum to the anterior sacral fascia and periosteum, this
step may potentially be reliably undertaken with the robotic
platform.
Recurrence After Initial Repair
Key Concept: Recurrence rates increase with longer follow up intervals and are typically higher with perineal procedures. An abdominal repair should be the initial approach
when the patient’s risk profi le permits, while the type of procedure (i.e., rectopexy alone, mesh, resection) does not seem
to infl uence recurrence rates.
Recurrence after initial prolapse repair has been reported
to occur in 2–60 % of patients. These recurrence rates vary
with type of approach, technique, preoperative anorectal and
pelvic anatomy and function, and length of follow-up among
other variables. Most studies have shown lower recurrence
rates for abdominal repairs; whereas the reasons for this difference are not exactly clear, it is likely due to inadequate
mobilization and resection of the rectum and sigmoid that
results from lack of direct visualization during the perineal
approach. Several studies have tried to identify predictors of
recurrence. To date, there is very little conclusive evidence
identifying specifi c risk factors. It is possible that rectal prolapse is just one symptom of overall pelvic fl oor dysfunction,
which may recur if the overall pelvic environment is not
changed.
Recurrence After Altemeier Procedure
Key Concept: The wide range of reported recurrence rates
following an Altemeier are likely multifactorial and include
technical variables (i.e., small resected segment, failure to
enter the peritoneal cavity) and patient-driven factors (prior
surgery, length of follow-up).
Several studies have examined the recurrence rates after
perineal rectosigmoidectomy. In a literature review, the
range of recurrence rates found for the Altemeier procedure
was between 0 and 58 % [ 2 ]. In a study performed by
Altomare et al., 17 (18 %) of 93 patients experienced complete recurrence after being followed for at least 12 months
(median 41, 12–112). Six other patients had recurrence of
mucosal prolapse only [ 2 ]. Of the 17 patients with full-
thickness recurrence, repeat Altemeier was performed in 6,
Delorme in 1, and Wells mesh rectopexy in 1; the 9 patients
refused further surgery [
previous surgery for prolapse was associated with higher
recurrence; other factors such as duration of follow-up,
length of resected specimen, levatorplasty, age, sex, and
severity of incontinence were not signifi cantly associated
[
2 ]. At Washington University in St. Louis, Glasgow et al.
found a recurrence rate of 8.5 % when 106 consecutive
patients with full-thickness rectal prolapse had perineal
proctectomy performed regardless of preoperative status
(age, comorbidities, previous abdominal or anorectal surgery). In a study by Cirocco et al. published in 2010, 103
consecutive patients with full-thickness rectal prolapse were
treated with perineal proctosigmoidectomy between 2000
and 2009. The authors reported that 61 % of patients had preoperative constipation; 94 % of these patients had improvement. Forty-seven percent had fecal incontinence, which
2 ]. These authors found that only
178
D.M. Hayden and S.D. Wexner
improved in 85 % of patients following surgery [ 7 ]. This
group found no recurrences with a mean follow-up of 43
months [
7 ]. In their discussion, the authors allude to their
lack of understanding regarding the historically high recurrence rates reported after perineal repair. Interestingly, in
their literature review, cumulative recurrence rate was 37 %
for studies performed before 1971 and only 10 % in reports
published after 1971 [ 7 ]. The higher rates of recurrence were
suspected to be due to poor surgical technique, especially in
those cases where the mobilization failed to enter the peritoneal cavity.
Several studies have reported lower recurrence and
improved outcomes after abdominal repair. Only one small
randomized trial compared the perineal to transabdominal
approach. Abdominal resection-rectopexy with pelvic fl oor
repair was compared to perineal rectosigmoidectomy with
pelvic fl oor repair in 20 elderly female patients with fullthickness rectal prolapse and fecal incontinence (10 patients
in each arm) [ 13 ]. There were no recurrences following
resection-rectopexy and only one after rectosigmoidectomy.
Continence, frequency of defecation, maximal resting pressure, and compliance all appeared to improve more after
resection-rectopexy versus perineal proctosigmoidectomy
[ 13 ]. However, according to a Cochrane review by Bachoo
et al. in 2000, which was updated by Tou et al. in 2008, no
conclusive data indicate that the abdominal approach is
superior to the perineal approach [ 14 , 15 ]. This conclusion is
likely due to the small number and size of randomized trials
directly comparing both approaches. Perineal proctosigmoidectomy continues to constitute 50–60 % of operations
conducted for rectal prolapse [ 15 ].
Recurrence After Abdominal Approach
Key Concept: Recurrence rates are similar among the various abdominal operations and in general are <10 % in single institutional studies, with larger series demonstrating
higher rates at extended follow-up intervals.
In 2005, the Rectal Prolapse Recurrence Study Group evaluated recurrence of full-thickness rectal prolapse after abdominal operations [ 9 ]. They examined the individual pooled data
for 643 patients. Overall recurrence was 1 %, 6 %, and almost
29 % at 1-, 5-, and 10-year follow-up, respectively, regardless
of the method employed [ 9 ]. The surgical technique, means of
access, and method of rectopexy all had no signifi cant effect
on recurrence [ 9 ]. Interestingly, the degree of complexity of
the operation also did not infl uence recurrence (mobilization
alone had similar recurrence compared to resection-rectopexy)
9 ]. Long-term recurrence rates were almost 30 % after 10
[
years, much higher than some proponents of the abdominal
approach have reported in the short term.
In 2011, the Standards Practice Task Force of the
American Society of Colon and Rectal Surgeons published
practice parameters for rectal prolapse based on studies
and trials performed between 1978 and 2010.
Recommendations were formulated and graded on quality
of evidence. This task force indicated that for patients who
are acceptable surgical candidates, transabdominal rectal
fi xation should be the procedure of choice for rectal prolapse [
4 ]. This recommendation was “strong, based on
moderate quality evidence” that described the transabdominal approach as generally superior, reporting recurrence
rates four times higher and postoperative function worse
for perineal proctosigmoidectomy [ 4 ]. Similar to the report
of Raftopoulos et al., this group noted that type of rectal
fi xation did not signifi cantly infl uence recurrence. They
noted recurrence after suture rectopexy to occur in 3–9 %
of patients [ 4 ], reporting that worsening of preoperative
constipation or new-onset constipation can occur with
suture rectopexy [
4 ]. This task force also indicated that the
addition of resection to rectopexy was associated with
lower recurrence and improved function for patients with
preoperative constipation. Recurrence rates after resection-rectopexy were noted to be 2–5 %. However, complications were higher, likely due to associated anastomotic
complications. It does appear that improvement of fecal
incontinence after resection-rectopexy is less than seen
without sigmoid colectomy [
4 ].
Recurrence rates are also low for mesh rectopexy.
Although higher morbidities did result from erosion or infection, recurrence was reported to be only 2.3–5 % [ 4 ]. A study
performed at Cleveland Clinic by Hool et al. investigated
recurrent rectal prolapse, management, and risk factors.
They reported on 24 patients who were operated on for
recurrent rectal prolapse out of 234 patients seen for prolapse
from 1963 to 1993. Median time to recurrence was 2 years;
however, 30 % occurred within 7 months of the initial operation [ 6 ]. The cause of recurrence was identifi ed in 12 of the
24 patients; 11 were found to be associated with mesh used
during the initial Ripstein repair (mesh pulled off from the
rectum or sacrum, loose sling, misplacement or removal of
mesh for pain) [ 6 ]. The majority of repairs for recurrent pro-
lapse were performed transabdominally; only one patient
had recurrence after the second repair (who also recurred
after a third operation) [ 6 ].
Types of Operations for Recurrence
Key Concept: An abdominal repair should be the preferred
approach, whenever possible, for recurrent prolapse patients.
Any prior anastomosis should be resected when performing
a second repair that involves a resection. You should exercise
caution when considering early surgical intervention in
patients with functional problems following abdominal prolapse repairs and rely instead on bowel regimen adjustments,
bowel training, and time.