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8 Rectal Prolapse andIntussusception
133
Abdominal Approaches
Overview ofAbdominal Approaches
Once the decision has been made to perform an
abdominal operation for correction of rectal prolapse, there are several additional questions to be
answered: open vs. laparoscopic; suture rectopexy vs. mesh rectopexy (vs. dissection alone)
and resection vs. non-resection. There are many
factors at play when making these decisions: surgeon experience and comfort with various techniques; patient body habitus and general health
status; a history of prior abdominopelvic surgery
or previous pelvic sepsis; a history of severe constipation and/or slow colonic transit; and the coexistence of other elements of pelvic oor
dysfunction.
When mobilizing the rectum for a prolapse
repair, division of the lateral ligaments has
been the subject of much debate and scrutiny.
While individual studies have demonstrated
evidence either for or against division of the
lateral ligaments [21], a review of the available
literature in 2005 demonstrated a trend towards
reduction of constipation with preservation of
the lateral ligaments [22]. A Cochrane review
reported similar ndings but also decreased
recurrence with division of the lateral ligaments [23]. A more recent review retrospectively evaluated 532 patients who had
undergone abdominal repair of rectal prolapse
and studied factors related to recurrence, specically looking at the extent of mobilization,
the type of rectal xation and surgical access
(i.e., open vs. laparoscopic). On multivariate
analysis, the only factor independently associated with recurrence was the degree of mobilization, in that circumferential mobilization led
to less recurrence (p=0.026) [24]. Nonetheless,
given the potential for lessening constipation
with sparing of the lateral ligaments, in patients
with pre-existing constipation and/or those
undergoing initial repair of their rectal prolapse, the decision of whether to divide the lateral ligaments needs to be individualized.
Open Rectopexy
The abdominal rectopexy procedure begins with
an abdominal exploration and exposure to the
pelvis. Once the small bowel has been packed
out of the pelvis, the sigmoid colon is grasped
and elevated while the peritoneal attachments
on the left and right side of the sigmoid mesentery are incised down beyond the level of the
sacral promontory. Care is taken to identify and
preserve the retroperitoneal structures, including the left ureter, gonadal vessels and hypogastric nerve plexus. Dissection is carried down
into the pelvis as the rectum is reected anteriorly to expose the avascular plane between the
mesorectal fascia and presacral fascia. This
plane is dissected sharply with electrocautery
down to the level of the levator ani muscles. The
extent of anterior dissection is up for debate but,
generally speaking, halting this dissection at the
level of the seminal vesicles in men or the upper/
mid-vagina in women will minimize the risk of
parasympathetic nerve injury. The peritoneum
over the lateral ligaments is incised but the bulk
of the neurovascular tissue along the lateral rectum is left in place. The rectum is then evaluated
for adequate mobility and for its ability to be
xed to the sacral promontory without tension
and with appropriate alignment. The peritoneum
and mesentery of the lateral rectum are then
secured to the periosteum of the sacral promontory using permanent suture. In the absence of
mesh placement, the peritoneum is typically left
open and drains are not mandated.
While various approaches to non-resection
abdominal repair for prolapse had been reported
for decades prior, Loygue rst described the conventional technique of xation of the rectum to
the sacral promontory in 1965 [25]. This technique has been further rened and reproduced
many times since, with excellent results in terms
of recurrence rates as low as 0–5% (Table 8.1)
[26–31]. It should be noted, however, that constipation is made worse in as many as 50% of
patients with pre-existing constipation, and denovo constipation arises in 15% without this dysfunction pre-operatively [32].
134
Table 8.1 Results of open rectopexy procedure
Author # Patients Recurrence (%) Morbidity (%) Mortality (%)
Loygue [25] 140 4 – 1
Carter [26] 32 3 – –
Blatchford etal. [27] 42 2 20 0
Novell etal. [28] 32 3 9 0
Khanna etal. [29] 65 5
Briel etal. [30] 24 0 – 0
a
Dened as recurrence of mucosal prolapse only
Table 8.2 Results of laparoscopic rectopexy
Author # Patients Recurrence (%) Morbidity (%) Mortality (%)
Foppa etal. [35] 179 20 4 0
Kariv etal. [36] 111 9 – –
Wilson etal. [37] 72 9 5.6 –
Sahoo etal. [38] 32 0 0 0
Kessler etal. [39] 32 6.3 9.4 0
Heah etal. [40] 25 0 20 0
a
– –
J. R. Snyder and I. M. Paquette
Laparoscopic Rectopexy
For laparoscopic rectopexy, the initial preparation and positioning (i.e., low lithotomy) are the
same as for an open approach. A camera port is
placed at the umbilicus and two working trocars
are placed in the right mid-abdomen and right
lower quadrant. Either one or two additional trocars can be placed on the left, depending on surgeon preference and the number of assistants
available. While elevating the rectosigmoid anteriorly, the dissection commences with either an
energy device or a scissors. A medial-to-lateral
dissection behind the distal sigmoid mesentery is
then performed, as the sigmoid mesentery is elevated and the left ureter, nerves and gonadal vessels are identied. The degree of dissection and
mobilization should recreate what would typically be done in an open procedure. The mobilized rectum is then evaluated for adequate
dissection and for ability to be appropriately
xed to the sacral promontory. Similar to the
open technique, xation is performed using permanent suture between the periosteum of the
sacral promontory and peritoneum and lateral
mesentery of the rectum. When introduced
through a lower port and as perpendicular to the
sacral promontory as possible, a laparoscopic
tacking device can also be used for xation and
has been shown to have good results [33]. Based
on surgeon comfort and experience, a handassisted approach may be benecial in cases of
difcult anatomy, recurrent prolapse or previous
pelvic sepsis. This method typically involves
placing a hand port at the level of the umbilicus
versus the lower abdomen via a Pfannenstiel
incision.
First described as a sutureless mesh rectopexy
in 1992 [34], the laparoscopic technique has been
widely adopted and has demonstrated durable
results with morbidity and recurrence rates comparable with those of an open approach
(Table8.2) [35–40]. The decision whether to perform a laparoscopic or open repair depends on
many factors: surgeon experience, patient body
habitus, previous abdominopelvic surgery, and
patient ability to tolerated prolonged general
anesthesia and steep Trendelenburg positioning.
For patients able to tolerate a laparoscopic repair,
there are decades of evidence supporting its
safety and outcomes.
In a retrospective review of 21 patients randomly assigned to either open or laparoscopic
rectopexy with preservation of the lateral ligaments, Boccasanta etal. found, with a roughly 2
year mean follow-up, that recurrence rates and
functional outcomes were similar between the
two groups, while patients who underwent laparoscopic repair experienced shorter hospital stays
8 Rectal Prolapse andIntussusception
135
and signicantly reduced cost [41]. A randomized trial of laparoscopic versus open approach
subsequently assessed at short-term measures of
success, including patient pain scores, use of narcotics and length of stay, and favored the laparoscopic approach in every category except for
operative time, which favored the open approach
by a mean of 49min [42].
When compared to the open approach, the
laparoscopic approach has been shown to reduce
length of stay by over 2days (p<0.001). In this
same study, post-operative constipation was more
likely to be improved in the laparoscopic group,
while the remaining post-operative outcomes of
improvement in continence and satisfaction
scores were similar between the two groups [36].
A Cochrane review of 12 randomized control trials concluded that a laparoscopic approach was
associated with fewer immediate complications
and shorter length of stay [43].
Even when followed for 10 years after surgery, laparoscopic repair has stood up well to
open repair in terms of recurrence rates and longterm functional results [44, 45]. As such, when
possible and safe to perform, a laparoscopic
repair should be considered primarily in the management of patients with rectal prolapse, particularly in those with no history of prior repair.
Mesh Techniques
Mesh is frequently used to bolster xation to the
sacral promontory. Many different types of mesh
have been used for this purpose over the years,
including PTFE and polypropylene, as well as, in
more recent years, biologic mesh products.
Reports of mesh erosion, infection, chronic pain
and constriction, as well as the increasingly litigious environment of medicine have led many
surgeons away from synthetic mesh and towards
biologic material.
Mesh can be anteriorly or posteriorly secured
and in a variety of congurations including partial wrap or complete wrap. Whether working
laparoscopically or in an open fashion, the set
up and dissection should be identical as for a
suture rectopexy. Once the initial dissection of
the rectum is complete, the mesh is then
secured.
When utilized as an anterior-based wrap, this
is most accurately described as a Ripstein procedure. As originally described, this method
involves mobilization of the rectum down to the
tip of the coccyx. The rectangular mesh is perpendicularly oriented to the axis of the rectum. It
is then placed around the anterior rectum at the
level of the peritoneal reection and secured with
interrupted sutures (permanent or absorbable
depending on the type of mesh) on the anterolateral rectum bilaterally prior to wrapping the mesh
around the rectum/mesorectum. It is then posteriorly xed to the presacral fascia with interrupted
sutures. This sling creates a change in the angulation of the rectum. In 1972, Ripstein reported on
a series of 289 patients with one death and no
recurrences [46]. Subsequent studies reported on
complications involving fecal impaction potentially due to a severe angulation of the rectum or
the sling being too tight and constricting the rectum [47].
A posterior-based wrap is identical in initial
setup and dissection. The rectangular mesh is
similarly oriented, perpendicular to the rectum.
The difference lies in initial xation, which
occurs to the presacral fascia with interrupted
suture (Fig. 8.4). The mesh is then anteriorly
wrapped around the rectum and either overlapped
prior to xation to the anterolateral rectum or
trimmed short to avoid a complete 360-degree
wrap and, thus, potentially minimize the risk of
rectal constriction.
Fig. 8.4 Posterior mesh rectopexy
136
J. R. Snyder and I. M. Paquette
When the mesh is used as a posterior vertical
strip, it is longitudinally oriented and secured to
the distal mesorectum. The mesh is then pulled in
a cephalad direction to establish appropriate tension on the repair. The tension should be such
that it prevents descent of the rectum while avoiding undue tension that would lead to pulling
through the tissue at the point of xation.
An anteriorly placed vertical strip may also be
posteriorly secured to the sacral promontory.
This approach has its own title, known as a ventral mesh rectopexy. This differs substantially
from the above-described procedures, in that the
posterior dissection is typically limited to exposure of the promontory. With this approach, the
right aspect of the distal sigmoid mesentery and
upper rectum are mobilized by incising the right
side of the peritoneal reection at the level of the
sacral promontory and then sweeping the mesentery off of the retroperitoneum in order to expose
a site of xation of the mesh to the sacral promontory. The left side of the peritoneum is left
intact, while the right peritoneum is incised in a
curvilinear fashion, over the lateral ligaments and
into the anterior peritoneal reection. The anterior dissection is undertaken to the level of the
mid-vagina or seminal vesicles. The mesh is
fashioned to the appropriate width and length and
is then secured to the anterior rectum with interrupted suture. The mesh then courses along the
right anterior rectum and is ultimately xed to the
sacral promontory in a similar fashion as previously described. Drains are not routinely placed.
With the ventral mesh rectopexy as well as all
other mesh procedures in rectal prolapse surgery,
the mesh is extraperitonealized, typically by closing the peritoneum with a running, absorbable
suture. This step is performed in order to theoretically minimize the potential for small bowel
obstruction secondary to adhesions to the mesh
as well as to minimize the potential for mesh erosion and stula formation.
Laparoscopic Mesh Rectopexy
The principles, anatomy and landmarks for laparoscopic mesh rectopexy are identical to those for
open mesh rectopexy, as detailed above. One
impact the use of mesh will have on a laparoscopic case may be port selection, as a 12 mm
port is typically required for introduction of the
mesh. While most synthetic mesh products can
be laparoscopically handled with similar ease as
in open procedures, many biologic grafts are
thick and the handling and suturing of such materials laparoscopically can pose a challenge. For
that reason, when selecting a biologic mesh for
laparoscopic rectopexy, a thinner and partially
transparent mesh may reduce some of the difculty and clumsiness when handling and securing
the mesh.
The use of robotic assisted surgery in rectal
prolapse repair is not discussed separately in this
chapter, as the dissection and points of xation
remain the same as for laparoscopic repair.
However, it should be noted that some surgeons
prefer the robotic approach for ease of deep pelvic dissection and knot tying.
Results ofMesh Rectopexy
In its various iterations, mesh rectopexy has performed well in terms of low recurrence rates, but
occasionally high morbidity rates have led to
evolution of the procedure over time (Table 8.3)
[38, 46–50]. With the original Ripstein repair,
Table 8.3 Results of mesh rectopexy
Author # Patients Recurrence (%) Morbidity (%) Mortality (%)
Gordon and Hoxter [47]
Ripstein [46]
Dyrberg etal. [48]
Tjandra etal. [49]
Dulucq etal. [50]
Sahoo etal. [38]
a
Denotes Ripstein procedure
b
Denotes laparoscopic posterior mesh rectopexy
a
a
1111 2 17 –
b
a
b
b
289 0 0 0.3
81 11.1 14.8 1.2
134 8 21 0.6
77 1 4 0
38 0 2.6 0
8 Rectal Prolapse andIntussusception
137
recurrence rates ranged from 4 to 10%, but the
morbidity was high, with complications including mesh erosion, large bowel obstruction, fecal
impaction and rectovaginal stula in up to 50%
of patients [47, 51, 52]. Secondary to this relatively high complication rate, Ripstein modied
the procedure to involve posterior xation of the
mesh with anterolateral xation to the rectum/
mesorectum with improved results [53].
The technique of posterior xation of the rectum to the sacrum with insertion of an Ivalon
sponge was rst described by Wells with excellent results and a low complication rate [54]. The
use of an Ivalon sponge was later abandoned following a randomized control trial demonstrating
signicant complication rates, including
increased constipation and pelvic abscess formation [28]. The principles of this technique have
persisted, however, with use of various synthetic
and absorbable mesh products, used in both open
and laparoscopic approaches [50, 55–57]. Due to
increased rates of complications, we believe that
mesh should likely only be utilized in a
laparoscopic ventral rectopexy procedure, or in a
repair of a recurrent prolapse.
Ventral Mesh Rectopexy
In 2004, D’Hoore et al. described their initial
results with laparoscopic ventral rectopexy in the
management of rectal prolapse [58]. The operative details are provided above. In brief, this technique involves xation of the rectum to the sacral
promontory by anchoring mesh to the anterior
rectum. The rationale is, in part, that an anterior
dissection alone may minimize the post-operative
morbidity of constipation, or sexual and bladder
dysfunction, more often seen with posterolateral
dissection of the mesorectum and exposure of the
autonomic nerves. In addition, the placement of
mesh anteriorly, rather than circumferentially
around the rectum, as in a Ripstein procedure,
should minimize the possibility of rectal constriction and decreased rectal lling capacity.
Every patient with rectal prolapse has, by denition, an element of pelvic oor dysfunction. The
various components of pelvic oor dysfunction
(rectocele, enterocele, cystocele, uterine or vaginal prolapse, for example) often co-exist. Another
advantage of a ventral rectopexy is that, if the dissection is carried low enough, it can concomitantly address a symptomatic rectocele as well
with low recurrence rates [59, 60]. Ventral mesh
rectopexy has demonstrated excellent results in
terms of low rates of major morbidity and mortality with recurrence rates of 0–6% and no higher
than 8.2% in long-term follow-up (Table8.4) [58,
61–63, 65–68].
The recurrence rate of the original 109 patients
was 3.7% and the rate of minor morbidity 7%,
with no peri-operative mortality [64]. Nearly a
decade later, as this cohort grew in number to 919
consecutive patients between two institutions, the
results were once again examined, demonstrating
a long-term (10-year) recurrence rate of 8.2%
[62]. Mesh-related complications, including
mesh erosion into the vagina, occurred in 4.6% of
patients studied. Rates of obstructed defecation
and fecal incontinence decreased signicantly
(P<0.00001).
Laparoscopic ventral rectopexy has repeatedly been demonstrated to have a positive impact
on patients with existing constipation. In 2010,
Boons etal. published a series of 65 consecutive
patients who underwent laparoscopic ventral rec-
Table 8.4 Results of ventral mesh rectopexy
Author # Patients Recurrence (%) Morbidity (%) Mortality (%)
Evans etal. [61] 2203 – 13 0.1
Consten etal. [62] 919 8.2 4.6 –
Randall etal. [63] 190 3 – 1
D’Hoore etal. [64] 109 3.7 7 0
Boons etal. [65] 65 2 17 0
Sileri etal. [66] 34 5.9 23.5 –
Bloemendaal etal. [67] 28 7 14 –
Owais etal. [68] 18 0 20 0
138
J. R. Snyder and I. M. Paquette
topexy for external rectal prolapse [65]. They
report only one (2%) recurrence and found that
constipation was improved in 72% at 3months
and mildly induced in 2% (P < 0.00001).
Continence scores also improved in 83% and
worsened in 5% (P<0.00001). A review of 12
non-randomized case series with 574 patients
who underwent laparoscopic ventral rectopexy
demonstrated improvement in constipation ranging from 3–72% and worsening constipation in
0–20%. Incontinence improved in 31–84% of
patients with varying degrees of preoperative
fecal incontinence [69].
When a cohort of patients undergoing laparoscopic ventral rectopexy was compared to a
similar cohort undergoing laparoscopic resection rectopexy, signicant improvements in
both constipation and incontinence were found
in both groups [70]. While there was a trend
towards greater improvements in continence in
the laparoscopic resection rectopexy group
(P = 0.09), the resection group also experienced a signicantly higher rate of complications than the laparoscopic ventral rectopexy
group (P<0.05).
The use of biologic mesh in the exercise of
laparoscopic ventral rectopexy has been evaluated in multiple studies and reviewed in conjunction with nearly a dozen studies using
synthetic mesh [71]. The authors found that, at
least in short term follow-up of 12 months,
there was no difference in recurrence between
the use of synthetic (3.7%) and biologic mesh
components (4.0%, P=0.78). The incidence of
mesh complications (0.7% synthetic and 0%
biologic) were no different between the two
approaches. Similar results have been found in
other retrospective analyses over the short term
[72, 73].
More recently, a multi-institutional review of
2203 patients undergoing laparoscopic ventral
rectopexy with either synthetic mesh (80.1%) or
biologic grafts (19.9%) examined the incidence
of mesh-related complications in either group
[61]. The authors report erosion of mesh in 2.4%
of cases using synthetic mesh and 0.7% of those
using biologic mesh. The median time to mesh
erosion was 23 months. Recurrences of rectal
prolapse were not included in the outcomes and
were not reported in either group.
Resection Rectopexy
The decision to combine a segmental resection
with a rectopexy should be made pre-operatively, not only for the sake of clarity in the surgeon’s planning, but largely for the sake of the
patient, as the risk of anastomotic leak and subsequent need for diversion and/or removal of
infected mesh need to be carefully disclosed to
the patient ahead of time. In cases of severe
colonic inertia, as demonstrated by pre-operative colonic transit studies, a total abdominal
colectomy with ileorectal anastomosis may
need to be performed at the time of prolapse
repair. Regardless of the surgical technique
being used, careful attention should be paid to
the patient’s co-existing functional and anatomic disorders, in the event that these elements
of dysfunction need to be addressed prior to surgery or in the operative theater. In cases of complex pelvic oor dysfunction, consideration
should be given to a multi-disciplinary approach,
employing the expertise of a gynecologist, urologist or urogynecologist in addition to that of
the colorectal surgeon.
The idea of sigmoid resection combined with
rectopexy was rst described by Frykman in
1955 [74] and further developed and popularized
by Goldberg; it ultimately became known as the
Frykman-Goldberg procedure [75].
Indications to consider resection at the time
of rectopexy include the following: constipation not managed on an easily sustainable
bowel regimen; the presence of severe diverticular disease or other pathology independently warranting resection; and the presence
of signicant redundancy of the sigmoid colon
that would otherwise predispose the patient to
future sigmoid volvulus. The last of these features is difcult to objectively dene and is not
routinely a singular indication for resection.
While patients with severe constipation should
be considered for resection, those with chronic
diarrhea, incontinence or otherwise normal
function should be considered for a rectopexy
alone [76].
8 Rectal Prolapse andIntussusception
Table 8.5 Results of resection rectopexy
Author # Patients Recurrence (%) Morbidity (%) Mortality (%)
Laubert etal. [78]
Ashari etal. [79]
Watts and Thompson [80] 102 2 4 0
Husa etal. [81] 48 9 0 2
Huber etal. [82] 39 0 7 0
Luukonen etal. [83] 15 0 20 7
Sayfan etal. [84] 13 0 23 0
a
Denotes laparoscopic resection rectopexy
a
a
152 11.1 19.2 0.7
117 2.5 9 0.8
139
Although not necessarily an indicator for clinically signicant differences in outcomes, it has
been demonstrated that mesh rectopexy without resection produces radiographic evidence of
slower colonic transit. In a prospective study of 30
patients undergoing a Ripstein procedure for rectal prolapse, post-operative transit studies demonstrated retention of signicantly more markers
when compared with pre-operative results.
Additionally, retention of markers pre-operatively
was predictive of post-operative constipation following the non-resection approach [77].
The overall results of resection rectopexy are
quite good in terms of recurrence rates in the low
single-digit range, (Table 8.5) [78–84] with one
study reporting 11.1% recurrence [78]. The morbidity of this operation, however, ranges from
0–23% again drawing attention to the fact that
resection should not be routinely offered outside
of specic indications, namely severe constipation [76].
Perineal Approaches
Perineal approaches most commonly include the
full-thickness perineal rectosigmoidectomy (i.e.,
Altemeier) procedure or the partial-thickness
(i.e., Delorme) resection. Randomized comparisons of outcomes of these two techniques are
lacking. The one available study, the PROSPER
study did randomize patients to either a Delorme
or Altemeier procedure. Recurrence rates were
24% for the Altemeier procedure vs. 31% for
the Delorme procedure (p=0.4). There were no
major differences noted in functional outcomes
between the two procedures [11]. A retrospec-
tive series from the Cleveland Clinic compared
outcomes of 22 Altemeier and 53 Delorme procedures performed from 2005–2013. The recurrence rate was 9% in the Altemeier group vs.
16% in the Delorme group (p=NS). Quality of
life was no different in the two treatment groups
[85]. However, an earlier study from Cleveland
Clinic Florida found the Altemeier to offer
a lower recurrence rate, a longer recurrencefree interval, and better function than did the
Delorme [85].
Perineal Rectosigmoidectomy
The perineal rectosigmoidectomy involves a full
thickness perineal resection of the rectum with
coloanal anastomosis and sometimes includes an
anterior levatoroplasty [86–99]. It is thought to be
the better option for a patient with a longer segment full thickness prolapse [7]. This procedure
has a low complication rate; in general, <20%
of cases. Most of the complications described
are mild, however, severe complications such as
anastomotic leak have been described [7]. The
procedure begins with exteriorization of the prolapse. A full-thickness circumferential incision
is then made through all layers of the outer wall
about 1 cm from the dentate line. The anteriorly based hernia sac at the peritoneal reection
needs to be opened. The redundant bowel is then
delivered from the perineum, as the mesentery
is ligated sequentially until there is no further
redundancy noted. Following this maneuver, a
levatoroplasty may eliminate the defect in the
pelvic oor [100–102]. The bowel is then sequentially transected while a hand-sewn anastomosis
140
ab
J. R. Snyder and I. M. Paquette
is performed (Fig. 8.5). However, a modied
anastomotic technique using a circular stapler
has been described [96]. There is some evidence
that the addition of a levatoroplasty may reduce
the recurrence rate to as low as 7% in patients
who have a levator diastasis [100, 101]. In addition, a transperineal colonic J pouch with either
hand sewn or stapled coloanal anastomosis may
be performed [103, 104].
The Altemeier operation is generally performed with low morbidity, but a high rate of
recurrent prolapse (Table8.6). Recurrence rates
have been shown to be as high as 39% in some
series [11, 98]. However, two large series by
Altemeier and Cirrocco provide some of the best
available data regarding this procedure, and suggest that with meticulous attention to detail, this
procedure may be performed with low rates of
recurrent prolapse [87, 95, 105]. Dr. Altemeier’s
series published in 1971 described 106 patients
treated with perineal rectosigmoidectomy. The
recurrence rate was 2.8% in this series. Major
surgical complications consisted of four anastomotic leaks, which were all treated with local
drainage and antibiotics. The late complications
described included three pelvic abscesses.
Fig. 8.5 Perineal rectosigmoidectomy: (a) Full thickness division of the rectum. (b) Final result of rectal
mobilization
Table 8.6 Results of Altemeier procedure
# Patients Recurrence (%) Morbidity (%) Mortality (%)
Williams etal. [16] 114 10 12 0
Ding etal. [98] 113 18 16.8 0
Altemeier etal. [87] 106 3 24 0
Cirocco [95] 103 0 14 0
Kimmins etal. [91] 63 6.4 10 0
Cardiello etal. [97] 41 2 2.4 0
Steele etal. [99]
Senapati etal. [11] 28 26.9 – 0
Elagili etal. [86] 23 9 22 0
a
Procedures performed for recurrent prolapse
a
51 37 10 0
8 Rectal Prolapse andIntussusception
141
Though these procedures are typically performed
in older and more frail individuals, there was no
mortality noted in this series [87].
Cirrocco reported on a series 103 patients with
a median follow up of 43months with no recurrences [95]. The incidence of complications was
14%, and these included primarily medical problems, such as pneumonia, C. difcile colitis, myocardial infarction, pleural effusion, pulmonary
edema, and atrial brillation. The two specic surgical complications reported were two rectovaginal stulas and two anastomotic strictures [95].
Delorme
Another commonly performed perineal approach
for rectal prolapse is the Delorme procedure, rst
described in 1900. The Delorme procedure is
often used in patients with a mucosal prolapse, or
with a short segment, full thickness prolapse, as
the recurrence rate is thought to be higher than
that of an Altemeier procedure in the setting of a
longer segment full thickness prolapse [7]. This
distinction is important because the majority of
clinical series describing this procedure have
included mostly patients with short segment prolapse. This feature introduces potential selection
bias when trying to compare case series of
Altemeier vs. Delorme procedures.
The procedure begins with eversion of the
prolapsed segment. A circumferential mucosal
incision in then made 1cm above the dentate
line and the mucosa and submucosa are dis-
sected free from the muscularis propria
(Fig.8.6). A mucosal sleeve resection is then
performed and the muscular layer is then plicated circumferentially. The mucosal ends are
then sutured together [106]. Recurrence rates
as high as 27% have been described and morbidity has been reported in 9.6–45% of patients
(Table 8.7) [80, 86, 106–112, 114–118].
Fig. 8.6 Partial thickness dissection of a Delorme
procedure
Table 8.7 Results of Delorme procedure
# Patients Recurrence (%) Morbidity (%) Mortality (%)
Watts and Thompson [80] 101 27 – 4
Senapati etal. [11] 99 31 – 2
Lechaux and Johann [107] 85 14 14 1.2
Lieberth etal. [108] 76 8 15 0
Marchal etal. [109] 60 23 15 7
Elagili etal. [86] 53 16 7 0
Watkins etal. [110] 52 10 4 0
Fazeli etal. [106] 52 9.8 9.6 0
Tobin and Scott [111] 43 26 – 0
Pescatori etal. [112] 33 18 45 0
Chen etal. [113] 25 4 32 0
Series with at least 25 patients treated with Delorme’s procedure
142
J. R. Snyder and I. M. Paquette
Complications are typically minor, though
serious complications such as ischemic proctitis have been described [119].
Anal Encirclement
Anal encirclement was a historically used
approach to treat rectal prolapse in patients who
were not t for surgery [120]. The procedure
involves bilateral radial incisions in the perianal
skin, lateral to the external sphincter muscle. A
tunnel is created outside of the external sphincter
muscle and the encircling material is delivered
through this tunnel. The repair is performed with
either the surgeon’s nger, or a Hegar dilator in
the anal canal to attempt to prevent excessive
tightening [120–123]. Multiple materials have
been utilized including nylon, PDS, silastic rods,
Marlex mesh, magnets, fascia, tendon, and
Dacron [122, 124–134].
Though this procedure has been shown to
have some benet in improving prolapse symptoms, the notable outcomes include an infection
rate as high as 44%, and morbidity in up to 59%
of cases [122, 127, 131, 135–138]. This procedure has been largely abandoned [139].
Recurrent Rectal Prolapse
Since all methods of rectal prolapse repair have
at least some chance of recurrence, the surgeon
needs to have an organized approach to determine why the recurrence occurred and determine
what the best strategy is to treat the recurrence.
The most important factor to consider is the initial type of repair. The most common reason for
recurrence seems to be related to technical factors [99, 140]. Blood supply to the rectum is also
a critical element in choosing an option for recurrent rectal prolapse. If blood supply has been
divided during an abdominal procedure such as
resection rectopexpy, then an Altemeier procedure would not be available for subsequent repair
due to the risk of leaving an ischemic segment of
rectum or vice versa.
Literature regarding the best method of repair
for recurrent prolapse is difcult to interpret due
to the large number of procedures used in both
the primary and the recurrent setting. A recent
systematic review of all patients undergoing
repair for recurrent rectal prolapse from 1950–
2014 was unable to provide a rational algorithm
for treatment of recurrent prolapse because the
literature consisted of small case series and a heterogeneous array of approaches [141].
A study by Ding etal. examined 23 patients
having an Altemeier procedure for recurrent rectal prolapse compared to patients having the
same operation for primary prolapse. When comparing the two groups, there was no difference in
overall complication rates, but the recurrence rate
was signicantly higher for patients in the recurrent prolapse group (39% vs. 18%). Some of the
factors associated with recurrence were an inadequate length of resection, inexperienced surgeon, a long length of follow up, and not
performing a levatoroplasty [98].
Steele etal. examined 78 patients who underwent surgery for recurrent rectal prolapse. The
rate of second time recurrence with a perineal
approach was 37.3% vs. 14.8% with an abdominal approach (p=0.03) [99]. These data suggest
that an abdominal approach should be undertaken
for recurrent rectal prolapse if the patient’s risk
prole is acceptable for abdominal surgery.
However, management of recurrent prolapse is
an area where well-designed comparative studies
are clearly needed.
Rectal Intussusception
Rectal intussusception refers to prolapse of the
rectal wall, which does not protrude through the
anus. It is also known as occult prolapse, internal
rectal procidentia, rectal invagination, or occult/
hidden intussusception. The diagnosis truly has
only developed with the advent of radiographic
studies capable of detecting this anomaly, specically defecography, either via uoroscopy or
functional magnetic resonance imaging (fMRI).
The clinical elements which would lead one to