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INDICATIONS/CONTRAINDICATIONS

Whendecidingwhichsurgicalproceduretoperform,thebalancebetween thepatient’smorbidities,frailty,previousproceduresforprolapse,and therecurrencerisksforeachprocedureshouldbecarefullyconsidered. Abdominalprocedureshavelowerrecurrencerates,butperineal procedures—suchastheDelorme—poselessrisktothepatient,have lowercomplicationrates,andshowfasterrecovery.
IndicationsforaDelormeincludepatientswithashortsegmentoffull­thicknessrectalprolapse,whoareunfitorunwillingtoundergogeneral anesthesiaandamajorabdominaloperation.TheDelormeprocedureis relativelycontraindicatedinpatientswithinternalprolapse, intussusception,adistancefromthedentatelinetothedistalpartofthe prolapselongerthan4cm,thoseindividualsinwhomthedistance betweenthedistalpartoftheprolapseandthedentatelineisfixeddueto previousanorectalsurgery,radiation,phenolinjections,orotherlow rectaloranalpathology.Itisalsorelativelycontraindicatedinthose patientswhosufferfrominflammatoryboweldiseases—thedecision makingshouldbeindividualizedhere.Treatmentofaverylongprolapse withthisoperationcanbedifficultandinthesecircumstances,the Altemeieroperationmaybemoreappropriate.
Patientsshouldbemadeawareoftherecurrencerate,thepossibilityof redoingtheprocedureifneededandthefactthatnotmuchassurancecan begivenregardingtheimprovementofcontinence.
PREOPERATIVEPLANNING
PatientswhoareofferedtheDelormeprocedureforrectalprolapse shouldbefullyinvestigatedtoexcludeothercolonicpathologiesthatcan precipitaterectalprolapse,suchaslowsigmoidorrectaltumors.In additiontoahistoryandphysicalexaminationincludingdigital examination,rigidsigmoidoscopy,andproctoscopy,patientsshouldhave anappropriateendoscopicexamination(flexiblesigmoidoscopyor colonoscopy)orabariumenema.Analphysiologicstudiesandendoanal ultrasoundtestsarenotamandatorypartofourroutinepreoperative assessment.
p.137
p.138
Informedconsentontheprocedure,risks,andbenefitsshouldbe obtained,withattentiongiventothehighriskofrecurrence.
Twophosphateenemasadministered2hoursbeforetheprocedureare usedforbowelpreparation.Additionalenemascanbegivenasnecessary. Prophylacticantibioticsareadministeredoninductionofgeneral endotrachealanesthesia(theauthorsuseciprofloxacinand metronidazole).Thromboembolicprophylaxisshouldberoutinelyusedin allpatients.Ingeneral,sequentialcompressionstockingsandifnot medicallycontraindicatedheparinorlow-molecular-weightheparinmay beused.

SURGERY

Anesthesia
TheDelormeprocedureisamendabletodifferentmodalitiesof anesthesia.Althoughgeneralanesthesiaisthemostpreferredmodality,it issafeandacceptabletousespinalanesthesia.High-riskpatientscan havetheprocedureundercaudalblockorevenlocalanesthesiawithor withoutintravenoussedation.
Positioning
TheauthorsusuallyundertaketheDelormeprocedurewiththepatientin theproneposition.However,theprocedurecanalsobeperformedwhile thepatientisinlithotomyposition.Thechoiceofpositionshouldbe basedonthepatient’sabilitytobeinthesurgicalpositionforthe durationoftheoperation,surgicalaccess,andpatient’scardiacand respiratoryneeds.
Urinarybladdercatheterizationshouldbeinitiatedunderaseptic conditions.Theauthorpreferstoperformasterilestraight(inandout) catheterizationpriortowakingthepatientfromanesthesia,toreducethe riskofurinaryretention.
Technique
theanalvergeisretractedandthefullprolapseisreproduced.Theuseof Allisclampsoraspongestickcanhelpdelivertheprolapsedsegment. Thesubmucosalspaceisinjectedwitha1:100,000solutionofnormal salinewithepinephrinetofacilitatetheseparationofthemucosafrom therectalmusculartube.Usingelectrocautery,themucosais circumferentiallyincisedholdingitsedgewithapairoftissueforceps. Thisinitialincisionismadeatadistanceofapproximately1cmcephalad tothedentateline.Electrocauteryordissectingscissorscanbeused.Any bloodvesselsencounteredatthisstagecanbecontrolledusing electrocauteryorbipolardiathermy(Fig.18-1).
FIGURE18-1Submucosalinjectionofdilute
epinephrinetofacilitatetheseparationofthemucosa fromtherectalmusculartube.
thesolutioninjectedinthisspace.Theedgesofthemucosaltubeare heldwithgentletractiontofacilitatefurtherdissection.Avoidholesin themucosaltubeorinjurytothemuscleduringthedissection.During theprocedure,smalltearsinthecircularmusclecanbeincludedinthe plicationsuturesoftherepair.However,ifamajordefectinadvertently occurs,ascanbethecasewithrepeatDelorme,thesurgeonmay abandontheprocedureandswitchtoanAltemeierprocedure.The lengthofthemucosaltubedissectedshouldbetwicethelengthofthe muscletubeprolapse.
easier.Thisprocessshouldcontinuetilltheapexoftheintussusception isreachedandthemucosallayerbecomesadherenttothemuscular layer(Fig.18-2).
FIGURE18-2Themucosaltubedissectedoffof
theunderlyingmuscletube,withagoaloftwicethe lengthoftheprolapse.
attheanteriormidlineandthemuscularplicationcommences.The authorsprefertouse2/0PDS.Plicationsuturesareplacedfromthe dentatelinetowardtheapexoftheprolapseincludingthedentateline mucosaandtheproximalrectalmucosaateachendoftheplication suture.Thesutureincorporates1cmofmusclewitheachpassand progressesanother1cmtothepointofnextpassageinaverticalline alongthemusculartube.Thesutureistaggedwithanarteryforcepsand hungonthecircularretractor;thisprocedureisrepeatedattheposterior midline,leftlateral,andrightlateralpositions.Themucosaisthen excisedandsentforhistology.Theplicationstepisrepeatedbetweenthe quadrantsuturestakingthenumberofverticalplicationsuturestoeight intotal.Thesesuturesarethentightenedupwhilecareistakento ensurethatthemuscletubeisinvertedandheldonthearteryforceps
beforebeingtied(Fig.18-3).Theprolapseisfullyreducedandthe plicatedringofthefoldedrectaltubesitsatthelevelofthesphincters.
FIGURE18-3Plicationsuturesplacedfromthe
dentatelinetotheapexoftheprolapse.
additionallayerof2/0Vicrylinterruptedsutures,aligningmucosa-to­mucosaoverthegaps.
POSTOPERATIVEMANAGEMENT
PostoperativePlan
Thepostoperativeplanisasfollows:
Analgesia:Ifthepatientisundergeneralanesthesia,apudendalblock canbeperformedattheendoftheoperativeprocedure.Oralanalgesia
shouldbeintroducedearlyintheformofregularparacetamoland nonsteroidalanalgesics.
Prophylacticantibiotics:Nopostoperativeantibioticsareindicated. Thromboembolicprophylaxes:Thrombo-embolicdeterrent
stockings(TEDS)stockingsanddailyheparinorlow-molecular-weight heparinshouldbeofferedtoallpatientsuntildischarge,unlessthereare contraindications.
Normalactivities:Patientsshouldcommencearegulardietassoonas possible,andearlymobilizationisencouraged.Ifthepatientiswell,
passingurineafterremovingthecatheter,andopeningtheirbowel, dischargefromhospitalshouldbeconsidered.

COMPLICATIONS

OperativecomplicationsareuncommonwithaDelorme,althoughthere isariskofbleedingandhematomaformation.Theseproblemsare usuallyself-limited,butcanbeprospectivelymanagedbyplacinga degradablehemostaticagentintotheanalcanal.Forongoingor significantbleeding,anexaminationunderanesthesiaandoversewing anybleedingpointswillprovidesatisfactoryhemostasis.Urinary retentionisariskinanyanorectalsurgery;catheterizationtoemptythe bladderaddressesthis.Ifthepatientcannoturinateafterthecatheteris removed,straightcatheterizationorreplacementofanindwelling cathetermaybeneeded.Pelvicsepsisisararecomplication,butshould beanearlypartofthedifferentialinthecaseoffeverandpain.Ifitis suspected,empiricantibiotictherapyshouldbeinitiated,imagingwitha CTscanoranMRIobtained,andsurgicalinterventionconsidered.If thereisnoimprovement,anexaminationunderanesthesiawith transanaldrainageofanysepticfocusmaybeindicated.

RESULTS

WhereasoperativecomplicationsrelatedtotheDelormeprocedureare low,prolapserecurrenceratesarehigh,rangingfrom16%to30%. Informedconsentpriortotheprocedureshoulddisclosethis.Patient satisfactionishighpostoperatively,asbothcontinenceandqualityoflife mightimprovesignificantly.

CONCLUSIONS

TheDelormeprocedureisasimpleandasafeoperationthatshouldbein thesurgeon’sarmamentariumofprolapseprocedures.Theprocedurecan improvethesymptomsandfunctioninprolapse,significantlyimproving thequalityoflife.Thehighrecurrencerateisoffsetbythehighpatient satisfaction,needforalow-riskprocedureinhigh-riskpatients,andthe possibilitytorepeattheprocedure,asneeded.
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