Ingeneral,surgicalrepairofarectalprolapsemaybeapproachedviaa transabdominaloratransperinealtechnique.Therearenumerous advantagestothetransperinealapproachinmanypatients.Aperineal rectosigmoidectomyprovidesafullthicknessresectionoftheprolapsing rectum.Italsoallowspotentialaccesstothelevatormusclesfora concurrentlevatorplasty,theadvantagesofwhichwillbediscussedin greaterdetaillaterinthechapter.Therearerelativelyfew contraindicationstoaperinealrectosigmoidectomy,butacircumferential full-thicknessrectalprolapseshouldbedemonstratedbeforeembarking onthisprocedure.Thus,thisprocedureisnotappropriateforaninternal intussusceptionorasuspectedrectalprolapse,asakeycomponentofthe operativeprocedureisexternalprolapseoftherectumtotransanally performtheresection.Ashortsegmentprolapsemaybedifficulttorepair throughaperinealrectosigmoidectomy,becauseitmaybechallengingto reproducesuchaprolapseunderanesthesiaandwithoutactivepatient

Thedecisionbetweenanabdominalandaperinealapproachtorepair ofarectalprolapseismadebasedonpatientpreferenceandpatient comorbidities.Historically,aperinealrectosigmoidectomywasthought toprovidealowerperioperativeriskoptionforrectalprolapserepair,at theexpenseofahigherrecurrencerate,whencomparedwiththe abdominalapproach.Morerecentstudieswouldsuggestthatthe recurrencerateisacceptableforbothapproachesandlikelynotas significantlydifferentbetweenthetwoapproachesaswasoncethought. Forpatientswhohavehadpriorabdominalsurgeries,aperineal rectosigmoidectomywilllikelybeafastersurgerywithlowerriskof intraoperativeinjurytootherstructuressuchassmallbowel,when comparedwithatransabdominalrectopexy.Thehospitalstayisusually limitedto1or2daysafterperinealrectosigmoidectomy,whichisoften shorterthantheabdominalapproachespeciallyifasigmoidresection andrectopexyareperformed.Inthelaparoscopicandenhancedrecovery aftersurgeryeras,hospitalstaysarebecomingshorterinallcases.

Paintendstobeveryeasilycontrolledandissometimesminimalafter perinealrectosigmoidectomy,whichisclearlyimportanttomanypatients whendecidingbetweentheabdominalandperinealapproaches.Inthe medicallyfrailpatient,perinealrectosigmoidectomyisoften recommendedandiscertainlyappealingformanyreasons.Avoidingthe potentialmorbidityofanabdominalincisionaspartofarectopexyora resectionwithrectopexyisnotinsignificantinmanypatients; specifically,thoseatriskofsurgicalsiteinfections,the immunosuppressed,diabetic,ortobaccosmokers.Patientswhoare anticipatedtohavedifficultpostoperativepaincontrolmayalsowishto avoidthediscomfortoflaparoscopyorlaparotomy.Tothatend,perineal rectosigmoidectomycanbeperformedunderspinalorepidural anesthetic,avoidingageneralanestheticaltogether.Fortheelderlyor medicallyfrailpatientswhorepresentalargeproportionofpatients seekingrepairofrectalprolapse,aperinealrectosigmoidectomyisoften themostdesiredandmedicallysoundapproachtoavoidadverse physiologiceffectsandmorbidity.Itshouldbenoted,though,that perinealrectosigmoidectomymayalsobeappealingtoyoungpatients withrectalprolapsewhowishtoavoidextendedrecoverytimeandpelvic dissection.Ayoungmale,forexample,withrectalprolapsemayconsider thepotentialnerveandfertilityeffectsofapelvicdissectionandtimeoff workforrecoverywhendecidingontreatment.