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dangerousandlife-threateningconditionifleftuntreated.Therectum maynotbeviableandrequireresection,andtheperineal rectosigmoidectomyoffersamuchsaferandfasteroptionfor proctectomythanreductionandemergenttransabdominalproctectomy. Inaddition,perinealrectosigmoidectomymaybetheonlysurgical option,iftherectalprolapseremainsincarcerateddespitesedationand attemptedreduction.Aperinealrectosigmoidectomyinthisuncommon situationmaybethesafestsurgicaloption.Theopportunitytoavoidan emergenttransabdominalpelvicdissectioncannotbeoverestimatedin importancefortheseillpatients.
Patientswithrectalprolapsemaysufferassociatedconstipationand straining,orincontinence.Forthosewhohaveassociatedincontinence andaweakpelvicfloorandpoorsphinctertoneonphysicalexamination, theadditionofalevatorplastytoaperinealrectosigmoidectomyshould beconsidered.TheDelormeprolapserepairdoesnotallowfor levatorplastybecausethereisnoaccesstothelevatorsandtherefore incontinenceisagainarelativeindicationforafullthicknessperineal repairofrectalprolapse.Incontrast,strainingandconstipation­dominantsymptomsarenotaloneanindicationforatransabdominal resectionrectopexy,giventhataresectionisalsoachievedthrougha perinealrectosigmoidectomy,thoughanabdominalapproachshould certainlybeconsideredagainstaperinealapproachinthissubsetof patientswithrectalprolapse.
PREOPERATIVEPLANNING
Rectalprolapseiscommonlyconfusedbytheinexperiencedclinicianfor manyotheranorectalconditions,includingprolapsinginternal hemorrhoids,externalhemorrhoidsorskintags,andevenrectalandanal cancers.Assuch,itisessentialthatafull-thicknessrectalprolapsewith concentricringsofmucosaprogressingalongthelengthofthebowelbe personallydocumentedbythesurgeononphysicalexaminationbefore embarkingonrepair.Thisisbestdonewiththepatientintheupright sittingpositiononacommodeortoilet,leaningforwardtoexposethe rectalprolapsetotheexaminer.Strainingintheleftlateraldecubitus positionisdifficultandoftenineffectivetoreproducetherectalprolapse, potentiallyleadingtoamisseddiagnosis.Acolonoscopyoratleasta flexiblesigmoidoscopyshouldbeperformedinallpatientstodocument thattherearenootherpathologiesintherectumoranymoreproximal lesionsthatneedtobedealtwithconcurrentlyorbeforerectalprolapse repair.Colorectalcancerscreeningshouldbeup-to-datebefore proceedingwithaperinealrectosigmoidectomy.Pelvicfloortestingisnot generallyneededinthemanagementofrectalprolapse;however,anal sphinctertoneshouldbedocumentedonphysicalexamination.Thisstep isimportanttohelpguidethepotentialroleforlevatorplastyatthetime ofprolapserepair,andalsotocounselpatientsonexpectationsinthe earlypostoperativeperiod.Thatistosay,incontinencemaytaketimeto improveafterthechronicstretchingtraumaoftheprolapsingrectumon theanalsphincterisremoved.Therectummayhave,inessence,been actingasa“plug.”Defecographyshouldbeconsideredinthosepatients withaconvincingsubjectivehistoryofrectalprolapse,butinwhoma prolapsecannotbedocumentedonphysicalexamination,evenwith strainingonthecommode.Ifaprolapseisvisible,however,during physicalexamination,defecographyisnotanecessarypartof preoperativeplanning.
Medicaloptimizationtowardnormalbodyhabitus,smokingcessation, gooddiabeticcontrol,andotherendpointsshouldbepursuedbeforethe surgery.Unlessincarcerated,repairofrectalprolapseisanelective procedureandallcareshouldbetakentoimprovetheperformancestatus ofpatientsbeforeembarkingonsurgicalrepair.Whenoneconsidersa perinealrectosigmoidectomy,thepatientsareoftenelderlyand somewhatfrail,andtheendpointsofoptimizationmaybelimited. Nonetheless,appropriateconsultationsshouldbesoughttooptimizethe patient’sstatus.Medicalclearanceshouldbeperformed.Preoperative bloodworkandcardiacinvestigationsshouldbedirectedbythepatient’s medicalhistoryandorderedasneeded.Consultationwithanesthesiacan
bequitehelpfultoguideanestheticplanning.Inspecific,inanelderlyor frailpatient,alternativesoradjunctstoageneralanestheticshouldbe considered,includingspinalorepiduralanesthesia.Thesemayaugment thenecessarydepthofananestheticorallowforthecompleteavoidance ofdeepsedation.Asaperinealrectosigmoidectomymaybedoneinthe lithotomyorpronepositions,anestheticconcernsmustplayaroleinthe decisionofappropriatepatientpositioning.

SURGERY

Onthedayofsurgery,thepatientshouldhavereceivedeitherenemasto cleartherectumoramechanicalbowelpreparation.Theauthorprefers toutilizepreoperativeenemastoavoidthenuisanceofamechanical bowelpreparationintheseoftenelderlypatientsandthediscomfort associatedwithrectalprolapseduringmultipleandfrequentbowel movements.Preoperativeantibioticscoveringgram-negativeandaerobic bacteriashouldbeadministeredpriortobeginningtheprocedure,as shouldprophylacticsubcutaneousinjectionforvenousthromboembolism prophylaxis,inaccordancewiththelocalhospitalguidelines.
Thepatientshouldbeplacedineitherthelithotomyorpronejackknife position.Theauthor’spreferenceisthepronepositionforoptimal visualizationandsurgeonergonomics;however,thisdecisionismadein conjunctionwithanesthesiaregardingtheplannedanestheticandpatient healthfactors.Keypositioningconsiderationsforthelithotomy positioningincludebringingthepatient’sperineumquitelowbeyondthe edgeofthetable,ensuringthatthekneesandhipsareplacedat appropriateanglesinstirrupsandraisingthelegstogainaccesstothe perineum.Intheproneposition,thepatient’shipsshouldbeovera bolsterorpillows,thetableshouldbeplacedinthejackknifepositionto elevateandangletheoperativefield,andthebuttockstapedapart.Arms andshouldersshouldofcoursebeappropriatelypaddedaswell.Figures
20-1and20-2demonstratethepronejackknifeandlithotomy
positioning,respectively.
FIGURE20-1Patientpositioning,pronejack-knife
position.
FIGURE20-2Patientpositioning,lithotomy.
Aftertheperineumispreppedanddrapedaccordingly,therectum shouldbemanuallyprolapsedwiththehelpofgraspersifnecessary(Figs.
20-3and20-4).Foratraditionalhand-sewnperineal
rectosigmoidectomy,theinitialcircumferentialrectalmucosalincision shouldbemarkedatleast1cmproximaltothedentatelinetofacilitate reanastomosis(Fig.20-5).Thisshouldbedonewithelectrocautery.The circumferentialincisionshouldthenbedeepened,incisingthefull thicknessofthedistalrectalresectionmargin.Aselfretainingretractor
suchastheLoneStar®retractor(CooperSurgical,Trumbull,CT)should beplacedforvisualization.Oncefullthicknessisincised,theglistening serosaoftheinnerlayerofrectumorsigmoidshouldbevisualized, indicatingthatindeedafullthicknesscircumferentialdistalrectal incisionhasbeenmade.Graspersshouldbeplacedontherectumto facilitategentletraction.Usingeitherahand-heldenergydeviceor clampsandties,themesorectumshouldbedividedcircumferentiallyat thelevelofdissection(Fig.20-6).Eventually,thevisceralperitoneum overlyingthemoreproximalrectumshouldbeencounteredanddivided, togainentryintotheperitonealcavity.Thisiseasiestdoneeither posteriorlyoranteriorlyinanolderfemalewithadeepPouchofDouglas. Caremustbetakentobesurethattheposteriorwallofthevaginaisnot breached,whichcanbeeasilydoneinawomanwithadeepcul-de-sacor thinrectovaginalseptum.Placinganindexfingerinthevaginafor localizationduringtheanteriordissectionishelpfulandcanbedoneby
theoperatingsurgeonorassistant.Posteriorly,themesorectumshouldbe releasedsequentiallyfromdistaltoproximal,dividedatthelevelof prolapsedrectum,butnohigher.Therectumandsigmoidcolonshould bepulledtransanallyandcarefullydissecteduntilsometensionis encountered(Fig.20-7).Onceitisclearthatthereistensionpresentand nofurtherredundantbowelcanberemoved,theproximalresection marginshouldbechosenattheleveloftheanalverge.
FIGURE20-3Rectalprolapse,lithotomyview.
FIGURE20-4ProductionofrectalprolapsewithBabcock
clamps,proneview.
FIGURE20-5Circumferentialincision1cmproximalto
dentatelineandplacementofretractor,proneview.
FIGURE20-6Divisionofmesorectum,proneview.
FIGURE20-7Rectumfreecircumferentiallywithentry
intoperitonealcavity,proneview.
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p.152
Atthispoint,priortoatransectingthebowel,alevatorplastyshouldbe considered.Ananteriororposteriorlevatorplastycanbeperformed, althoughtheposteriorapproachispreferred.Levatorplastyisperformed byidentifyingtheV-shapedlevatormusclesoneithersidelateraltothe rectum.Theymaysometimesbedifficulttovisualizeandgraspifthe levatorplastymusclesareattenuatedinanolderfemalewithpelvicfloor weakness.Tofacilitateidentificationofthelevators,retractorsmustbe placedtoelevatetherectumanteriorlyandmedically,andthesphincter musclesretractedlaterallytovisualizethelevatorsabovethesphincters. ThelevatorsshouldbegraspedwithaclampsuchasaBabcockorAllis andapproximatedtowardthemidline.Suturesshouldbethenbeplaced. Permanentorslowlyabsorbablesutureshouldbeused,andtheauthor’s preferenceisapolydioxanonesuture.Simpleinterruptedorfigure-of­eightsuturesshouldbeplacedtoapproximatethelevatorsinthe posteriormidline(Fig.20-8).Caremustbetakennottotightenthespace toomuch,placingthepatientatriskofanaloutletobstruction.Gently placingafingerbetweenthelevatorrepairandtherectumwithease shouldsignalasnugbutnotoverlytightrepair.
FIGURE20-8Placementofsuturesforlevatorplasty,
lithotomyview.
ConsiderationofacolonicJpouchshouldthenbemadepriorto resectingthebowel.AcolonicJpouchhastheaddedbenefitof postoperativelysimulatingareservoirintheproctectomypopulation,in theabsenceofanativerectum.ToformacolonicJpouch,therectumand sigmoidshouldbedeliveredtransanally.Theresectionmarginshouldbe chosentopermittheformationofa6to8cmlongcolonicpouch,using thesigmoidorleftcolon.Thebowelshouldbetransectedwithalinear cuttingstapler.Itshouldthenbefoldedbackalongitsantimesenteric ordertofashionthecolonicpouch.Acolotomyshouldbemadewith scissorsorelectrocauteryandthepouchshouldbeformedwithalinear cuttingstapleralongtheantimesentericborder.Staysuturesmaybe placedtofacilitatethis.Caremustbetakentoaccommodateforthe lengthofthepouchwhenchoosingthetransectionmargin,soastoavoid endingupwithananastomosisundertension.Iftheproximalrectumor distalsigmoidiscapacious,onemaychoosenottoperformaJpouch, andratherperformanend-to-endanastomosis.
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p.153
Ahand-sewncolorectalanastomosisisperformedusingdissolvable sutures,suchasVicryl.Tostart,fourstaysuturesareplacedanteriorly, posteriorly,andlaterally,seeFigure20-9.Interveninginterrupted suturesarethenplacedtocompletetheanastomosis(Figs.20-10and20-
11).
FIGURE20-9Four-quadrantstaysuturesofcolorectal
anastomosis,proneview.
FIGURE20-10Completedhand-sewnanastomosis,
proneview.
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