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FIGURE20-11Anusafterprocedurecompleted
(anastomosisnotvisible),proneview.
Analternativetoahand-sewnanastomosisisthestapledtechnique.It isessentialthatifthesurgeonplanstoperformastapledanastomosis, theinitialrectalcircumferentialincisionshouldbeatleast2to3cm abovethedentateline,asonewilllosesomedistallengthduetothe anastomoticringbeingpartofthestapledanastomosis,andrisk entrappingsomesphincterfibersinaverylowstapledanastomosis.After theperinealrectosigmoidectomyiscomplete,apursestringsutureis placedontheproximalmarginandtheanvilisplacedandsecured.A secondpursestringisplacedalongthedistalrectalmarginandtheanvil isattachedtothespikeofthestapler.Thecircularstapledanastomosisis thencompletedwithcarebeingtakentoavoidthesphinctercomplexand theposteriorvaginalwall.Althoughthestapledtechniquemaybefaster, thereisoftenasizediscrepancybetweenthesigmoidanddistalrectal resectionmargins,andsometimesahand-sewntechniquebetter reapproximatestheanastomoticlines.Thechoiceoftechniqueshouldbe lefttothesurgeon’spreference.Regardlessoftheanastomotictechnique, indocyaninegreenperfusionassessmentmaybeutilizedtoverify vascularitypriortoand/oraftercreatingtheanastomosis.
POSTOPERATIVECARE
Patientsshouldbeadmittedtohospitalfollowingaperineal rectosigmoidectomy.Lengthofstayisusuallyoneortwonights.Early ambulationandfeedingshouldbeencouraged,aswellasother componentsofenhancedrecoveryaftersurgeryguidelines.Vitalsign monitoringandpainassessmentsshouldberegularlycompleted. Constipationshouldbeavoidedsoasnottodisrupttheanastomosisby thetraumaoflargehardstool.Patientstendtohavelittlepain,andare veryoftenabletobedischargedfromthehospitalusingacetaminophen only.Somedo,however,requirestrongeranalgesicsforashortperiodof time.Patientexpectationsshouldbeoutlinedbythesurgeon,especially withrespecttoshort-termincontinence.Sphincter-strengthening exercisesshouldbeconsideredandencouraged.Afollow-upoutpatient appointmentshouldbescheduledforaphysicalexamination, considerationofdirectmucosalvisualizationwithananoscopeor sigmoidoscope,andassessmentofsphinctertonewithdigitalrectal examination.Theauthordoesnotroutinelyscopepatients postoperativelybutratherassessestheanastomoticintegrityand sphinctertonethroughdigitalrectalexamination.
Patientsmustbecounseledregardingtheworrisomesignsoffever, impaction,pelvicorrectalpain,andfoulrectaldischarge.Thesesignsof pelvicsepsisandleakmustnotbeunderstatedandshouldbeinvestigated emergently.

COMPLICATIONS

Postoperativebleedingisaconcernafterperinealrectosigmoidectomy andmayinitiallybedifficulttodiagnosebecausetheremaybenoobvious rectalbleeding.Ifthereisbleedingfromthemesorectuminthe postoperativeperiod,thismaymanifestasonlyvaguepelvicpainbecause thepatientisbleedingintra-abdominally.Serialcompletebloodcounts maybehelpfultomakethediagnosis,aswouldearlypostoperative hemodynamicinstability.Ifpostoperativehemorrhageissuspected,the patientshouldreturntotheoperatingroomforexplorationandpriorto takingdowntheanastomosis,adiagnosticlaparoscopyshouldbe consideredfortransabdominalcontrol.Ifslowbleedingissuspectedbut thepatientisstable,onecouldconsiderjudiciousbloodtransfusionwith closemonitoringintheeventofatamponadedhematoma.Any coagulopathyshouldalsobecorrected.
Asmentionedearlier,anastomoticleakandpelvicsepsisplacethe patientatriskofseriousmorbidityandpotentialmortality.Agentle digitalexaminationbyanexperiencedsurgeonmaybehelpfulto documentadefectintheanastomosis.Othersignssuchaspelvicpain, feverandleukocytosisaddtosuspicion.Anearlyanastomoticdehiscence maybetreatedwithatransanalapproachtorepairtheanastomosis,with theself-retainingretractorusedforvisualization.Acontrolledorsealed leakmaybetreatedwithatransabdominalortransrectaldrainwiththe assistanceofinterventionalradiology.Diversionwithastomaisnot routinelyperformedduringaroutineperinealrectosigmoidectomy,but maybeneededintheeventofasmallbutclinicallysignificantleak. Anastomoticleakordehiscencerequiringlaparotomyandacomplete takedownanddiversionhavebeendocumentedbuttheincidenceofthis appearstobequiteuncommon.
Ischemiaofthesigmoidcolonisalsorare,butshouldbeconsideredif thepatientisnotrecoveringasexpected.Commonsignsarebloodyor graydischargealongwithpelvicorperinealorrectalpain.Foulsmelling dischargeorflatusisoftenthesentinelsign.Occasionally,thediagnosis maybemadebysimplyeffacingtheanus,giventhatthesepatientsoften haverelativelypoorsphinctercontrol,oralternativelyperforminga gentleflexiblesigmoidoscopybyanexperiencedsurgeon,takingcarenot todisrupttheanastomosis.Mildischemiamaybeoccasionallymonitored forresolutionwithserialphysicalexaminationsinendoscopyinthe hospital.However,moderatetosevereischemiaofthesigmoidcolon shouldbetakenseriouslyandthereshouldbealowthresholdfor bringingthepatienttotheoperatingroomforsigmoidresection,likely withacolostomyormoreuncommonlyaredoanastomosis.Extreme
cautionshouldbeundertakenintraoperativelyduringaperineal rectosigmoidectomytoensurethattheanastomosisisnotundertension andthatdivisionofthemesorectumisonlyundertakenatthelevelof rectaldissectionandnohigher.Itisquiteeasytocontinuewiththe divisionofthemesorectumwithoutbeingcognizantoftheproposedlevel ofproximaltransectionandthismustbeavoidedatallcosts.
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Recurrenceafterperinealrectosigmoidectomyremainsaconcern. Certainly,withanysurgicalapproachtorectalprolapserepair,thereisan associatedriskofrecurrence.Thismanifestsasasimilarsensationofa transanalbulgingespeciallywithstraining.Anecdotally,itseemsthat patient-directedsphincter-strengtheningexercisesseemtohelp,andall patientsshouldbecounseledthattheyshouldavoidstrainingwithbowel movementsandpreventconstipation,especiallyintheearly postoperativeperiod.Recurrentrectalprolapsemaybetreatedwith eitheraredoperinealrectosigmoidectomywithlevatorplastyorpossibly atransabdominalrectopexy.Aresectionwithrectopexyinmostcases shouldbeavoided,asdivisionofthebranchesofthemesentericartery duringresectionmayplacethepelviccolonleadingdowntothecolorectal anastomosisatriskofsegmentalischemia.

RESULTS

WhenMilesfirstdescribedthisapproachintheEnglishliteraturein 1933,hecoinedthetermrectosigmoidectomy.Hisdescriptionof31 patients,including24females,hadgoodresultswithlowmorbidityand onlyonerecurrence.AltemeierandCulbertsonreportedtheirseriesof 106patientsin1971,andtheirlargevolumeofexperienceatthetimelead totheeponymousnamingoftheprocedureafterAltemeier.Theirresults showedthatperinealrectosigmoidectomywassafeandverywell toleratedwithalowriskofabscessorleak.Itshouldbenotedthattheir patientstendedtobeelderly,inkeepingwiththepresent-daypopulation commonlyundergoingperinealrectosigmoidectomyforprolapserepair, andthatonlythreepatients(2.8%)developedrecurrentrectalprolapse. Theychampionedtheprocedureforelderlyandfrailpatients,andnoted itssuccessevenafterpreviousrepairshadfailed.
Recurrenceafterrectalprolpaserepairhastraditionallybeenofalarge concern,especiallyforperinealapproaches.Therecurrenceratesin publishedretrospectivereviewsvary,butappeartobearound10%, takingintoaccounttheaveragesofthelargerreviews.A2017systematic reviewbyWexnerandcolleaguesof39studiesofperinealoperationsfor rectalprolapsefoundthattheoverallrecurrenceratewas16.6%,andthe medianrecurrenceratefortheAltemeierprocedurewas11%.Therewas heterogeneitybetweenstudies,andsocomparativeoutcomesbetween perinealapproachescouldnotbeassessed.Ithasbeenwelldocumented intheseandothersmallretrospectivecohortstudiesthatperineal rectosigmoidectomyissafe,eveninelderlyandfrailpatients.Low morbidityandmortalitymakethisprocedureespeciallyappealing. Recurrencedoesnotseemtovarymuchwhencomparingelderlyversus youngerpatients.
Whencounselingpatientsindecidingbetweenabdominalrepairand perinealrectosigmoidectomy,ithasbeentrulydifficulttogivehistorically comparativedata.ArecentlyupdatedCochranedatabasereviewfound thateventhoughtherearesomerandomizedtrialsstudyingrectal prolapse,onlyonecomparedabdominalandperinealapproaches,and mostothertrialsinvolvedsmallnumbersofpatients.Thereissignificant heterogeneitybetweentrialsofrectalprolapserepairs,andthus,the authorsoftheCochraneupdateconcludedthatthereisstillapaucityof datatoallowforcomparisonbetweenapproachesorstrongevidence­basedpatientguidancewhenchoosingamongsurgicalapproaches. RicciardiandcolleaguesexaminedinpatientdatafromCaliforniaduring a36-monthperiodandfoundthatreoperationratesforrectalprolapse (largelyduetorecurrence)werenotstatisticallydifferentwhen
comparingabdominalorperinealrepairs.Therecurrenceinterval, extrapolatedfromtimetoreoperation,doesnotseemtodifferbetween abdominalorperinealapproacheseither.Thelong-awaitedPROSPER trialwaspublishedin2013.Thisrandomizedtrialcomparedabdominal andperinealsurgicalapproaches,andalsocomparedintraapproach differences,namely,suturerectopexyversusresectionandrectopexy,and perinealrectosigmoidectomyversusDelorme.Itshouldbenotedthat somepatientsdidchoosetohaveaspecificapproachorprocedure,ifthey hadadefinitepreference,andsothetreatmentarmallocationswerenot anentirelyrandomizedprocess.Overall,therewasnosignificant differenceinrecurrenceratesbetweentransabdominalandtransanal approaches,althoughtherecurrenceratesweresurprisinglyhigherthan thoseinstudiespreviouslypublished,around20%.
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ThechoicebetweenperinealrectosigmoidectomyandDelorme proceduresislargelybasedonthesurgeon’spreference,although certainlyashortsegmentofprolapseismoreamenabletomucosal resectiononly,versusalong-segmentprolapse.ThePROSPERtrial compared213patientsrandomizedwiththosewhohadundergone perinealprolapserepair,andfoundnosignificantdifferenceinprolapse recurrencebetweenthetwoapproaches.Inaddition,improvementinthe qualityoflifeandotheroutcomesseemedsimilarbetweenperineal rectosigmoidectomyandDelorme.Aretrospectivereviewofacontinuous cohortofpatientsattheClevelandClinic,Florida,foundthatperineal rectosigmoidectomywithlevatorplastywassuperiortoDelormeand perinealrectosigmoidectomyproceduresinvariousoutcomes,including prolapserecurrenceandincontinencescores.Althoughtheseandother earlierstudiessuggestedarelativelyhigherrecurrencerateforthe Delormeprocedure,thePROSPERtrialforcesonetoreconsiderthis paradigm.ThereislikelystillaroleforDelormeinrectalprolapse, especiallyforshort-segmentprolapseorinverymorbidpatients.
Theadditionofalevatorplastytoaperinealrectosigmoidectomywould intuitivelyimprovepelvicfloorstrengthandcontinencepotentially,once theprolapseisremoved.Therearenorandomizedtrialstodocumenta significantbenefit;however,therearesomeresultsintheliteratureto guidepractice.Wexnerandcolleaguesfoundinaretrospectivereview thatperinealrectosigmoidectomywithlevatorplastywassuperiorto rectosigmoidectomyaloneorDelormeprocedure.Incontrast,another retrospectivereviewof60patients,amongwhom21hadaconcomitant levatorplasty,foundnosignificantdifferenceinrecurrencebetween groups.Manyothertrialsincludedpatientswhounderwentlevatorplasty
atthetimeofrepairandfoundthatoutcomesweregoodwithimproved continenceandacceptablerecurrencerates,butdidnotdirectlyassess theimpactoflevatorplasty.Moredataareneededtomakeadefinitive statementontheroleoflevatorplasty,butitcertainlydoesnotseemtobe harmfuloraddtotheperioperativerisksintheseretrospectivereviews.
Similartothedataonlevatorplasty,theroleofacolonicJpouchover straightanastomosisinaperinealrectosigmoidectomyisnotabundant. Therearenodetailedreportsofitsbenefitintheperineal rectosigmoidectomypatientpopulationinspecific.Inpatients undergoingabdominalproctectomywithlowrectalanastomosis, randomizedstudieshavefoundthattheadditionofacolonicreservoir (colonicJpouchorcoloplasty)improvedbowelfunctionbyreducing symptomsoffrequencyandurgency,withcontinuedimprovement observedevenoverayearpostoperatively.Thepotentialbenefitmaybe extrapolatedtotheperinealrectosigmoidectomypatientpopulation.Two smallreportsdocumentedgoodfunctionwithaconcomitantcolonicJ pouchandperinealrectosigmoidectomy,inparticularinthesettingofan extensivecolorectalprolapseexcision.Apouchreservoirshouldbe considered,thoughisnotnecessary,asanoptionforpatientswith enoughlengthtopermititsformationaspartofaperineal rectosigmoidectomy.

CONCLUSIONS

Perinealrectosigmoidectomyisaneffectiveanddurableoptionfor patientswithfull-thicknessrectalprolapse.Thedecisionbetween abdominalandperinealsurgicalapproachestorectalprolapserepair shouldlargelybelefttoapatient’spreferenceandconsiderationof patient’shealthstatus.Perinealrectosigmoidectomyoffersarelatively noninvasiveapproachtosurgicalrepairandisassociatedwitharelatively shortrecoveryperiodandcertainlyminimalpostoperativepain.Itisan especiallygoodoptionforelderlypatientsorthoseathigherperioperative risk.
Thekeystepsofaperinealrectosigmoidectomy,asoutlinedinthis chapter,shouldbewellstudiedbytheoperatingsurgeon,toavoid unnecessarymorbiditytothepatient.Injurytootherstructuresor bleedingcanoccur,andrecurrenceremainsaconcernafterperineal rectosigmoidectomy.Theadditionofalevatorplastytoaperineal rectosigmoidectomyshouldbeconsideredinmostpatients,especially thosewithfecalincontinenceandaweakpelvicfloor.AcolonicJpouch shouldalsobepreoperativelydiscussedwiththepatientbecauseitaddsa reservoirandmayimproveearlypostoperativefunction.Withtheadvent ofimprovedstaplingtechniques,theapproachtotheanastomosismay changeinthefuture,butatthistimethehand-sewnsuturetechnique remainsthemostcommonandacceptedanastomotictechnique.Withall thesesurgicalfactorsconsidered,aperinealrectosigmoidectomyshould bestronglyconsideredinmanypatientswithfull-thicknessrectal prolapse,andmayindeedbethepreferredapproachinmany circumstances.
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