Once separated from the rectal muscle, the pro­lapsed mucosal cylinder has to be removed from the middle rectum, using diathermy to divide the small terminal branches of the low rectal artery, possibly avoiding both intraoperative hemorrhage and deep ischemia of the proximal rectal epithelium, which might favor anastomotic breakdown. At this point, the second step of the Delorme is performed, i.e., plication of the denuded rectal muscle, avoiding excessive tightening of the sutures in order to pre­vent rectal muscle lacerations. Downwards dis­placement of the middle or upper rectum by means of the concertina-like sutures will result in the approximation of the proximal and distal epithelia, allowing the final step to be performed, a recto-anal anastomosis above the dentate line, with interrupt­ed 2/0 vicryl sutures following removal of the Lone Star retractor (Fig. 10.2). The anastomosis, similar to a colo-anal one, should not be under tension, to minimize the risk of dehiscence. The operation is now complete. I check that the suture is intact and that, after a while, when the stretched sphincters’s tone is partly restored, it has “disappeared” upwards in the anal canal, to avoid mucosal ectro­pion, which might cause postoperative soiling.

The Delorme procedure carries a low postoper­ative morbidity, but is likely to be followed by postoperative incontinence. Therefore, to recall the concept of tailored surgery, it should be per­formed in patents without severe sphincter defects. The ideal candidate is an elderly or frag­ile patient with respiratory problems that might indicate spinal anesthesia, a prevalently mucosal external prolapse < 8 cm in size, and satisfactory continence.

For purposes of comparison, not based on ran­domized prospective trials and therefore not high­ly scientific, the re-intervention rates due to post­operative complications following other resection­al procedures for similar diseases, as reported in studies cited in the previous two chapters of this book, were: 2% after Delorme for external rectal prolapse, 4% after Delorme for rectal internal pro-

Postoperative morbidity following perineal proctosigmoidectomy, as reported by the authors cited in Table 10.4, was between 5 and 24%. Most early complications were related to lung, cardio­vascular, and renal diseases, such as pulmonary embolism, myocardial infarction, hypokalemia, and hypertension (Chun et al. 2004). The advanced age of the patients in Altomare’s series, including one 93-year-old patient, was a signifi­cant factor. Among the complications noted in the studies cited in the table, rectovaginal fistulae and anastomotic bleeding occurred less frequently.

According to these data, perineal proctosig­moidectomy is associated with a low postopera-

As mentioned in the “Live Surgery” section, a crucial step of the operation is when the pouch of Douglas is encountered. It is always prolapsed and often contains an enterocele, namely, a sigmoido­cele. Injury to the pouch in cases in which it has to be opened and partly resected and the prolapsed bowel lifted up must be strictly avoided, in order to prevent damage to the small bowel.

It should be noted that two of the authors list­ed in the table had patients requiring re-operation for pelvic/presacral hematoma. Intraoperative bleeding rarely occurs when the lower sigmoid is divided; however, according Boccasanta et al. (2006) and Gravante and Venditti (2006), the risk