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10 Complete Rectal Prolapse in Adults
ab
Fig. 10.2 ( a ) Prolapsed Hemorrhoids, ( b ) complete rectal prolapse
133
manometric physiologic testing to establish the
state of sphincter mechanism is helpful in cases
of weakened pelvic musculature. Anal manometry can assess the sphincter functioning. Flexible
sigmoidoscopy should be performed to rule out
any mucosal abnormalities like neoplasia as it
may be the cause or an association. Pudendal
nerve terminal motor latency (PNTML) and elec-
tromyography may be of value in patients with a
history of severe straining. Glasgow et al. ( 2006 )
suggested that patients with preoperative maximal squeeze pressures of more than 60 mm of Hg
have signifi cantly improved outcomes with
respect to continence after perineal proctectomy.
The presence of constipation can have a signifi cant impact on the choice of operation for patients
with rectal prolapse. Colonic transit study is
essential for the evaluation of patients with infrequent bowel movements or those with frequent
use of laxatives to choose correct operation.
10.5 Treatment
Conservative measures are only supportive. A
tailored surgical approach is the treatment modality for complete rectal prolapse. Till date, more
than 100 operations have been described for prolapse of the rectum, thereby suggesting no tech-
nique is perfect. The ideal surgical procedure
should be simple and restore the normal anatomy
with acceptable recurrence and complication
rates. It should also address the functional disturbances such as constipation and incontinence.
The goal can be achieved by narrowing the anal
orifi ce, resection or plication of redundant bowel
with or without fi xation of rectum to sacrum, and
restoration of strong and functional pelvic fl oor
by plication of the puborectalis anterior to the
rectum (Kuijpers
1992 ). Factors which must be
considered before planning surgery include
patient’s age, comorbidities, gender, preoperative
bowel functions, and associated uterine or bladder prolapse. The operation can be performed
either through abdominal or perineal approach.
10.5.1 Abdominal Procedure
Various abdominal techniques have been
described which differ only in the extent of rectal
mobilization, method used for rectal fi xation, and
the inclusion or exclusion of resection (Kuijpers
1992 ). Rectal fi xation using synthetic material is
less preferred due to associated complications
such as infection, obstruction, and bowel erosion
(Kuijpers 1992 ; Gordon and Hoexter 1978 ;
Novell et al. 1994 ).
134
A.K. Khanna
In abdominal approach, the rectum should be
completely mobilized from the sacrum up to the
anorectal junction/levator fl oor posteriorly and
then fi xed to the upper sacrum. Failure to completely straighten the rectum could result in
immediate failure due to continued prolapse of
rectal segment distal to that which has been fi xed
to the sacrum. The rationale of rectal fi xation is
to keep the rectum attached in desired elevated
position until it becomes fi xed by fi brosis. In
incontinent patients, the patulous sphincter
begins to regain its tone approximately 1 month
after the procedure with full gain of continence
by 2–3 months.
10.5.1.1 Suture Rectopexy
It was fi rst described by Cutait in 1959 for elderly
frail patients. This operation is useful for patients
with associated constipation. It involves thorough mobilization, cephalic elevation, and fi xation of the rectum to presacral fascia just below
sacral promontory. The mobilization and subsequent healing by fi brosis keeps the rectum fi xed
in an elevated position. In various series reported
on suture rectopexy, there was no reported mortality. Recurrence rates ranged from 0 to 9 %
(Briel et al. 1997 ; Carter 1983 ; Novell et al. 1994 ;
Graf et al. 1996 ; Khanna et al. 1996 ). Most of the
reports showed an improvement in fecal continence (Khanna et al. 1996 ). The infl uence on
constipation was variable. Briel et al. ( 1997 ) in a
review of suture rectopexy on 24 patients with
rectal prolapse and incontinence noted a better
overall clinical outcome in males. They postulated that the low success rate in female patients
might be explained by the presence of an occult
sphincter defect. This assumption was underlined
by the history of obstetric tear or episiotomy in
females with persistent anal incontinence after
rectopexy. These patients should be considered
for endoanal ultrasound and subsequent sphincter
repair. A randomized controlled trial was conducted by Karas et al. (
2011 ) to study whether it
is a must to fi x the rectum or not. They came out
with the conclusion that recurrence rates following no rectopexy are more as compared with
those following rectopexy (8.6 % vs 1.5 %).
Khanna has reported a simplifi ed technique of
Fig. 10.3 Midline suture for posterior rectopexy
(Khanna)
sacral rectopexy. After mobilization of the rectum by cutting the peritoneum only on the right
side with no anterior mobilization or division of
lateral ligaments, fi xation is done by using only
one or two sutures at the sacral promontory in the
midline (Fig.
10.3 ).
The advantages of cutting the peritoneum only
on the right side is technically easier as on the left
side, the left ureter comes in close proximity to
the rectum. Further avoiding division of lateral
ligaments helps in the preservation of sexual
function. None of their patients had sexual problems after this technique (Khanna et al. 1996 ).
Preservation of ligaments is associated with
improvement in continence and constipation
(Watts et al. 1985 ).
10.5.1.2 Prosthetic or Mesh Rectopexy
The use of synthetic material for rectal fi xation is
not favored now because of associated complications (Kuijpers 1992 ; Gordon and Hoexter 1978 ;
Novell et al. 1994 ). The assumption was that these
foreign materials promote more fi brous tissue formation than ordinary suture rectopexy. Materials
used include the fascia lata and nonabsorbable
synthetic meshes such as nylon, polypropylene
(Prolene), polyvinyl alcohol (Ivalon), polytef
(Tefl on), absorbable meshes such as polyglactin
(Vicryl), and polyglycolic acid (Dexon). There
are three types of mesh rectopexies: posterior
mesh rectopexy, anterior sling rectopexy (Ripstein
procedure), and ventral rectopexy.
10 Complete Rectal Prolapse in Adults
135
Fig. 10.4 Posterior mesh rectopexy
10.5.1.3 Posterior Mesh Rectopexy
In this procedure, after thorough mobilization of
the rectum, the prosthetic material or mesh is
placed between the sacrum and the rectum and
sutured fi rst to the rectum and then to the periosteum of sacral promontory (Fig. 10.4 ). In sponge
rectopexy (Wells 1959 ), polyvinyl alcohol
sponge prosthesis is placed between the rectum
and the sacrum. The recurrence rate with these
procedures has been reported to be 0–6 %
(Luukkonen et al. 1992 ; Kim et al. 1999 ).
10.5.1.4 Ripstein Procedure (Anterior Sling Rectopexy)
• This procedure was originally described by
Ripstein in 1952 . It involved an anterior leva-
tor plication reinforced with the fascia lata. He
then modifi ed the procedure in 1963 to what is
now known as the classic Ripstein repair. This
operation is undertaken to restore the posterior
curve of the rectum. The operation is commenced by mobilizing the rectum to the level
of the levator muscle as mentioned above. A
piece of prosthetic mesh is placed around the
anterior wall of the rectum at the level of the
peritoneal refl ection. Mesh is secured to the
presacral fascia 1 cm from midline on either
side. The anterior wall of the rectum is sutured
to the sling to prevent the sutures from pene-
Fig. 10.5 Anterior sling rectopexy (Ripstein)
trating the rectal wall (Fig.
10.5 ). The cul-de-
sac is obliterated with nonabsorbable sutures.
The technique using prosthetic material has
lost its popularity because of better alternatives, problems associated with mesh, exacerbation of obstructive symptoms, and higher
recurrence rate of 10 % Roberts et al. ( 1988 ).
10.5.1.5 Rectopexy with Resection
Rectopexy with resection technique was reported
by Frykman and Goldbergh 1969 . The concept
of rectosigmoid resection is based on the observation that after low anterior resection, a dense
area of fi brosis forms between the anastomotic
suture line and sacrum, thereby securing it to the
sacrum (Kuijpers
1992 ). Resection of the redun-
dant rectosigmoid prevents torsion or volvulus,
achieving a straighter course of the left colon
which acts as yet another fi xative step (Kuijpers
1992 ; Jacobs et al. 1997 ). It also relieves consti-
pation in a selected group of patients (Madden
et al. 1992 ). This technique is suitable for
patients with a long redundant sigmoid and a
long history of constipation. In resection technique, the sigmoid colon is mobilized and a standard resection is performed using stapled or
hand-sewn anastomosis (Fig. 10.6 ). The
descending colon is not mobilized, as it supports
the anastomosis and prevents recurrence.
136
A.K. Khanna
Fig. 10.7 Ventral rectopexy
of reduced pain, shorter hospital stay, early
recovery, and early return to work (Kellokumpu
Fig. 10.6 Rectopexy with resection
2000 ). The procedure involves either suture
et al.
or posterior mesh rectopexy, with or without
Removal of redundant sigmoid colon improves
constipation and reduces straining, thereby
breaking the vicious circle (Kuijpers 1992 ;
Jacobs et al. 1997 ; Frykman and Goldberg 1969 ;
Solla et al. 1989 ; Stevenson et al. 1998 ).
Rectopexy with anterior sigmoid resection is the
most popular operation in the United States currently with a recurrence rate of 0–9 %
(Luukkonen et al. 1992 ; Kim et al. 1999 ).
resection. It has gained popularity as it is relatively simple and easily accomplished. Resection
with anastomosis may be added if required
(Heah et al. 2000 ; Kessler et al. 1999 ; Bruch
et al. 1999 ; Benoist et al. 2001 ; Darzi et al.
1995 ). The mortality for laparoscopic rectopexy
has been reported from 0 to 3 %, with recurrence
rates of 0–10 % with follow-up of 8–30 months.
These studies have demonstrated that this
approach is as effective as open technique in the
10.5.1.6 Ventral Rectopexy
It is a novel procedure done by open or laparoscopic technique for internal and external rectal
prolapse. It is safe and improves obstructed defecation symptoms without introducing new-onset
constipation as seen after posterior rectopexy.
The rectum is freed anteriorly and on the right
treatment of rectal prolapse. The effect on continence and constipation depends on the type of
rectopexy performed. Two randomized reports
compared open with laparoscopic procedure
using mesh rectopexy and found no difference in
the recurrence rate (Boccasanta et al.
1999 ;
Solomon et al. 2002 ).
side. Strip of mesh is fi xed to the pelvic fl oor and
lower rectum, pulled up, and fi xed to the presacral fascia (Fig. 10.7 ). Complete posterior dissec-
tion is avoided, thereby reducing the risk of injury
to the pelvic nerves (Sileri et al. 2012 ).
10.5.1.8 Robotic-Assisted
Laparoscopic Rectopexy
Germain et al. ( 2014 ) reported their experience
on robotic-assisted laparoscopic rectopexy
(RALR) on 77 patients. They compared their
10.5.1.7 Laparoscopic Rectopexy
The fi rst laparoscopic rectopexy was reported in
1993 (Munro et al. 1993 ). Compared to laparot-
omy, laparoscopic rectopexy has the advantages
results in patients less than 75 years of age with
those of more than 75 years of age. They found
no difference in improvement of fecal incontinence, recurrence, and the degree of satisfaction
10 Complete Rectal Prolapse in Adults
137
and concluded that RALR is safe even in elderly
patients. Robotic rectopexy seems to be feasible
and safe with encouraging results which are as
good as laparoscopic rectopexy but with longer
operation time and higher cost. Functional and
long-term results are awaited as experience is
still limited (Buch et al. 2013 ).
10.5.2 Perineal Procedure
The perineal procedures are advantageous in that
they avoid laparotomy, which makes them suitable for high-risk patients. In fact, these are
becoming popular even in healthy young patients
because of no risk of bladder and sexual
a
dysfunction. Subsequent abdominal procedure
can be performed for recurrence.
10.5.2.1 Thiersch Procedure
This anal encirclement operation described fi rst
by Thiersch in 1988 aims at narrowing the anal
orifi ce by supplementing or replacing the anal
sphincter by silver wire. It initiates foreign body
reaction and induces fi brosis.
Because of problems of breakage and skin
erosions by silver wire, other materials like
nylon, dacron, polypropylene mesh, silastic
mesh, tefl on, fascia lata, and silicon were introduced (Fig. 10.8a ). The anal encircling opera-
tions do not rectify the prolapse but merely
prevent its descent and have high recurrence
b
c
e
Fig. 10.8 ( a ) Diagrammatic representation of the Thiersch procedure. ( b – e ) Steps of surgery in perineal rectopexy by
rectal encirclement (modifi ed Thiersch) procedure
d
138
A.K. Khanna
rate of 33–44 % (Jacobs et al. 1997 ; Wassef
et al. 1986 ; Kuijpers 1992 ; Dietzen and
Pemberton 1989 ). Complications include ste-
nosis ulceration, sepsis, and fecal impaction.
Because of high rate of recurrence and complications, this procedure is reserved for most
seriously ill patients not fi t for other perineal
operations.
There are many modifi cations for encirclement of the rectum. One of them is making incisions at 12, 3, 6, and 9 o’clock positions and
getting the seromuscular layer of prolapsed rectum hitched to pelvic walls at different levels
with Prolene 1.0. These threads are then tied in a
sequence with the most superfi cial thread last of
all with two fi ngers of assistant in the rectum.
The fi ngers should snugly fi t in the encirclement.
These Prolene threads are then buried under skin
cover with the help of Vicryl 1.0 suture. This procedure becomes a sort of minimally invasive
a b
perineal encirclement or modifi ed Thiersch
operation (Fig. 10.8b–e ).
10.5.2.2 Delorme Operation
This procedure was described by Delorme in
1900 . It involves the separation and excision of
the mucosa and submucosa starting 2 cm from
dentate line up to the tip of prolapse followed by
plication of the muscularis propria (Fig. 10.9a–h ).
An additional advantage is the excision of an
associated rectal ulcer if present (Pescatori et al.
1998 ). The Delorme procedure provides a surgi-
cal alternative for patients who are unable to tolerate a more extensive operation, such as the
elderly, frail, patients, and those who are medically unfi t for major surgery. The complications
reported include hemorrhage, urinary retention,
suture line breakdown, diarrhea, and stricture.
These occur in 0–32 % of patients. Pescatori
et al. combined the Delorme procedure with
cd
Fig. 10.9 ( a – h ) Steps of the Delorme procedure
10 Complete Rectal Prolapse in Adults
139
ef
gh
Fig. 10.9 (continued)
sphincteroplasty in 33 patients with good results
achieved in 79 % of patients. Continence
improved in 70 %, and in 44 %, constipation was
cured. They concluded that the Delorme procedure combined with sphincteroplasty is indicated
when both clinical and physiological fi ndings
show a concomitant severe pelvic fl oor dysfunction. However, many other series without sphincteroplasty have shown improvement in continence
in 40–50 % of patients (Lechaux et al.
1995 ;
Agachan et al. 1997 ; Oliver et al. 1994 ; Watts and
Thompson 2000 ). Recurrence rates are higher
(7–22 %) than Altemeier’s procedure (Oliver
et al. 1994 ; Graf et al. 1996 ; Agachan et al. 1997 ).
Factors associated with failure for the Delorme
operation include proximal procidentia with
retrosacral separation on defecography, fecal
incontinence, chronic diarrhea, and major peri-
neal descent (>9 cm on straining). In the absence
of these factors, the Delorme procedure provides
a satisfactory and durable outcome and ideally
suited for patients with full-thickness prolapse
limited to partial circumference (e.g., anterior
wall) and small full-thickness prolapse of less
than 4 cm (Takesue et al. 1999 ).
10.5.2.3 Perineal Rectosigmoidectomy (Altemeier’s Procedure)
This procedure was fi rst advocated by Mikulicz
in 1889 and Miles in 1933 and popularized by
Altemeier et al. in 1971 . It involves a full-
thickness excision of the rectum and if possible a
portion of the sigmoid colon with anastomosis
using interrupted absorbable suture or a stapling
device (Fig. 10.10a–j ). Excision of redundant
anterior peritoneum forming the pouch of
140
ab
A.K. Khanna
c
de
Fig. 10.10 ( a – j ) Steps of Altemeier’s perineal rectosigmoidectomy
10 Complete Rectal Prolapse in Adults
f g
h
i
141
j
Fig. 10.10 (continued)
Douglas should be performed as a part of resection. Complete mobilization is critical for success. Excess resection of bowel can lead to
anastomosis under tension, and ligating the mesentery too far proximally may lead to ischemia. It
is the procedure of choice for patients presenting
with full-thickness large prolapse and incarcerated, gangrenous rectal prolapse and also in a
patient with recurrence after other perineal procedures. The reported overall mortality rates
range from 0 to 5 %, and recurrence rates from 0
to 16 % (Kim et al. 1999 ; Xynos et al. 1999 )
which is mainly due to incomplete resection of
redundant bowel. The postoperative course after
perineal rectosigmoidectomy is generally
uneventful. Patients have minimal pain. Oral
142
A.K. Khanna
intake can generally be commenced within
24–48 h after surgery, and bowel function returns
within few days of surgery (Takesue et al. 1999 ).
The potential complications include bleeding,
leak, and pelvic sepsis. The procedure has been
reported to yield functional problems like soiling,
fecal urgency, and fecal incontinence with loss of
rectal reservoir function (Deen et al. 1994 ).
Tension and poor blood supply can cause anastomotic dehiscence. Reduction in resting anal pressure and compromised compliance makes this
procedure unphysiological. Therefore, some
authors have suggested supplementing the perineal rectosigmoidectomy with levatorplasty. The
addition of levatorplasty has given the largest
recurrence-free interval, lowest recurrence rate,
and signifi cant improvement in incontinence, as
it recreates anorectal angle (Takesue et al. 1999 ).
Altemeier’s procedure is best suited for elderly
high-risk patients with large full-thickness prolapse in whom abdominal rectopexy is contraindicated. The addition of levatorplasty has made
this operation suited for those with associated
incontinence.
10.6 Comparison of Different Procedures and Approaches
In 2001, Benoist et al. published the results of
laparoscopic rectopexy in 48 patients. There
was no difference in outcome in all three modes
of laparoscopic intervention i.e., suture, mesh,
and resection rectopexy. Laparoscopic rectopexy is also associated with less risk of surgical site infection and hospital stay as compared
with open abdominal rectopexy (Magruder
et al.
2013 ). Laparoscopic abdominal recto-
pexy is a safe and feasible procedure, which
may be comparable with open technique with
regard to recurrence, incontinence, and constipation (Cadeddu et al. 2012 ). Madiba et al. in a
review article on surgical management of rectal
prolapse concluded that there is always an edge
of abdominal rectopexy over perineal rectopexy
in terms of control of symptoms. Only very
high-risk patients should be offered perineal
rectopexy.
10.7 Choice of Operation
Surgery is the choice of treatment in complete rectal prolapse. Straining and constipation are predisposing factors, but correcting these will not correct
prolapse. Surgery can be performed using an
abdominal approach (either open or laparoscopic)
or a perineal approach. The former approach is
preferred in younger, healthier patients, while the
latter is preferred in older and high-risk patients
unfi t for abdominal procedure. Open abdominal
suture rectopexy is still the best in terms of results
(lower recurrence and better functional outcome).
The addition of mesh posteriorly in rectopexy
does not provide any advantage but has defi nite
drawbacks because of complications associated
with foreign body. Patients with redundant sigmoid colon having associated chronic constipation should be offered resection rectopexy.
Laparoscopic approach has the advantage of
less morbidity, less pain, shorter hospital stay,
early recovery, and early return to work.
Outcomes in terms of recurrence and functional
improvement are similar to open abdominal
approach. So if expertise is available for laparoscopic approach, it should be the preferred mode
of intervention. Perineal rectopexy associated
with high recurrence rates is only recommended
in frail, elderly, and high-risk patients.
10.8 Recurrent Prolapse
Patients with recurrence should be thoroughly
reevaluated for constipation and other pelvic fl oor
abnormalities. Perineal procedures have higher
recurrence rate than abdominal procedures. If the
patient has undergone initial Altemeier’s operation, it can be repeated or abdominal rectopexy
(without resection, as it increases risk of ischemia) can be performed safely. Patients who have
undergone abdominal procedure initially can be
offered redo abdominal surgery with or without
resection or perineal rectosigmoidectomy. Those
with prior abdominal resection rectopexy should
undergo redo abdominal rectopexy with or without re-resection, but perineal rectosigmoidectomy should be avoided.