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improved outcomes in colon and rectal surgery
113. Pinta T, Kylanpaa-Back ML, Salmi T, Jarvinen HJ, Luukkonen
P. Delayed sphincter repair for obstetric ruptures: analysis
of failure. Colorectal Dis 2003; 5: 73–8.
114. Evans C, Davis K, Kumar D. Overlapping anal sphincter repair
and anterior levatorplasty: effect of patient’s age and duration
of follow-up. Int J Colorectal Dis 2006; 21: 795–801.
115. Londono-Schimmer EE, Garcia-Duperly R, Nicholls RJ
et al. Overlapping anal sphincter repair for faecal incontinence due to sphincter trauma: five year follow-up functional results. Int J Colorectal Dis 1994; 9: 110–3.
116. Halverson AL, Hull TL. Long-term outcome of overlapping
anal sphincter repair. Dis Colon Rectum 2002; 45: 345–8.
117. Zorcolo L, Covotta L, Bartolo DC. Outcome of anterior
sphincter repair for obstetric injury: comparison of early
and late results. Dis Colon Rectum 2005; 48: 524–31.
118. Grey BR, Sheldon RR, Telford KJ, Kiff ES. Anterior anal
sphincter repair can be of long term benefit: a 12-year case
cohort from a single surgeon. BMC Surg 2007; 7: 1.
119. Jarrett ME, Varma JS, Duthie GS, Nicholls RJ, Kamm MA.
Sacral nerve stimulation for faecal incontinence in the UK.
Br J Surg 2004; 91: 755–61.
120. Leroi AM, Parc Y, Lehur PA et al. Efficacy of sacral
nerve stimulation for fecal incontinence: results of a
multicenter double-blind crossover study. Ann Surg
2005; 242: 662–9.
121. Holzer B, Rosen HR, Novi G et al. Sacral Nerve Stimulation
in Patients with Severe Constipation. Dis Colon Rectum
2008; 51(5): 524–29.
Surgery for rectal prolapse
Steven R Hunt
INTRODUCTION
Rectal prolapse (rectal procidentia) is defined as the full thickness
intussusception of the rectum through the anal canal. The annual
incidence of rectal prolapse is estimated to be 2.5 per 100,000 population.(1) The disorder tends to affect elderly women, psychiatric patients, and patients with neurologic disorders. Presenting
symptoms are usually referable to the prolapse itself. Additional
presenting complaints include constipation, straining, incontinence, and mucous soilage of the undergarments.
Surgery remains the only definitive therapy for rectal prolapse.
Over 100 operations have been described for the treatment of
procidentia. Generally, these procedures can be divided into peritoneal and abdominal approaches. The optimal procedure for
each patient should be determined by presenting symptoms and
patient comorbid disease.
CLASSIFICATION
In the strictest sense, rectal prolapse refers only to full thickness,
circumferential protrusion of the rectum beyond the anal canal.
While it is often clinically obvious, several other anorectal disorders can imitate the condition. Circumferential prolapsed internal
hemorrhoids, when large, are frequently diagnosed as prolapse,
and prolapse is often diagnosed as hemorrhoids. Rectal polyps or
cancer can protrude through the anus and mimic prolapse. It is
important to differentiate between true procidentia and mucosal
prolapse, as the entities may have similar presenting symptoms.
Patients with mucosal prolapse frequently have a history of prior
anorectal procedures or trauma and the prolapse is often asymmetric. Solitary rectal ulcers and colitis cystica profunda can
present with symptoms similar to rectal prolapse. These disorders
are associated with internal intussusception of the rectum, but
may coexist in patients with rectal prolapse. Both solitary rectal
ulcer and colitis cystica profunda are hypothesized to result from
repeated mucosal trauma and ischemia at the lead point of the
prolase. Significant rectal bleeding is relatively rare in patients
with procidentia, although it is a common presentation in solitary rectal ulcer syndrome and colitis cystica profunda.
Internal rectal intussusception without prolapse may be a predecessor to rectal prolapse, although this association has not been
proven.(2) Rectal intussusception is frequently identified during
defecography performed to evaluate obstructed defecation or constipation. It is also a common finding in asymptomatic patients.
(3) While it is clear that surgery is the mainstay of treatment for
complete rectal prolapse, the indications for surgical intervention
in cases of internal intussusception are less clear. Some authors
advocate surgical intervention in cases of symptomatic intussusception, while others are more cautious in their approach.(4, 5)
In the author’s section, the initial approach to patients with rectal
intussusception is dietary modification and pelvic floor retraining through biofeedback. Surgery is generally reserved for patients
with complications of internal prolapse (solitary rectal ulcers and
colitis cystica profunda) who have failed conservative therapy.
Patient Evaluation and Investigations
As rectal prolapse is a benign disease, surgery need only be considered if the symptoms are debilitating. Frequency of the prolapse
and initiating factors (defecation, straining or standing) should
be documented. The presence of severe constipation or symptoms of obstructed defecation should be noted, as these patients
may require further evaluation. Fecal incontinence occurs in
60–80% of patients, and a frank discussion should ensue regarding expected surgical outcomes with regard to continence. Most
large series show improvement in fecal incontinence in >40% of
procidentia patients after surgery, regardless of the approach.(6)
Continence may continue to improve over the first 6 to 12 months
postoperatively.
A detailed surgical history should be obtained, with special
attention to anorectal and pelvic operations, as this may influence
the ultimate surgical approach. In patients with recurrent rectal
prolapse, operative notes from the prior procedures should be
obtained and scrutinized. Female patients may have a history
of bladder or uterine prolapse, requiring consultation with a
urogynecologist and a combined approach. All patients with
prolapse should have a recent colonoscopy to rule out any
mucosal lesions.
Physical Exam
The diagnosis of procidentia is made by demonstration of the
prolapse in the surgeon’s office. Patients with advanced prolapse
may be able to produce the prolapse on the examination table
with minimal straining. If the patient cannot prolapse on the
examination table, they should be examined after straining on the
toilet. Once the prolapse has been achieved, the examiner should
first differentiate between full thickness prolapse and hemorrhoidal or mucosal prolapse. Full thickness prolapse is characterized
by concentric mucosal rings, as opposed to the radially oriented
sulci seen with mucosal and hemorrhoidal prolapse.
The digital rectal exam should exclude other anorectal pathology, and the sphincter tone and the squeeze pressure should be
evaluated. Female patients should be evaluated for the presence
of an enterocele or rectocele. Rigid proctoscopy should be performed in the office to rule out any rectal tumors, and to evaluate
for solitary ulcer and colitis cystica profunda.
Generally, a physical exam and demonstration of the complete prolapse in the office is sufficient evaluation before surgery.
Additional studies are sometimes required in certain cases.
Anal Physiology
Patients with chronic severe straining at stool should be evaluated
with anal physiology testing. Electromyography that demonstrates
improved outcomes in colon and rectal surgery
a nonrelaxing puborectalis should prompt initiation of biofeedback therapy as an adjunct to surgery.
day 5, in the setting of severe constipation, is an indication for a
resection rectopexy.
Postoperative continence can also be predicted on the basis of a
prolonged pudendal nerve terminal motor latency (PNTML) and
poor resting sphincter tone.(7, 8) We do not routinely obtain physiologic studies in the evaluation of procidentia, as they are expensive
and a prolonged PNTML is not a contraindication for surgery.
OPERATIVE REPAIRS
Although the modern operative procedures for rectal prolapse are
not particularly morbid, the patients are frequently elderly, and
morbidity is not trivial. Some series report mortalities as high as
7%. These patients often have significant comorbid conditions, and
Additional Studies
When the patient is unable to reproduce the rectal prolapse in
the office, defecography may be used to evaluate for internal prolapse or other defecatory pathology. In patients with severe con-
the operative approach (perineal, open or laparoscopic) should take
these factors into account. The choice of procedure is frequently
dictated by surgeon preference and experience; however, a one-
size-fits-all approach may not be suitable for all patients.
stipation and prolapse, a colonic transit study may be obtained.
Concentration of the markers in the left and sigmoid colon on
(A) (B) (C)
various surgical approaches to rectal prolapse must take efficacy and
In addition to the morbidity of the procedure, the evaluation of the
(D)
(E)
Figure 23.1 Perineal rectosigmoidectomy. (A & B) Incision of rectal wall. (C)
Division of vessel adjacent to bowel wall. (D) Mesenteric vessels ligated. Stay
sutures previously placed in distal edge of outer cylinder are placed in cut edge of
inner cylinder. (E) Anastomosis of distal aspect of remaining colon to the short
rectal stump. (From Beck DE, Whitlow CB. Rectal prolapse and intussusception.
In Beck DE. Handbook of colorectal surgery. 2nd edition. Marcel Dekker: New
York, 2003; 301–24. With permission.)
surgery for rectal prolapse
(A) (B) (C) (D)
(D)
(E)
functional outcomes into account. Some techniques have excellent
results in terms of recurrence, but can predispose the patients to constipation or evacuatory difficulties, trading one problem for another.
Perineal Repairs
The preponderance of the historical literature suggests that the
abdominal approach to rectal prolapse is superior to the perineal
approach in terms of recurrence rates. While most single institution studies report better outcomes for abdominal procedures,
this difference is not demonstrated in meta-analysis.(9, 10)
The major advantage of the perineal approach is the ability to conduct the operation under spinal or even local, anesthetic. The avoidance of general anesthesia and an abdominal dissection makes this
the preferred approach for patients with significant comorbidities.
Perineal Proctosigmoidectomy (Altmeier Procedure)
The technique of perineal proctosigmoidectomy involves mobilization and resection of the prolapsed rectosigmoid colon via a perineal
Figure 23.2 Delorme’s procedure. (A) Subcutaneous infiltration of dilute epinephrine solution. (B) Circumferential mucosal incision. (C) Dissection of
mucosa off muscular layer. (D) Plicating stitch approximating cut edge of mucosa,
muscular wall, and mucosa just proximal to dentate line. (E) Plicating stitch tied.
(F) Completed anastomosis. (From Beck DE, Whitlow CB. Rectal prolapse and
intussusception. In Beck DE. Handbook of colorectal surgery. 2nd edition. Marcel
Dekker: New York, 2003, 301–24. With permission.)
approach. Patients should have a complete mechanical bowel preparation. The prone-jackknife or left lateral position is preferred over
lithotomy, as it allows easy access to the operative field for the surgeon and assistant. While general anesthetic provides more comfort
for the patient, it is often necessary to use local or spinal anesthesia
in frail patients. The buttocks should be taped apart and a Lonestar
retractor is used to efface the anus and provide optimal exposure.
The procedure is begun by recreating the prolapse. Once the bowel
has been completely prolapsed, a circumferential incision is made
in the rectum approximately 1.5–2 cm proximal to the dentate line.
Using the electrocautery, this incision should be continued until the
full thickness of the rectal wall has been incised circumferentially.
The incised rectum is then everted and pulled downward. The
vaginal wall is frequently adherent to the prolapsed segment and
should be dissected away from the rectum to avoid the devastating
complication of a postoperative colovaginal fistula. The peritoneal
cavity is then entered by incising the peritoneum of the Pouch of
Douglas anteriorly. Entrance into the peritoneal cavity facilitates
improved outcomes in colon and rectal surgery
(A) (B) (C)
Figure 23.3 Anal encirclement (Thiersch). (A) Lateral incisions with prosthetic mesh tunneled around the anus. (B) Mesh completely encircling the anal opening.
(C) Completed anal encirclement procedure. (From Beck DE, Whitlow CB. Rectal prolapse and intussusception. In Beck DE. Handbook of colorectal surgery.
2nd edition. Marcel Dekker: New York, 2003, 301–24. With permission.)
delivery of the prolapsed rectum and division of the mesorectum.
The mesorectum is then divided and ligated with ligatures, or
alternatively, a vessel sealing device may be used. Division of the
mesorectum should be continued, advancing proximally on the
bowel until tension is encountered (Figure 23.1).
Once the redundant rectosigmoid has been mobilized, the anterior peritoneum should be repaired, including seromuscular bites of
the anterior bowel wall, with a running absorbable suture to obliterate the pouch. A levatorplasty should be considered if a defect is
present in the pelvic floor. If the levator muscles can be identified
without extensive dissection, plication should be performed anteriorly and posteriorly. The redundant bowel is then divided and a
hand-sewn anastomosis is fashioned using interrupted absorbable
sutures. Alternatively, the anastomosis may be created using a circular stapler with acceptable results.(11, 12)
Generally, patients have minimal narcotic requirements postoperatively and ileus is exceedingly rare. Patients should be
ambu lated and their diet is advanced on postoperative day 1.
Constipating regimens have no proven beneficial results. It is the
author’s practice to discharge patients after the first bowel movement, but in some centers, the Altmeier procedure is performed
on an outpatient basis.(11)
In experienced hands, the Altmeier procedure has excellent
results, rivaling the abdominal procedures for recurrence rates.
Several recent large series report recurrence rates ranging from
6% to 16%.(7, 9, 11) Both incontinence and constipation are also
significantly improved after perineal proctectomy.(7, 9, 13) Some
authors describe significant improvement in recurrence rates if a
levatorplasty is performed.(14)
Fortunately, major morbidity and mortality for this procedure are
rare. The anastomotic leak rates are reportedly 1–2%, with significant bleeding occurring in a similar percentage of patients.(7, 9, 14)
Delorme’s Procedure
Delorme’s procedure offers another alternative to the Altmeier
repair. The technique involves a submucosal resection of the
prolapsed rectum, with plication of the muscularis propria. The
submucosal nature of the dissection in this procedure does not
allow for a concomitant levatorplasty.
As with the Altmeier procedure, mechanical bowel preparation
should be performed and the procedure conducted in the pronejackknife or left lateral position with effacement of the anus. Again,
local or spinal anesthesia may be used for infirm patients. The rectal
prolapse is delivered, and the submucosal plane is infiltrated with local
anesthetic containing epinephrine. A circumferential mucosal incision
is made 1 cm proximal to the dentate line. The submucosal plane
is identified and downward traction is applied to the mucosal tube.
Dissection is carried out within this plane to the apex of the prolapsed
segment of rectum. At this point, the exposed muscularis propria is
plicated with multiple bites in four quadrants using an absorbable
monofilament or braided suture. The redundant mucosa is then
excised and the plication sutures are tied. The mucosal edges are then
reapproximated using interrupted absorbable sutures (Figure 23.2).
The recurrence rate in most recent large series ranges from
13–27%.(15–17) The morbidity and mortality rates are similar
to those of the Altmeier repair. Improvement is reported in both
continence and constipation in most series where these functional outcomes were evaluated.(16–18)
Given the uniformly inferior results of Delorme’s procedure
relative to the Altmeier repair, it is the author’s feeling that this
approach should not be used as a first-line perineal procedure.
Many advocate this procedure for the treatment of mucosal
prolapse; however, other, less involved techniques exist for this
disorder. Elastic rubber band ligation is frequently adequate for
modest mucosal prolapse. The circular stapler technique used in
surgery for rectal prolapse
(A) (B)
(D)(C)
Figure 23.4 Mesh rectopexy (Ripstein). (A) Posterior fixation of sling on one side. (B) Sling brought anteriorly around mobilized rectum. (C) Sling fixed posteriorly on
the opposite side. (D) Sagittal view of the completed rectopexy. (From Beck DE, Whitlow CB. Rectal prolapse and intussusception. In Beck DE. Handbook of colorectal
surgery. 2nd edition. Marcel Dekker: New York, 2003, 301–24. With permission.)
the treatment of hemorrhoids is a second appealing option for
more advanced mucosal prolapse.
Anal Encirclement (Thiersch Repair)
Anal encirclement has almost reached the status of historical interest, as it has been replaced by other procedures with more favorable results. The procedure can be performed in a short period of
time with only local anesthetic. The original repair described by
Thiersch used a silver wire to encircle the anal sphincter complex.
The wire encirclement has fallen out of favor as the wire can break
or erode through the sphincters and anoderm. Marlex or Mersilene
mesh are the preferred alternative to wire, as they are softer and less
prone to breakage or erosion.
The operation can be performed in the prone-jackknife or
lithotomy position. After meticulous antiseptic preparation,
small posterior and anterior incisions are made 1 cm outside
the anal verge. A curved clamp is then tunneled through the
ischiorectal fossa from the anterior incision to the posterior
improved outcomes in colon and rectal surgery
incision and one end of the mesh is then pulled through the
tunnel. This is duplicated on the opposite side and the other end
of the mesh is delivered. The redundant mesh is pulled through
and the prosthetic is tightened around an 18F Hegar dilator.
The mesh is then overlapped anteriorly and sewn to itself with
a nonabsorbable suture. The small incisions are then closed
with absorbable subcuticular sutures and the wounds are sealed
with Dermabond, to prevent subsequent soilage of the wounds
(Figure 23.3).
Anal encirclement procedures do not repair the prolapse, but
merely prevent external prolapse. Infectious complications are
common with the synthetic mesh, occurring in up to 33% of
patients.(19) Postoperatively, these patients frequently experience
tenesmus and difficulty with evacuation.(20) This procedure
should be reserved for patients who have significant contraindications to more formal repairs. One relative indication for this
repair is the patient with significant hepatic ascites (not amenable
to transjugular intrahepatic portosystemic shunt) and debilitating
rectal prolapse.
Open Abdominal Repairs
A prerequisite to the open approach is the patient’s ability to tolerate a general anesthetic and laparotomy. A variety of abdominal
repairs are described in the literature, but only a few have withstood
the test of time. The common theme among these time-tested procedures is complete rectal mobilization and fixation of the rectum
to the sacrum. It is suggested that the fibrosis resulting from the
rectal mobilization is responsible for the long term fixation of the
rectum and avoidance of recurrence.(21)
All of the large series involving abdominal procedures show
improvement in fecal continence. The same cannot be said for
constipation, as rectopexy alone tends to worsen constipation. In
cases of severe constipation preoperatively, a sigmoidectomy may
be combined with rectal fixation.
The repairs discussed below all involve complete rectal mobilization. In all cases, the rectal mobilization should be carried out
in the avascular plane outside the mesorectal fascia. The peritoneum at the sacral promontory is incised and the plane posterior
to the superior rectal artery is identified. Great care should be
taken to prevent injury to the hypogastric plexus and the ureters
should be identified and avoided. When rectal fixation sutures
are placed, the position of the ureters should be reconfirmed
to prevent inclusion in the suture. These approaches are not
immune to the usual pitfalls of open laparotomy, with complications including small bowel obstruction, prolonged ileus, and
wound complications.
There is some controversy regarding the extent of rectal mobilization. While some authors advocate division of the lateral rectal
ligaments to improve recurrence rates, there are some reports of
worsening constipation if the lateral ligaments are divided.(22) In
a small randomized prospective study comparing rectal mobilization with and without division of the lateral ligaments, Mollen et
al. reported no difference between the two groups with regard to
constipation scores or to total colonic transit time. Anterior rectal mobilization is recommended with all of these procedures, but
this is generally a minimal dissection as these patients tend to have
a deep Pouch of Douglas.
Mesh Sling Repair (Ripstein Procedure)
The Ripstein procedure involves the posterior mobilization of the
rectum down to the pelvic floor followed by fixation of the rectum to the sacrum using a mesh sling. Before the advent of the
laparoscopic approach, this procedure was one of the most commonly employed abdominal techniques for rectal prolapse.
Patients should undergo a complete mechanical bowel preparation and the operation is performed in the lithotomy position.
A complete rectal mobilization is carried down to the pelvic floor.
A 3–4 cm wide piece of PTFE or polypropylene mesh is then fixed
to the sacrum approximately 1 cm to the right of the midline
using several nonabsorbable sutures. Traction is then applied to
the rectum in a cephalad direction and the mesh is fixed at multiple points to the anterior rectum by seromuscular bites of nonabsorbable suture. The mesh is then secured to the left side of the
sacrum approximately 1 cm off the midline, taking care to ensure
that the mesh does not constrict the rectum (Figure 23.4).
The results of the Ripstein repair are excellent in terms of
recurrence, with recurrence rates of 0–7% reported in large
recent series.(6, 23, 24) In spite of these enviable results, enthusiasm for this procedure has waned because of reports of mesh
erosion into the rectum, late colovaginal fistulas, stenosis, and
significant constipation following the procedure.(23) In light of
these complications and the success of other alternative therapies,
the Ripstein procedure’s role in the modern treatment of rectal
prolapse should be limited.
Posterior Mesh Fixation (Wells Operation)
The technique of the Wells operation is similar to that of the
Ripstein procedure, except the mesh fixation to the sacral promontory is posterior. Theoretically, this posterior mesh orientation may
reduce the problems typically associated with the anterior sling.
The procedure was originally described using an Ivalon (polyvinyl alcohol) sponge. In the US, experience with the Ivalon sponge
is limited, as it has not been approved for implantation. Instead,
many centers perform the procedure using polypropylene mesh.
Full mechanical bowel prep is performed and the patient is positioned in lithotomy position. The rectum is mobilized down to the
pelvic floor. Retracting the rectum anteriorly, a 5 × 8 cm piece of
mesh is then anchored to the sacrum in the midline using nonabsorbable suture. The rectum is then retracted cephalad and the
redundancy is eliminated. With the rectum under traction, the mesh
is sutured bilaterally to the lateral rectal mesentery. The mesh wrap
forms a trough around the dorsal half of the rectum and does not
cover the anterior rectal wall. The peritoneum is then closed over
the mesh to exclude it from the abdominal cavity (Figure 23.5).
With regard to recurrence, the Wells operation has exceptional
results with recurrence rates generally between 0–5% for most large
open series.(25–27) While there are fewer reported mesh complications, these series uniformly show a worsening of constipation
after the procedure.(25–28)
Suture Rectopexy
Before the laparoscopic era, suture rectopexy alone was not a
common procedure. This technique involves rectal mobilization
followed by suture fixation to the sacral promontory. Its appeal
lies in the fact that no foreign bodies are used, thus negating
surgery for rectal prolapse
(A) (B)
(C)
the complications of mesh infection and erosion. A prospective
randomized trial comparing open suture rectopexy to the Wells
operation found no difference in the two procedures in terms of
recurrence.(25) This procedure will be described in more detail
under laparoscopy, as it has evolved primarily as a laparoscopic
technique.
Resection Rectopexy (Frykman-Goldberg Procedure)
Constipation clearly worsens after rectopexy alone. Many authors
advocate sigmoid colectomy with rectopexy to alleviate postoperative constipation. This technique, termed the Frykman-Goldberg
procedure, involves full rectal mobilization, sigmoid colectomy
Figure 23.5 Ivalalon (polyvinyl alcohol) sponge rectopexy (Wells). (A) Polyvinyl
sponge being fixed to the sacrum. (B) Sponge in place before fixation to the rectum.
(C) Incomplete encirclement of the rectum anteriorly with the sponge sutured in
place. (From Beck DE, Whitlow CB. Rectal prolapse and intussusception. In Beck
DE. Handbook of colorectal surgery. 2nd edition. Marcel Dekker:New York, 2003,
p301–324. With permission.)
with colorectal anastomosis, and suture fixation of the rectum to
the sacrum.
Patients require a complete mechanical bowel preparation and
are positioned in lithotomy. The rectum is completely mobilized
to the pelvic floor posteriorly. The lateral stalks are left intact. The
rectum is then retracted into the abdomen and the posterolateral
mesorectum is fixed to the presacral fascia using nonabsorbable
sutures. The sigmoid colon and upper rectum are then resected.
Mobilization of the splenic flexure is usually not required as the
redundant sigmoid colon allows for resection and subsequent
anastomosis without tension. The anastomosis is created with circular stapler. The original description of this procedure involved
improved outcomes in colon and rectal surgery
fixation of the anterior rectum to the endopelvic fascia to eliminate
the cul-de-sac. Most modern proponents of this operation have
abandoned these anterior sutures as they have no proven benefit
and can be difficult to place safely.
The resection rectopexy has superior results with respect to
both recurrence and constipation. Most large series report recurrence rates in the low single digits.(9, 29–31) Morbidity rates range
from 0 to 35% and mortality from this procedure is low.(9, 29)
This remains the only commonly employed abdominal procedure
with significant improvement in postoperative constipation. One
relative contraindication to resection rectopexy is severe incontinence with compromise of the anal sphincter, as sigmoidectomy
can worsen incontinence in this patient population.
The addition of a sigmoid resection confers a significantly
increased risk of anastomotic complications when compared to
rectopexy alone. Careful adherence to the usual tenets of a safe
colorectal anastomosis (a good proximal and distal blood supply,
a tension-free anastomosis, and air testing of the anastomosis)
should allow safe practice of this procedure.
Laparoscopy
Over the past decade, the laparoscopic approach to colorectal
diseases has become pervasive. The literature has been flooded
with series reporting the successful treatment of rectal prolapse
through minimally invasive techniques. Rectal prolapse lends
itself extraordinarily well to the laparoscopic approach, as the
procedure is isolated to one sector of the abdomen, and there is
frequently no specimen removal or anastomosis required, avoiding a conventional incision altogether. Recent reports comparing open to laparoscopic treatment of rectal prolapse find that
there are significant patient benefits to laparoscopy, including
decreased pain, quicker resumption of diet, earlier return of
bowel function, shorter length of stay, reduced hernia rates, and
a lower incidence of small bowel obstruction.(32–34) Mortality
rates for the laparoscopic approach are low. All of the open procedures discussed previously can be performed laparoscopically,
however the Ripstein procedure has proven tedious to complete
laparoscopically and is seldom performed.
In general, these laparoscopic procedures require a steep
Trendelenburg position to keep the small bowel and sigmoid
colon out of the pelvis. The mesorectum is frequently elongated
and thin in these patients. The mesorectal peritoneum is scored
at the sacral promontory and the plane behind the superior rectal artery is identified with the aid of pneumoperitoneum. The
hypogastric nerves should be spared and the ureters identified.
The initial mesorectal mobilization should be posterior in the
avascular plane. As with the open approach, division of the lateral
ligaments is controversial. The author performs a circumferential
mobilization to the pelvic floor, including division of the lateral
ligaments. The editors prefer to leave the lateral ligaments intact.
The Wells repair has proven more amenable to the laparoscopic
approach than the Ripstein procedure. The laparoscopic technique
is similar to the open technique. Three or four laparoscopic ports
are required and the procedure is most easily accomplished with
a 30° camera, to allow for visualization deep in the pelvis. This
approach requires skill in laparoscopic sewing and knot tying. As
with the open Wells procedure, the recurrence rate is excellent,
with recurrence rates ranging from 0 to 4% in recent series.(35–37)
Functional outcomes were also analogous to the open procedure
in these series, with improvement in continence, but worsening of
constipation. Morbidity and mortality are low.
Laparoscopists, forever testing the premise that less is more, have
trended toward more suture repairs without mesh. The laparoscopic
suture rectopexy is more manageable, as it does not require challenging manipulations of mesh and involves less suturing. Again, three to
four ports are required and a 30° camera is recommended. After the
rectum is mobilized, it should be pulled in a cephalad direction and
the lateral stalks are sutured to the sacral promontory using nonabsorbable sutures. One suture on each side of the rectum is generally
sufficient. Patient’s diets may be advanced rapidly and they should be
ambulated early after surgery. It has been our practice to discharge
patients after their first bowel movement, however many centers perform this procedure with only a short postoperative stay.
The laparoscopic suture rectopexy has been proven effective in
several recently published series, with recurrence rates from 0%to
6%.(38–40) Continence is improved postoperatively, but the
benefit of this simple technique may be found in improvement
in postoperative constipation.(38, 40, 41) These series provide
hope that the suture rectopexy alone, without mesh, may rival the
mesh repair in efficacy, without the long term complication of
constipation. This may obviate the need for a concomitant resection, and thus decrease the difficulty and morbidity of the repair.
Some centers still favor laparoscopic resection rectopexy as the
primary procedure for rectal prolapse. As with the open technique, splenic flexure mobilization is usually not required. The
addition of sigmoidectomy increases the operative time relative
to suture rectopexy alone by nearly 100 minutes.(41, 42) Results,
as with the open technique, are excellent, with recurrence rates
from 0% to 2.5%.(4, 43) Both constipation and incontinence are
improved postoperatively.
No comparative studies between open and laparoscopic techniques
have proven a significant reduction in morbidity or mortality for
the laparoscopic approach, but trends seem to favor the laparoscopic approach.(34, 44) What is clear from the literature is that
the minimally invasive approach to rectal prolapse is not inferior.
The clear benefits of the laparoscopic approach in terms of cost,
length of stay, and decreased pain mandate consideration of this
approach when it is feasible.
RECURRENT PROLAPSE
Recurrent rectal prolapse occurs with every procedure, and the surgical approach to repair of the recurrence requires consideration
of the initial procedure. The mean time to recurrence is between
18 and 24 months. Patients who have recurred require physiologic
testing and defecography to evaluate for anismus. If anismus is
identified, these patients should be referred for biofeedback before
any surgical therapy.
There is no clear algorithm for management of recurrent prolapse. Some authors advocate for a change in approach, performing
perineal procedures if the initial approach was abdominal, and vice
versa. Others promote the use of the same approach for repair of
the recurrence. No definitive published data exists on the proper
selection of the second procedure. The only absolute principle in
the treatment of recurrent prolapse is that if a resection is planned,
surgery for rectal prolapse
any prior anastomoses must be resected in order to avoid an intervening ischemic segment. Again, comorbid disease should play a
role in the selection of the procedure. Patients unfit for general
anesthetic should be offered a perineal approach if at all possible.
The few published series on the treatment of recurrent prolapse
offer little to no insight on the best approach. A series from the
University of Minnesota suggests that the abdominal approach is
superior to the perineal approach in terms of rerecurrence.(45) The
Cleveland Clinic Florida has published one of the larger series on
treatment of recurrent prolapse. Various surgical approaches were
used and it is not clear how the procedures are selected. Compared
to primary operations for rectal prolapse, there was no difference
in terms of recurrence, morbidity, and bowel function.(46)
A difficult situation arises in the patient who has had a prior
abdominal resection rectopexy, but is now unfit for general anesthetic. Before undertaking a perineal proctectomy in such a patient,
the surgeon must be sure he can mobilize and resect the prior anastomosis. If not, the surgeon is left with three less than desirable
options. The patient may be counseled that an operation is not in
their best interest. A Delorme procedure may be performed, or the
patient may be offered anal encirclement.
CONCLUSION
While many procedures exist for rectal prolapse, only a few offer
acceptable results in terms of recurrence, postoperative bowel
function, and morbidity. Of the perineal techniques, the Altmeier
procedure appears to offer superior outcomes in terms of these
principles. All of the described open abdominal approaches have
satisfactory recurrence rates, but only the resection rectopexy shows
improvement in postoperative bowel function. Laparoscopy, with
all of its inherent advantages, may be the preferred approach. Of
these procedures, the laparoscopic suture rectopexy appears to
offer the best hope of achieving favored status, given the relative
simplicity of the procedure and its exceptional outcomes with
minimal morbidity.
The surgeon who treats this disease should possess the flexibility
and breadth of skills to tailor the procedure to the individual patient.
Surgeon preference and experience should play a role in the choice of
procedure, but should not justify a single procedure for a complex disease. An algorithm used in our section is to offer laparoscopic suture
rectopexy as the default technique. If a patient has severe constipation, a laparoscopic resection rectopexy is performed. The patient
with a hostile abdomen or the patient who is too infirm to undergo
an abdominal procedure is offered a perineal proctosigmoidectomy.
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