Evidence Based approach to Rectal

Prolapse
Dr T V Aditya Chowdary

 Complete rectal prolapse (procedentia)

Circumferential full thickness descent of the
rectum outside the anus

Pathophysiology of rectal prolapse - DISTAL

INTUSSUSCEPTION of the rectum
Associated Factors
Weak levator ani and anal sphincter muscles,
A redundant rectosigmoid colon
A deep cul-de-sac
Loss of fixation of the rectum to the sacrum

 Complete rectal prolapse (procedentia)

Circumferential full thickness descent of the
rectum outside the anus

Pathophysiology of rectal prolapse - DISTAL

INTUSSUSCEPTION of the rectum
Associated Conditions
Mental Illness (fourfold risk)
connective tissue disorders
pelvic outlet obstruction
pelvic floor laxity
spina bifida
multiple sclerosis
cystic fibrosis
anorexia and bulimia nervosa
excess straining

Clinical Features
Mass PR
Bleeding
Constipation 67 %
Diarrhea
-- 15 %
Incontinence 70 %

Management

Abdominal Approach
Rectopexy
Ripstein
Wells
Resection
Resection Rectopexy
Fuykwan

Perineal Approach
Perineal
Proctosigmoidectomy Altaemeier
Anorectal Mucosectomy
With Muscular PlicationDelorme
Anal Encirclement Therisch

Preoperative workup
Document baseline anorectal anatomy and function

prior to repair

Anal manometry
Ultrasonography
Pudendal nerve terminal motor latency
Dvorkin LS, Chan CL, Knowles CH, et al: Anal sphincter morphology in patients with full-thickness rectal prolapse. Dis Colon
Rectum 47:198, 2004.

Plain X ray r/o Spina Bifida

Cine Defecography r/o Hidden internal prolapse
Colonoscopy r/o Mass Lesion
History of constipation and rectal prolapse Evaluate Colonic Transit time
Eu KW, Seow-Choen F: Functional problems in adult rectal prolapse and controversies in surgical treatment.
Br J Surg 84:904, 1997.

Planned perineal approach RP with cystocoel/uterine prolapse Do IVP for

course of ureters

CONTROVERSIES IN SURGICAL
APPROACH
Neither the type of procedure (intra-abdominal
versus perineal) nor the approach (open versus
minimally invasive) has been identified as optimal
Suture or mesh rectopexy
Anterior or posterior mesh wrap
Rectopexy alone or with sigmoid resection
Extent of pelvic dissection and division of the lateral ligaments
Anterior versus posterior mobilization
Perineal approach in young men to spare risk of pelvic nerve
injury

Abdominal Vs Perineal
Recurrence Rates
Abdominal 0% to 5 % , Perineal 10% 15%

The perineal procedures are generally reserved for the most elderly
and
frail, particularly
who are an
notintra-abdominal
candidates for either
an
Comorbid
illnesses those
that preclude
procedure
open
or laparoscopic
approach
Failed
previous intra-abdominal
rectal procidentia repair procedure
Prior
surgery
Clark
CE, pelvic
Jupiter DC,
Thomas JS, Papaconstantinou. Rectal Prolapse in the Elderly: Trends in Surgical
and Outcomes from the American College of Surgeons National Surgical Quality
Management
Prior pelvic
radiation therapy
Improvement Program Database. JACS 2012;215:709.
Surgical
management
of rectal
prolapse.
Madiba TE, Baig
Wexner
SD Arch Surg.
2005
Young
males, in
order
to minimize
theMK,
risk
of erectile
dysfunction.
Jan;140(1):63-73

There is little, if any, risk of damage to the hypogastric nerves with

the perineal procedures.

Mahmoud SA, Omar W, Abdel-Elah K, Farid M. Delorme's Procedure for Full-Thickness Rectal Prolapse;
Does it Alter Anorectal Function. Indian J Surg 2012; 74:381.

Suture Vs Mesh Rectopexy

Suture Rectopexy the redundant sigmoid colon may
cause the onset of or exacerbate preexisting constipation
Blatchford G J, Perry R E, Thorson A G, Christensen M A.
Rectopexy without resection for rectal prolapse. Am J Surg.
(1989);158(6):574576.

A single centre comparative study of laparoscopic mesh

rectopexy versus suture rectopexy M R Sahoo, A K
Thimmegowda, Manoj S Gowda
J Minim Access Surg. 2014 Jan-Mar; 10(1): 1822.

NO Significant difference in outcome

Slightly better symptomatic relief of constipation and
continence in suture group

Anterior vs Posterior
Rectopexy

Recurrence rates for anterior and posterior

rectopexy are similar.

Rate of stricture and postoperative constipation

- posterior < anterior rectopexy

15% experience new onset constipation and 50% have worsening

of
constipation with rectopexy alone
Functional results of operative treatment of rectal prolapse over an 11year
period: emphasis on transabdominal approach.
Aitola PT1, Hiltunen KM, Matikainen MJ. Dis Colon Rectum. 1999 May;42(5):655-60.

Resection Alone
Anterior resection alone associated with higher
recurrence rates and significant operative and
postoperative morbidity

Recurrence rate 9%
Deterioration of continence has been reported in 10
20%
Schlinkert R T, Beart R W Jr, Wolff B G, Pemberton J H.
Anterior resection for complete rectal prolapse. Dis Colon
Rectum 1985. (1985);28(6):409412.

Resection with sacral fixation

Advantage of removing excess bowel and

restoring the normal rectal angulation.
This approach improves symptoms of both
incontinence and constipation.
Madof RD, Williams JG, Wong WD, et al: Long-term
functional results of colon resection and rectopexy for
overt rectal prolapse. Am J Gastroenterol 87:101, 1992.

Lateral stalk Mobilizations

Division of the lateral stalls will allow for better
rectal mobilization and fixation and prevent
recurrence but at a cost of worsening
constipation
Speakman CT, Madden MV, Nicholls RJ, et al: Lateral
ligament division during rectopexy causes constipation
but prevents recurrence: Results of a prospective
randomized study. Br J Surg 78:1431, 1991.

Division may result in denervation of the rectum due

to damage to the parasympathetic component of the
inferior hypogastric Plexus (Varma).

Lap Vs Open
Minimally-invasive (eg, laparoscopic, laparoscopicassisted, or robotic-assisted) colon and rectal procedures
have the advantages of reduced postoperative pain,
early return of bowel function, and shortened length of
hospital stay
(Boccasanta 1998; Solomon 2002)

Lap = Open

Better Functional results short term

PROSPER: a randomised comparison

of surgical treatments for rectal
prolapse.
Senapati A1, Gray RG, Middleton LJ, Harding J, Hills RK,
Armitage NC, Buckley L, Northover JM; PROSPER Collaborative
Group.
Abdominal
Perineal doi:
Colorectal
Dis. 2013 Jul;15(7):858-68.
10.1111/codi.12177.
Suture VS Resection
Altemeiers vs Delormes

rectopexy
RECURRANCE
Suture

26%

Resection Rectopexy

13%

Altemeiers

24%

Delormes

31%

QOL and
incontinance upto
3 years was
mostly equal

Conclusion : No significant differences were seen in any

of the randomised comparisons, although substantial
improvements from baseline in quality of life were noted
following all procedures.

DeloRes trial: study protocol for a

randomized trial comparing two standardized
surgical approaches in rectal prolapse Delorme's procedure versus resection
rectopexy

2012 Aug 29;13:155. doi:

10.1186/1745-6215-13-155.