Similar to many disorders of the pelvic floor, rectal prolapse is a complex and likely underreported disease process. It is frequently observed in patients who have a history of straining associated with intractable constipation or frequent diarrhea. It is most commonly seen in older patients with a peak incidence in the seventh decade and in individuals with a history of multiparity, neuromuscular deficit from previous operation, neurologic disorder, or psychiatric illness. Rectal prolapse often occurs in conjunction with other disorders of the pelvic floor, including cystocele and rectocele. Chronic prolapse may be associated with progressive fecal incontinence due to trauma to the anal canal from repeated prolapse and reduction of rectal tissue as well as pudendal neuropathy.

Despite the many benefits of medical management and/or physiotherapy for other disorders of the pelvic floor, surgical intervention is the gold standard of care in the management of full-thickness rectal prolapse. Therefore, there is no benefit in waiting, and surgery is indicated for patients who are good operative candidates once full-thickness prolapse is identified. Traditionally, relapse can be managed either via an abdominal or a perineal approach. The choice of surgical approach is highly personalized and based on the balance of operative morbidity, long-term outcome, recurrence, and any prior repair. It is generally accepted that an abdominal rectopexy has a lower recurrence rate and better postoperative function; however, it carries with it an increased complication rate and longer hospitalization. For these reasons, the perineal approach was previously selected for patients who have significant medical comorbidities. Given improvements in anesthesia and laparoscopy, the abdominal approach is now offered to a wider range of patients.

The most common operation offered for primary rectal prolapse in North America may be suture rectopexy with or without sigmoid colon resection. Laparoscopic rectopexy is appealing over the open approach because laparoscopic colorectal surgery has consistently been shown to decrease length of hospital stay, postoperative pain, and cost as compared to open surgery. However, laparoscopic rectal dissection and intracorporeal suturing are difficult and advanced laparoscopic techniques. Some surgeons overcome this difficulty with a hand-assisted laparoscopic approach to abdominal rectopexy. Benefits of this approach include improved tissue handling with tactile feedback, more effective and versatile rectal retraction, and ability to apply direct pressure for management of difficult to control presacral bleeding. For some, these benefits would result in decreased operative time with very little increase in morbidity, particularly if the hand port site doubles as the specimen extraction site in the case of resection rectopexy. Hand-assisted surgery for segmental colorectal resection has been shown to decrease conversion rate to open as well as operative time with no difference in length of hospital stay, severity of postoperative pain, time to flatus, or rate of functional recovery as compared to straight laparoscopy. The hand-assisted technique may be of further benefit in those elderly or highly morbid patients who would previously have been offered a perineal approach alone. Hand assistance can also be considered when a laparoscopic surgeon who does not utilize the hand-assisted technique encounters a difficult case where conversion may be the next step in proceeding to completion. Hand assistance is also useful for surgeons who are in the beginning of their laparoscopic learning curve or who are not tremendously laparoscopically adept because it may also prevent conversion to an open procedure, particularly if the case is complex or difficult.