Complete rectal prolapse
(a) Prolapsed Hemorrhoids, (b) complete rectal prolapse
The diagnosis of rectal prolapse is clinical and is confirmed by proper history and complete anorectal examination. Preoperative workup of a patient with complete rectal prolapse include proctoscopy, colonoscopy and in some patients manometry, pudendal nerve terminal motor latency test, cinevideography, and colonic transit studies. Frequently prolapse is in reduced state which can be elicited by placing patient on commode and asking him to strain which demonstrates the prolapse properly. A rectal prolapse may be hidden or internal or occult, making the diagnosis more difficult. In this situation, defecography may be helpful. In this examination, x-ray is taken while the patient is having a bowel movement. It can also assist in determining whether surgery may be beneficial and which operation may be appropriate. It is more useful for evaluating internal prolapse. Baseline 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 electromyography 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 significantly improved outcomes with respect to continence after perineal proctectomy. The presence of constipation can have a significant 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.
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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 technique 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 orifice, resection or plication of redundant bowel with or without fixation of rectum to sacrum, and restoration of strong and functional pelvic floor 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 fixation, and the inclusion or exclusion of resection (Kuijpers 1992). Rectal fixation 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).
In abdominal approach, the rectum should be completely mobilized from the sacrum up to the anorectal junction/levator floor posteriorly and then fixed 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 fixed to the sacrum. The rationale of rectal fixation is to keep the rectum attached in desired elevated position until it becomes fixed by fibrosis. 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 first 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 fixation of the rectum to presacral fascia just below sacral promontory. The mobilization and subsequent healing by fibrosis keeps the rectum fixed 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 influence 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 fix 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 simplified technique of 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, fixation is done by using only one or two sutures at the sacral promontory in the midline (Fig. 10.3).
Midline suture for posterior rectopexy (Khanna)
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 fixation 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 fibrous 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 (Teflon), 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.
10.5.1.3 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 first 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).
Posterior mesh rectopexy
10.5.1.4 Ripstein Procedure (Anterior Sling Rectopexy)
This procedure was originally described by Ripstein in 1952. It involved an anterior levator plication reinforced with the fascia lata. He then modified 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 reflection. 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 penetrating 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).
Anterior sling rectopexy (Ripstein)
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 fibrosis forms between the anastomotic suture line and sacrum, thereby securing it to the sacrum (Kuijpers 1992). Resection of the redundant rectosigmoid prevents torsion or volvulus, achieving a straighter course of the left colon which acts as yet another fixative step (Kuijpers 1992; Jacobs et al. 1997). It also relieves constipation 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. 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).
Rectopexy with resection
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 side. Strip of mesh is fixed to the pelvic floor and lower rectum, pulled up, and fixed to the presacral fascia (Fig. 10.7). Complete posterior dissection is avoided, thereby reducing the risk of injury to the pelvic nerves (Sileri et al. 2012).
10.5.1.7 Laparoscopic Rectopexy
The first laparoscopic rectopexy was reported in 1993 (Munro et al. 1993). Compared to laparotomy, laparoscopic rectopexy has the advantages of reduced pain, shorter hospital stay, early recovery, and early return to work (Kellokumpu et al. 2000). The procedure involves either suture or posterior mesh rectopexy, with or without 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 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).
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 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 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 dysfunction. Subsequent abdominal procedure can be performed for recurrence.
10.5.2.1 Thiersch Procedure
This anal encirclement operation described first by Thiersch in 1988 aims at narrowing the anal orifice by supplementing or replacing the anal sphincter by silver wire. It initiates foreign body reaction and induces fibrosis.
Because of problems of breakage and skin erosions by silver wire, other materials like nylon, dacron, polypropylene mesh, silastic mesh, teflon, fascia lata, and silicon were introduced (Fig. 10.8a). The anal encircling operations do not rectify the prolapse but merely prevent its descent and have high recurrence rate of 33–44 % (Jacobs et al. 1997; Wassef et al. 1986; Kuijpers 1992; Dietzen and Pemberton 1989). Complications include stenosis ulceration, sepsis, and fecal impaction. Because of high rate of recurrence and complications, this procedure is reserved for most seriously ill patients not fit for other perineal operations.
(a) Diagrammatic representation of the Thiersch procedure. (b–e) Steps of surgery in perineal rectopexy by rectal encirclement (modified Thiersch) procedure
There are many modifications 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 superficial thread last of all with two fingers of assistant in the rectum. The fingers should snugly fit 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 perineal encirclement or modified 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 surgical alternative for patients who are unable to tolerate a more extensive operation, such as the elderly, frail, patients, and those who are medically unfit 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 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 findings show a concomitant severe pelvic floor 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 perineal 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).
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