Rectal prolapse remains a relatively rare colorectal problem that affects women more often than men. There have been many theories proposed as to the cause of this disabling condition, including a lack of fixity of the rectum to the sacrum, sigmoid colon redundancy, a deep rectovaginal or rectovesical pouch or space, poor lateral rectal attachments, and a weakened pelvic floor musculature. Operative procedures designed for repair of prolapse all address one or several of these specific etiologies, thereby resulting in numerous different procedures to treat this condition (Fig. 55-1).

Fortunately, rectal prolapse is a completely benign disease process. However, it often causes significant disability and anxiety to those affected patients as well as their family members. Elderly and more infirm patients may be affected in even greater numbers; and in many cases those individuals may not be competent to make decisions about their own health care, leaving the burden of whether to have the prolapse repaired and what type of repair to be done to other family members or a designated health care surrogate.

One certain fact is there is no nonoperative approach to repair prolapse and the alternative to surgery is simply to live with the condition. Fortunately, in many cases, chronically affected patients simply achieve reduction of the prolapse spontaneously; however, other individuals require daily manual reduction. Some patients may present with frank incarceration of the prolapse that could result in gangrene of the bowel, requiring emergent surgical repair. Long-term complications from chronic relapsing prolapse may also result in anal sphincter laxity, which may result in varying degrees of fecal incontinence. In addition, many affected patients may suffer long-term constipation, which may lend itself as a causative factor in creating this condition.

One of the more contentious debates within the discipline of colon and rectal surgery arises from the proper method in which to repair rectal prolapse. There have been numerous procedures described to surgically fix this problem, which may make both the patient and surgeon wary that no one has ever found the perfect operation to treat this condition. This is in part due to the fact that there is a general lack of consensus on what really causes rectal prolapse. As such, each operation is designed to address a particular aspect of the theory behind the cause of rectal prolapse.

The repair debate generally focuses on either abdominal or perineal repairs. The abdominal procedures, mainly open surgical options, are the focus of this chapter. The basic premise behind all of these approaches is to lift the rectum and fixate it to the sacrum in some sort of way to prevent recurrence. This may be combined with resection of a portion of redundant sigmoid colon, another potentially causative factor in creating the condition, which may also alleviate some of the constipation symptoms often seen in patients with prolapse.

The essential element in planning for surgery includes deciding on the proper approach to repair the prolapse. Perhaps making the decision of which operation to perform even more difficult, as seen in the recent review of the Cochrane Database relating to rectal prolapse. A massive review of the literature in this database found 12 randomized controlled trials relating to rectal prolapse surgery; one trial compared abdominal with perineal approaches for surgery; three trials compared different fixation methods; three trials reviewed division of lateral ligaments; one trial compared techniques of rectosigmoid resection; two trials compared laparoscopic with open surgery, and two trials compared resection with no resection and rectopexy. The reviewers concluded that there were insufficient data to determine whether abdominal or perineal approaches for rectal prolapse were better. They found no differences in the various techniques used for rectopexy, but did see lower recurrence rates with division of the lateral ligaments, although with increased incidences of constipation. Lower constipation rates were noted in patients who underwent segmental resection. In addition, laparoscopic cases had fewer complications and shorter hospital stays. This study was updated in 2015 by the same authors, this time reviewing just over 1,000 patients, divided among 15 randomized trials. Although such a comprehensive review made it very difficult to draw any specific conclusions because of the heterogeneity within the study population, some basic facts remained evident. Once again, it was noted that the patients undergoing laparoscopic repair had a shorter length of hospital stay with fewer complications compared to those undergoing open surgery. In addition, division of lateral ligaments resulted in lower rates of recurrent prolapse, but higher incidences of constipation and recurrence were seen more frequently in those patients undergoing simple rectal mobilization rather than with formal rectopexy. Formal sigmoid bowel resection resulted in lower incidences of constipation, and there was no difference in any of the types of fixation used for rectal prolapse. The authors concluded that because of the relatively small number of patients within the trials, no specific conclusions that would alter current practice guidelines could be made.

One publication attempted to demonstrate a clinical examination that may help determine whether a patient should undergo abdominal or perineal repair of the prolapse. These authors describe a “hook test” based on rectal examination to decide whether patients have a low-type of prolapse or a high type. They claim that better results may be obtained with a perineal procedure for low-type prolapses.

A single surgeon experience over 21 years evaluated and compared those patients with external rectal prolapse who underwent repair either perineally or transabdominally. He found that those undergoing an abdominal procedure had a significantly lower recurrence rate, an improved incontinence score, but a higher constipation rate. He concluded that one must consider the alternatives in repair and tailor them to the individual patient based on the presenting patient’s overall degree of fitness and functional disorders.

The addition of robotic surgery may lend some belief that abdominal procedures should be more strongly considered in treating rectal prolapse. A potential benefit of robotic surgery may be in improved visualization, especially upon pelvic dissection, better ergonomics, and surgeon comfort, as well as the ease of robotic suturing for the rectopexy portion of the procedure. However, a recent study comparing robotic to laparoscopic repair failed to show any statistically significant benefit of the robot over laparoscopy. Another study comparing robotic to laparoscopic ventral mesh rectopexy showed similar safety and efficacy between the two groups with no recurrences in either group. Yet another study comparing open, laparoscopic, and robotic procedures for rectal prolapse repair showed a lower incidence of recurrence in the open group, although all the groups collectively improved from a functional standpoint.

A study comparing laparoscopic to open rectopexy showed 5- and 10-year recurrence rates of 6.9% and 10.8% in the laparoscopic group, whereas there was only a 2.4% recurrence (one patient) in the open group. Again, these groups did not show any functional outcome differences.

As previously mentioned, if the patient is younger and generally fit, an abdominal procedure is ideal. Once this decision has been made, one must then choose which abdominal procedure to actually perform. A basic list of the procedures includes the following: