Rectal Prolapse

Tracy Hull

Giovanna Da Silva Southwick

Perioperative Considerations

Rectal prolapse is a clinical diagnosis, as most patients present with a protruding “mass” that may spontaneously reduce or stay continuously prolapsed (Fig. 47-1).

FIGURE 47-1 ▪ Prolapsed rectum and initial exposure. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)
In severe (and rare) cases, patients may present with incarcerated or strangulated prolapse that requires emergent treatment.
Prolapse is more than an anatomical problem, as most patients have associated functional abnormalities, such as incontinence, constipation, and outlet obstruction.

Rectal prolapse repairs are plagued, in part, by high recurrence rates despite technical success.
Perineal rectosigmoidectomy (ie, Altemeier) involves the full-thickness excision of the rectum and potentially a portion of the sigmoid colon, followed by a coloanal anastomosis just proximal to the levators.
- The procedure is associated with relatively high rates of postoperative morbidity (up to 32%) and recurrence (up to 26% with prolonged follow-up).
- Functional outcomes may persist, including incontinence, soilage, and urgency—largely due to the loss of the compliant rectum along with a reduction in resting anal sphincter pressure.
The Delorme procedure involves stripping the mucosa of the prolapsing rectum from the sphincters and muscularis propria, followed by plication of the muscularis propria and reanastomosis of the mucosal ring.
- Recurrence rates range from 4% to 38%.
- Fecal incontinence can be seen up to 75% of patients, while 15%-65% of patients have concomitant constipation or evacuation disorders.
Abdominal approaches involve mobilization of the rectum and fixating it to the sacrum.
- Abdominal mobilization classically involves a predominately posterior mobilization with limited anterior and lateral dissection.
- Mesh may be used to aid in fixation to the sacrum.
- The addition of a sigmoidectomy is classically reserved for patients with severe constipation and a large redundant sigmoid colon.
Complications in the operating room typically occur in <5%.
- Most common is bleeding and hematoma.
- Bleeding is often self-limiting, although it may require takeback and oversewing. Pelvic sepsis, although rare, can occur.
- Other postoperative complications include hemorrhage, fecal impaction, deep space infections, anastomotic leak, urinary tract infections, surgical site infections, and respiratory infections.
- Late postoperative complications include bowel obstruction, ureteral fibrosis, rectovaginal fistula formation and worsening, or new fecal incontinence or constipation and recurrence.

Patient Positioning

The patient is placed in modified lithotomy. Legs are held in Yellowfins lithotomy position, giving the option to the surgeon to stand/sit between the legs for perineal procedures as well as for perineal access for abdominal procedures.
Alternatively, for the perineal procedures, a prone position may be preferred.
Patient should be well secured to the operative table, and body parts are well padded, and joints properly positioned as patient will be in steep Trendelenburg for the majority of the operative procedure when abdominal procedures are performed.
An orogastric tube is inserted as well as a Foley catheter, which comes out under the patient’s right leg.
The primary working monitor is on the patient’s left side or at the leg for abdominal minimally invasive procedures.
Patients are given a full bowel preparation, including oral antibiotics and perioperative intravenous (IV) antibiotics.

Equipment

Abdominal

Laparoscope with 0- and 30-degree camera
10-mm conventional laparoscopic port
5-mm ports ×3
10- to 12-mm conventional laparoscopic port for suturing (or stapler for cases with a sigmoidectomy)
Standard minimally invasive instrument tray
Large-pore, soft, lightweight mesh (optional)
Laparoscopic mechanical tacker (optional)
Bipolar energy device (optional)
Sutures
- Synthetic monofilament absorbable 3-0 suture
- 0-braided nylon nonabsorbable suture (for pexy)
- 2-0 polyglycolic acid, waxed suture
End-to-end sizers
Wound protector (if resection is performed)
Balfour retractor (optional, used if open approach)

Perineal

Anal eversion sutures or Lone Star retractor
Electrocautery
Bipolar energy device (optional)
2-0 and 3-0 Vicryl sutures

Anesthesia

General anesthesia is typically utilized.
Complete muscle relaxation is necessary for effective insufflation and laparoscopic visualization.
Epidural anesthesia is unnecessary. Pain is generally well controlled using multimodal analgesia with transversus abdominis plane perianal block, and oral and IV analgesia.

DELORME PROCEDURE

Technique

Anal eversion sutures or a Lone Star retractor is placed to provide exposure (Video 47-1).
The prolapse is grasped with a Babcock clamp(s) and exteriorized.
The mucosa is scored ˜1-3 cm proximal to the dentate line, and the initial incision is performed.
Infiltration of the submucosa with epinephrine-based local anesthesia (1:200 000) to separate it with the underlying muscle may facilitate dissection and reduce bleeding.
The mucosectomy/submucosectomy is continued circumferentially and proximally in an avascular plane, leaving a circular muscular tube (Fig. 47-2).

FIGURE 47-2 ▪ Continued proximal dissection in the submucosal plane. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)
Evert the mucosal/submucosal sleeve and continue the dissection proximally until unable to do so.
Plication sutures (˜8) are placed longitudinally in a circumferential manner with 2-0/3-0 Vicryl sutures or 2/0 polydioxanone (PDS) and tied down to bring the muscle together in an accordion manner (Fig. 47-3).
The excess mucosa/submucosa is resected and passed off to pathology.

FIGURE 47-3 ▪ Circumferential plication sutures. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)

FIGURE 47-4 ▪ Mucosal closure over the plication sutures. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)
The mucosa is reapproximated over the plication to create the handsewn anastomosis with 3-0 Vicryl sutures (Fig. 47-4).
Alternatively, 2/0 PDS sutures are placed at the edge of the anoderm and proceeding distally toward the apex and finishing with a suture through the colonic mucosa. As the sutures are tied, the muscle cuff is easily reduced and the edges of the mucosa approximated.