This technique was described in 1900 by the French military surgeon Edmond Delorme. It involves stripping the mucosa of the prolapsed rectum (sparing the muscular tube). A circular incision starts about 1 cm cephalad to the dentate line (to safeguard the internal anal sphincter). The submucosa is infiltrated with a diluted adrenaline solution, which facilitates the dissection. By placing interrupted sutures around the circumference, the muscle layer is plicated; this reduces the prolapse above the anal canal. The mucosal sleeve covers the plication and is anastomosed to the anal canal (Fig. 12.3).

This technique is better adapted to treat smaller rectal prolapses. A modified technique has been proposed, adding a postanal repair to reduce the enlarged hiatus [11].

In contrast to the Delorme procedure, a full-thickness resection of the prolapse is performed (rectum, rectosigmoid) with a coloanal anastomosis (Fig. 12.4). The prolapse is everted and a full-thickness incision is performed 1.5 cm above the dentate line.

Opening the pelvic pouch allows the surgeon to palpate in order to determine whether a redundant loop of sigmoid colon should be resected. All mesenterial vessels should be ligated with care. The colon should reach the line of anastomosis without any tension. Septic complications and suture-line dehiscence are rare, probably because of the weakness of the remaining sphincter.

Perineal procedures are indicated in frail, old patients with extensive morbidity. Smaller prolapses can be treated by Delorme mucosectomy. In larger prolapses, a perineal resection with dorsal levatorplasty is advisable. In the rare scenario of an incarcerated and gangrenous rectal prolapse, a perineal resection is indicated; abdominal rectopexy cannot be performed.

In young, healthy, male patients the use of a Delorme procedure is certainly worth considering because it avoids the risk for pelvic autonomic nerve injury.

This technique was first described by Cutait [19] in 1959. Nonresorbable sutures are used to fix the mesorectum of the elevated rectum to the presacral fascia and sacral promontory.

This procedure is also referred to as the “Frykman-Goldberg procedure” [20] and is still very popular in the United States. The procedure was initially intended to reduce the recurrence rates of suture rectopexy by resecting the redundant sigmoid colon. It significantly reduces the incidence of postoperative constipation, but adding a resection potentially increases the risk for complications.

In the original Wells procedure [21], a polyvinyl alcohol sponge (Ivalon) was inserted posterior to the mobilized mesorectum to stimulate inflammatory adhesion-fixation of the bowel to the presacral fascia. Later the same procedure was performed using polypropylene or Teflon mesh (Fig. 12.5).

In the Ripstein procedure [22], an anterior sling of fascia lata or synthetic material is positioned in front of the rectum and sutured to the sacral promontory. To overcome the risk of bowel obstruction, a modified technique (McMahan-Ripstein) [23] includes a posterior fixation of the mesh to the presacral fascia; the lateral mesh is anteriorly sutured to the rectum, deliberately leaving an anterior gap (Fig. 12.5).

In the so-called Orr-Loygue procedure [24, 25], lateral fixation (using either fascia lata strips or synthetic material) between the elevated rectum and the sacral promontory at both sides of the rectum is performed. This is done after full mobilization of the rectum.

Laparoscopic ventral mesh rectopexy (LVR) was first described by D’Hoore and Penninckx [26]. The laparoscopic dissection is limited to the anterior aspect of the rectum (rectovaginal septum), avoiding the risk of autonomic nerve damage. A synthetic mesh is sutured to the anterior aspect of the rectum to avoid further intussusception and fixed to the sacral promontory. If the uterosacral ligaments are lax, they can be hooked to the same mesh. Any descent of the vaginal vault can be restored by performing a colpopexy using the same mesh. The peritoneum is closed over the synthetic mesh to elevate the neo-Douglas and to avoid further adhesion to the mesh. The unique position of the mesh further reinforces the rectovaginal septum. It therefore can be used in the presence of a complex rectocele (Fig. 12.6).

The same procedure can be performed in male patients. Dissection is limited to the level of the seminal vesicles, and no attempt is made to dissect posterior to the prostate. Care should be taken to avoid any damage to the hypogastric nerve at the site of the sacral promontory.

Based on the safety of the technique (conversion to laparotomy rate of 2.9 %), a low long-term recurrence rate, and favorable long-term functional outcomes (low de novo constipation), LVR emerges as an efficient procedure for the treatment of patients with total rectal prolapse. It has gained wide acceptance as the procedure of choice in Europe.