When considering the Ripstein procedure for repair of rectal prolapse, it is important to realize that it is classically performed as an open transabdominal procedure. Given its infrequent use in today’s repertoire for rectal prolapse repair, there are little minimally invasive surgical outcome reports. Although there are severe complications associated with transperineal or transabdominal techniques, an abdominal approach does have substantially more infectious issues. As described, patient factors including age, ASA class, BMI > 25, prealbumin level < 2.5 must be taken into account when selecting patients for abdominal approaches such as Ripstein repair. Patients with multiple medical comorbidities may not tolerate an abdominal procedure or general anesthesia, and therefore some would advocate for transperineal repairs in the frail elderly patient. This recommendation is however historical and good level I evidence to support transperineal approaches over abdominal approaches for rectal prolapse is lacking.

Patients must undergo a complete physical examination with appropriate laboratory tests including a thorough anorectal examination to assess the integrity of the sphincter complex and pelvic floor musculature. The incidence of incontinence in patients who present with rectal prolapse is about 50% and thought to be secondary to stretching of the anal sphincter leading to trauma of the sphincter itself. It is imperative to demonstrate full-thickness rectal prolapse in the office. If patients are unable to demonstrate prolapse on the examination table, they should be asked to sit and strain over the toilet or commode for several minutes. The average prolapse extends beyond 4 cm from the anal verge, and over 30-50% of patients tend to have a lax anal sphincter on digital rectal examination.

A proctosigmoidoscopic examination should be performed on all patients. Women should be assessed for rectocele, enterocele, or other pelvic prolapse, in which combined repair may be required. Approximately 5% of patients have a solitary rectal ulcer and the presence of polyps or obstructing masses should be excluded. Rectal ulcers are thought to be the result of repeated mucosal trauma and resultant ischemia. It can, however, be confused with rectal cancer, which must be biopsied to exclude neoplasia.

Defecography may be useful in patients who are unable to demonstrate full-thickness prolapse in the office. However, the prolapse can often be produced in a more rapid cost-effective manner by having the patient feign evacuation while seated on a toilet. In many instances, patients would present with rectal intussusception that is defined as a circumferential descent of the entire thickness of the rectal wall, which might extend into the anal canal, but not through the anal verge. It was originally thought that internal rectal intussusception was a precursor to prolapse; however, many studies have shown these patients to be asymptomatic, rarely progressing to rectal prolapse. Not surprisingly, these patients have not shown the same functional improvements after repair, including after the Ripstein procedure.

The second most frequent complaint relates to bowel dysfunction, either incontinence or constipation. As mentioned, the incidence of incontinence is quite large in patients with rectal prolapse. The etiology can be unclear, with most instances caused by chronic stretching of the anal sphincter leading to trauma of the sphincter itself. The extent of the impact of rectal prolapse on sphincter function can be difficult to assess, especially in regard to predicting postoperative continence. Surgical treatment in these patients could affect the sphincter by removing the mechanical dilator or rectal distension that causes functional inhibition. Schultz et al. reviewed anorectal manometry as a predictor for improved continence after the Ripstein procedure. When maximum resting pressure (MRP) was measured preoperatively, 7 days and 6 months postoperatively, it was found that there was no change at 7 days, but an increase in MRP was seen at 6 months. Although the study demonstrated improved anal continence, the role of anal manometry itself has not been found to have any predictive value in determining which incontinent patients would regain continence.

Many studies have also looked at the incidence of constipation in these patients, with reports suggesting rates ranging from 15% to 65% in patients with rectal prolapse. In these patients, the Ripstein procedure has been shown to make constipation worse by decreasing the number of bowel movements. As such, it has been recommended that patients with rectal prolapse and constipation should not undergo Ripstein repair. However, the procedure may be best chosen for patients with incontinence and for those with an enterocele in addition to rectal prolapse or rectal intussusception.

Secondary data supporting modified Nichols preparation for all colorectal surgical cases have recently been published. It is for these reasons that many surgeons recommend both complete oral cathartic
mechanical and oral antibiotic bowel preparation before surgery. All patients should undergo some bowel preparation in the event low anterior resection is indicated and to facilitate intraoperative endoluminal evaluation.