During the 19th and 20th centuries, different perineal approaches were proposed for the treatment of external rectal prolapse, and despite the high recurrence rate of the prolapse they were preferred to the abdominal approach. In recent decades, the improvement in general anesthesia and perioperative care, and the widespread use of laparoscopic techniques, have enabled the abdominal approach to become more common, as it is believed to carry a lower recurrence rate and probably better functional results.

However, the perineal approach to rectal prolapse has not been abandoned altogether, and it is usually indicated in elderly, high-risk, frail patients for emergency incarcerated external prolapse [1] and gangrenous rectal prolapse [2], and it is often preferred to the abdominal approach in the USA because it is less invasive and results in a shorter length of hospital stay [3].

Perineal rectosigmoidectomy to treat external full-thickness rectal prolapse was first described by Altemeier in 1952 [4]. The procedure consists of a perianal rectosigmoidectomy, followed by a coloanal anastomosis, which is hand-sewn or stapled, and associated with a levatorplasty. It is indicated in symptomatic patients with an external prolapse exceeding 5 cm, which has an important impact on the quality of life because of bleeding, mucus discharge, and fecal incontinence.

Antibiotics and antithrombosis prophylaxis are indicated in the perioperative period. Preoperative bowel cleaning is also suggested. The anesthesia can be epidural (this is suggested because of fewer complications); general or local anesthesia have also been used by some surgeons. Patients can be placed in a lithotomy or jack-knife position; the latter is preferred because of its better and safer view of the operating field.

Using a Lone-Star self-retractor, the anal canal and the dentate line become more evident and the full-thickness rectal prolapse can be exteriorized with Babcock forceps. A mark is made with diathermy on the prolapsed mucosa to identify the dissection line; this line should be far enough away from the internal anal sphincter (5–6 cm from the anal verge) so that if a stapled anastomosis is planned it can be performed safely without the inclusion of the internal anal sphincter fibers.

The dissection is performed circumferentially by diathermy, including all the layers of the rectal wall, mobilizing all the extraperitoneal rectum, and sealing all the mesorectal vessels (with diathermy, ultrasound, or radiofrequency) close to the viscerum where they enter the posterior part of the rectum. When all the extraperitoneal rectum has been mobilized, the pouch of Douglas is opened and the peritoneal cavity can be explored. The dissection continues following the sigmoid wall, until the colon can be exteriorized without tension.

A posterior levatorplasty can be performed before resecting the colon, as this procedure is believed to decrease recurrence rate [5]. The levator ani muscle is exposed through the self retractor, and two or three nonabsorbable interrupted stitches (2-0 Prolene) are applied to its posterior plication. The sutures should allow a finger to be passed easily through the colon and the plicated muscle. Reclosure of the pouch of Douglas or the peritoneum is not strictly necessary.

The rectal wall is then cut anteriorly and a first absorbable stitch (3-0 Vicryl) is passed from the colonic wall to the anal canal, including both mucosa and muscle layers. The same action is repeated laterally, in the same way, leaving the posterior rectal wall as the last place to fix, after complete resection of the elongated colon. At least other two stitches are then apposed between each cardinal point in the same way. An excessive number of stitches or an uninterrupted suture could lead to stricture of the coloanal anastomosis.

During performance of the anastomosis, care should be taken to prevent contamination of the pouch of Douglas by stool. Once the hemostasis is controlled and the anastomosis is completed, the colon can be replaced inside the peritoneal cavity.

The coloanal anastomosis can be made by a circular stapler (31, 33, or 34 mm): a purse-string with nonabsorbable stitches (2-0 Prolene) is made on the proximal colonic wall where the head of the stapler is placed and another pursestring is fashioned on the anorectum around the stapler. After the introduction of the stapler into the anus, the sutures are narrowed and tied, and the device is activated and withdrawn. The resected sample should include about 1 cm of colon and anorectum. A hemostatic sponge can be left into the anus.

There is no need for postoperative medication, and postoperative analgesics can be delivered at the patient’s request; antibiotic prophylaxis is suggested for up to 2–3 days postoperatively, and oral feeding can be resumed after 1–2 days [4].

The overall complication rate ranges between 0% and 13% [6–96], and most complications are minor. Rare major complications reported include pelvic hematoma, anastomotic dehiscence and stricture, sigmoid perforation, pararectal abscess, and strangulated ileus trough transcoloanal anastomosis [10]. The mortality rate is relatively low (0–6%) [11–13] despite the inclusion of elderly frail patients in the case series, probably because of the mini-invasive approach of the procedure, the shorter hospital stay, and early mobilization.

The major drawback of Altemeier’s procedure is the high recurrence rate; the medical literature reports a wide range of recurrence from 0% to 58% [14–19], regardless of technical details and length of follow-up. Recurrence usually occurs in the first 2 years postoperatively, although the definition of recurrence is still not clear, because in some studies the presence of a minimal mucosal prolapse is also considered to be a recurrence. Most authors report a recurrence in about 10–20% of cases [12–13, 20]. A few authors [21, 22] have reported a lower recurrence rate (about 5–6%), but the sample size was too small (18 and 41 patients) and the follow-up period was too short (10 months) to produce meaningful results; in other studies with a larger sample of patients and longer follow-up, the reported recurrence rate was 14% and 18%, regardless of the length of the colon resected or the levatorplasty [7, 23].