RECTAL PROLAPSE

DR ANAS AHMADPGR – SURGICAL UNIT 2

SHALAMAR HOSPITAL- LAHORE

RECTAL PROLAPSE

FULL THICKNESS PROLAPSE

INTERNAL INTUSSUCEPTIO

N

MUCOSAL PROLAPSE

FULL THICKNESS PROLAPSE/ PROCIDENTIA

● Full-thickness protrusion of the rectum through

the anal sphincters

● Protrussion consists of all layers of rectal wall

● 4-15 cm in length

● More common in females. Female to male ratio

6:1

● Commonly associated with prolapse of uterus

● A “falling down” of the rectum so that it’s out of

the body

INTERNAL PROLAPSE/INTUSSUSCEPTION

● Occult rectoanal

intussusception

● Prolapse does not protude

from the anus

MUCOSAL PROLAPSE

Protusion of the rectoanal mucosa

MUCOSAL VS FULL RECTAL PROLAPSE

MUCOSAL VS FULL RECTAL PROLAPSE

Difference Between Rectal Prolapse and Hemorrhoids

Rectal Prolapse Hemorroids

Tissue Folds Circumferential Radial

Abnormality on Palpation

Double Rectal Wall

Hemorrhoidal Plexus

Resting and Squeeze Pressures

Decreased Normal

Difference Between Rectal Prolapse and Hemorrhoids

PATHOPHYSIOLOGY

INFANTS

Undeveloped sacral curve

CHILDREN

Attack of diarrhoea

ADULTS

Constipation (component of colonic dysmotility)

Weakening/malfunctioning of pelvic floor/sphincters

Anismus – spastic pelvic floor

Pudendal neuropathy (obstetric injuries, aging)

Sphincter dysfunction (trauma, aging)

Clinical Features

♦ Mucus Discharge

♦ Rectal Bleeding

♦ Soilage

♦ Feeling of incomplete evacuation

♦ Diarrhea

♦ Itching

Clinical Features

♦ Children: first three years (male=female)● Cystic fibrosis, malnutrition, diarrhea, severe cough, parasites

♦ Adults: majority are eldery female

● Females >50 – 6 times more likely than males ● 2/3 are multiparous

● Mental illness (depression, autism)● Neurologic disorder● Connective tissue disorder● Constipation and straining

Clinical Features

♦ Constipation is associated with prolapse in 30%-70% of pts

♦ Chronic straining, sensation of anorectal blockage, need of digital evacation

♦ 60% have coexisting incontinence ● Stretching of anal sphincters ● Impaired rectal compliance

♦ 20-35% have associated urinary incontinence

NON OPERATIVE MANAGMENT

Treat constipation Fiber supplements Stool softeners

Digital repositioning in infants and young children

Sub mucosal injection of 5% phenol in almond oil

Reduce incarcerated rectal prolapse Table sugar

Surgical Treatment♦ Mainstay in treatment of rectal prolapse

♦ Over 100 procedures♦ In infants and young children rectum is sutured to sacrum in prone jack-knife position.♦ In adults with unilateral prolapse, redundant mucosa is excised or, if circumferential, an endoluminal stapling technique can be used.

Full thickness prolapse:

♦ Perineal procedures● Resection, reefing, and encirclement

♦ Abdominal procedures● Fixation, colon resection or combination of both

Choosing Type of Surgery

♦ Abdominal● Recurrence low (<10%)● ↑ constipation 50% ● Higher M & M esp.

with anastomosis ● Mesh placement – stricture, migration, erosion, infection

♦ Perineal● Recurrence (20%) ● Constipation rate unchanged● Persistent incontinence worse rate due to removal of rectal resevoir ● Correction of associated abnormalities (rectoceole, sphincter)● No pelvic dissection – preserves sexual function

Perineal Procedures

♦ Perineal Proctosigmoidectomy – Altemeier

♦ Mucosal Sleeve Resection - Delorme

♦ Anal Encirclement - Thiersch Wire Technique ♦ Perineal suspension/fixation - Wyatt

Altemeier Procedure

Delorme Procedure

Delorme Procedure

Delorme Procedure

Thiersch Procedure

Abdominal Procedures

♦ Anterior rectopexy or Ripstein procedure/ sutured rectopexy

● Anterior wrapping of the rectum and fixation to sacrum ♦ Goldberg rectopexy/ resection rectopexy:

(Ant rectopexy+sigmoid resection) ♦ Posterior rectopexy - Wells procedure

● Synthetic mesh ● Sutures alone

♦ Sigmoid colectomy with sutured rectopexy

● Low recurrence ● Low morbidity ● Improves constipation

Ripstein Procedure

Ripstein Procedure

Laparoscopic Rectopexy

♦ Largely replacing open abdominal procedures

♦ Ease of performing rectopexy and colon resection simultaneously with shorter hospital stay

♦ Morbidity and mortality no different than open controls

♦ Recurrence rate lower but not statistically significant

Lap ventral mesh Rectopexy

Purpose of surgery : to correct prolapse, protect or

restore continence and avoid constipation

Correct middle compartment prolapse too

Dissection from sacral promontory avoiding nerves

Deep part of fold of Douglas retracted and incised

Polypropylene mesh sutured to anterior aspect of rectum and fixed to sacral promontory (Loosely)

Posterior vaginal suture

Further rectal sutures

Closure of peritoneum

Rectopexy +/- Resection

♦ Rectopexy with resection - Multiple papers ● Improvement in continence and constipation ● Mortality – 0-6.7% ● Recurrence – 0-5%

♦ Rectopexy without resection - Wilson et. Al ● 9% recurrence at 48 month f/u● 17% severe constipation managed by laxatives

Conclusions

♦ Consider surgery when conservative therapy fails

♦ Careful pt selection is crucial to satisfactory outcome

♦ Tailor surgery to the specific pt

♦ Laparoscopic rectopexy allows for quicker recovery

and shorter LOS but similar recurrence

♦ Regardless of material used, correct suture and tack

placements are crucial

♦ If severely constipated, perform sigmoidectomy

♦ Pts care as much about continence and constipation

Any questions??

THANK YOU