Rectal prolapse

Section: Colorectal Sub-section: Proctology Curriculum: Curriculum, page 19

Definition

External protrusion of the rectum through the anus

1. Mucosal
2. Full thickness

Investigation

Proctography

Risk factors

• Elderly women
• Connective tissue disorders e.g. Marfans, Ehler’s Danlos syndromes
• History of anorexia nervosa (due to poor cross-linking of collagen fibres in pelvic floor during adolescence)
• High BMI
• High birth weight during vaginal deliveries

Mucosal

• Can occur in isolation or with obstructive defecation syndrome and solitary rectal ulcer syndrome.
• Symptoms: perianal discomfort, passage of mucus or blood, constipation and straining

Treatment:

• Conservative: bulking agents, fibre, improving toileting technique.
• Surgical: banding, sclerotherapy, surgical excision or plication, RFA

Full-thickness

Conservative measures may improve symptoms, but usually need definitive surgery. Various approaches

• No difference in recurrence rate but all high rate. All associated with improvement in quality of life.

Definition

Operative management

Choice of procedure should take into account:

• Pelvic floor integrity
  • Presence of concurrent genital prolapse
  • History of pelvic floor injury
• Bowel function
  • Constipation
  • Difficulty evacuating
  • Incontinence

Perineal approach

Delorme’s procedure

• Good for elderly patients.
• Can be done under a spinal or even local anaesthetic.
• Is a mucosal proctectomy and muscularis plicating procedure
• Typically done in lithotomy with a lone-star retractor.
• Sponge forceps is used to pull the prolapse out, and guide the upper limit of resection.
• The mucosa is dissected off the underlying muscle and excised.
• The muscle layer is plicated (all the numbers of the clock face).
• The mucosa is re-approximated
• There is approximately a 30% recurrence rate but it can be repeated.

Altemeier’s procedure

• Can be described as a perineal rectosigmoidectomy.
• Is done where there is full thickness prolapse
• Can be done where there is ischaemia of the bowel wall (which would preclude a Delormes procedure)
• Patient placed in lithotomy.
• Prolapse is brought out through the anus.
• All layers are then excised, mesenteric vessels are ligated.
• Trans-anal coloanal anastomosis is then performed.
• Recurrence rate of 10%
• Does remove the rectum (or most of it) thus can have isses with capacity which can be another cause of faecal incontinence.
• Also has risk of anastomotic leak and pelvic sepsis.

Abdominal approach

Rectopexy - Rectal mobilisation and fixation to sacrum with either sutures or mesh.

• Posterior
  • Ivalon sponge (Wells’ procedure
  • Fascia lata (Orr Loygue operation)
  • Non-absorbable mesh
• Anterior
  • Anterior mesh slingaround rectum to sacrum (Ripstein’s procedure)
  • Ventral mesh rectopexy (VMR)
• Resection rectopexy (Frykman Goldberg procedure)
  • Sigmoid colectomy with handsewn or stapled anastomosis at sacral promontory.
• Can get worsening constipation, evacuatory difficulties or faecal incontinence following abdominal rectopexy.
• Division of lateral ligaments associated with lower recurrence rates but inconclusive on outcomes of postoperative constipation.

Laparoscopic ventral mesh rectopexy

• Laparoscopic approach with dissection along the right lateral aspect of the rectum
• Create a plane between the rectum and the vagina.
• Piece of mesh is sutured onto the front of the rectum, and side of the rectum.
• The top of the mesh is sutured to the top of the sacral promonentry which hitches the rectum up.
• Benefits – avoid posterior and lateral dissection which avoids dissection of the parasympathetic nerves (involved in rectal distension sensation)
• Non-absorbable polypropylene mesh is used.

Laparoscopic

• Fewer complications and shorter LOS Ventral mesh vs posterior suture
• No difference in recurrence rates, functional outcomes or complication rates.
• Increased colonic transit time for both, but significantly higher for posterior suture Recurrence:
• Limited evidence on best approach.