RECTAL PROLAPSE - 1

Procidentia: circumferential, full thickness protrusion of rectal wall thru anal orifice intussusception of rectum Categorized: occult (internal) mucosal (no muscularis layer) complete (external) Epidemiology: extremes of age Pediatric: o diagnosed by age 3 o 20% children with Cystic Fibrosis o equal gender Adult o peak after 5th decade o women 80-90% Natural history: Internal to complete Solitary rectal ulcer (result of internal prolapse of anterior rectal wall, injury or ischemia) Outlet constipation with urgency, straining sensation of incomplete evacuation Incarceration, strangulation uncommon Persistent: sphincter destruction, incontinence, mucous discharge, rectal bleeding, pruritis ani Associated: obstetric trauma prior anorectal surgery spina bifida back surgery psychiatric illness rectal bleeding pruritis ani not related to parity, nulliparity Pelvic floor o History of: constipation, incontinence, anatomic defects, rectoceles, enteroceles, cystoceles, uterine/vaginal prolapse, Fecal incontinence: 28-88%, cause or effect Nerve injury: pudendal Muscle injury: sphincter 182

Associated with duration of disease

Constipation: 15-65%, straining Anterior: solitary rectal ulcer, Posterior: loose sacral attachments, Colonic inertia Etiology: 2 theories: Sliding hernia Moschcowitz 1912 deep rectovaginal pouch or rectovesical pouch herniation of SB into the ant. wall of rectum push rectum down, deep cul-de-sac Circumferential intussusception of upper rectum/rectosigmoid Broden and Snellman 1968 describe both 6-8cm up rectum, increase with straining Anatomic features: Deep cul-de-sac Intussusception Absent fixation of rectum to the sacrum Redundant rectosigmoid Weakness of pelvic floor Rectocele Presentation: depend on type and degree Chronic constipation Fecal incontinence Anal discharge Rectal bleeding Evaluation: PMHx:DM, meningomyelocele, spina bifida, spinal injury, cauda equina, lumbar disk disease, spinal cerbral tumors, MS, diabetic neuropathy PSHx: Obstetrical surgery, hysterectomy, pelvic support defects PE: o Perineal skin, anal sphinter defects/strength, rectocele, enterocele, o Standing after straining, pruritus ani, scars, o Cutaneous sensation, anocutaneous reflex Colonoscopy, BE: neoplasms, stenosis, ulcers, inflammatory lesions, lead point Occult blood Colonic inertia: if fiber/fluids/stool softeners not therapeutic, transit study, defecating proctogram, small bowel contrast 183

Surgical disease - Goals: resection /plication redundant colon fixation of rectum to sacrum narrowing anal orifice obliterate pouch of Douglas restoration of pelvic floor improving sx Perineal 1. Thiersch encirclement or loop: o encircle anus with silver wire loop, mesh or nonabsorbable suture o local regional anesthesia o incision in perineal skin right anterior and left posterior position o blunt dissection, ischiorectal fossa enter laterally to external sphincters o pass curved clamp from one incision to the other o suture tied snuggly around index finger o advantages: local anesthesia o disadvantage: prolapse persists internally not fix anatomic abnormality failure rate up to 80%, severe constipation, fecal impaction, infection erosion, tenesmus, lump, incomplete evacuation, wound infection Strangulation risk with recurrent prolapse 2. Altmeier rectosigmoidectomy: o 1889, Mikulicz o regional or general anesthesia o external full thickness prolapse o prolapse as far as possible, submucosa epinephrine injection o incision 1.5cm proximal to dentate line, carried full thickness o posteriorly and laterally rectal vessels o 15-30cm of sigmoid resected o levatorplasty, 2-3 sutures through the levator ani and puborectalis, post o hernia sac amputated, suture to ant sigmoid wall o amputate prolapsed sigmoid, anastomosis interrupted absorbable suture. o Advantages: low complication, anastomosis, incontinence exacerbated because resection reduces capacity to expand 3. Delorme procedure: o shortening mucosal length, creating fibrosis in the plicated rectal muscle, o regional anesthesia, submucosal injection of epinephrine o mucosa 1-1.5cm above dentate line incised circumferentially o dissected from underlying muscle, continue until not able to pull mucosa further, plicate rectal muscle vertically in 4 quadrants, o excess mucosa excised, interrupted mucosa to mucosa anastomosis o Advantages: safe, 46-75% improved incontinence, no worsening of constipation

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4. Plication of rectal mucosa: o 3 or 4 quadrant plication, start anteriorly, repairing rectocele, o epinephrine submucosally, ellipse of rectal mucosa excised o dissect mucosa free from muscle, undermind defect 1cm both sides, o vertically plicate rectal muscle o close mucosa over muscle plication with runing stitch o repeated in further 2-3 quadrants, 5. Gant procedure: o mucosal prolapse o multiple rubber band ligations of redundant mucosa o inciting inflammatory response, thickening and scarring Abdominal: 1. Ripstein: o intussusception due to loss of rectal attachment to sacrum o fix rectum to sacrum with mesh wrap, no resection o posterior mobilization of rectum to tip of coccyx o division of upper portion of lateral stalks, rectum retracted cephalad o 5cm wide piece of mesh sewn to sacrum o wrapped around and sutured to ant wall of rectum o severe postop constipation, partial wrap 2. Frykman: o mobilization and sacral fixation o plication of the levator ani o segmental resection of sigmoid colon o less constipation postop 3. Ivalon sponge wrap: o Rectopexy with polyvinyl alcohol sponge o posterior to rectum wrapped partially around the bowel o mobilize rectum posteriorly proximal to lateral rectal stalks o sponge sutured to sacrum and wrapped around posterior and lateral o constipation high post op (48%), ? denervation lateral stalk 4. Sigmoid resection: o descending colon junction o into pelvis to rectosacral ligament o lateral rectal stalks preserved o rectum adheres to sacrum

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5. Rectopexy: o suspend rectum, with posterior rectal mobilization, o rectopexy temporary while adhesions form to presacral fascia, Perineal: Higher recurrence rates Low complication rates Less invasive nature Abdominal: More closely approximate normal anatomy Repair of associated disorders Lower recurrence rates Greater improvement of incontinence and constipation Higher complication rates Laparoscopy: rectopexy Results: recurrence incontinence or constipation complication rates simultaneous repair of other defects Decide: surgeons preference training age comorbidities functional status

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