Rectal prolapse, surgical options: An overview

and Delorme’s operation

Ashok kumar

Department of Surgical Gastroenterology, Sanjay Gandhi Post Graduate Institute of

Medical Sciences, Lucknow

RECTAL PROLAPSE

• It is a full thickness rectal intussuception ~3inches above dentate line and extending beyond anal verge

• Rectal prolapse occurs most often at extremes

of life e.g, in children between 1-5 years of

age and elderly people. More common

in female than male

• Young male patients tend to have psychiatric disorders

Types of rectal prolapse

Partial or incomplete prolapse when the mucous

membrane lining the anal canal protrudes through

the anus only

Complete prolapse in which the whole thickness

of the bowel protudes through the anus

Grading of rectal prolapse:

• Grade 1: occult prolapse

• Grade 2: prolapse to but not through anus

• Grade 3: any protrusion through anus

Rectal prolapse can be distinguished from

prolapsed incarcerated internal

hemorroids by the characteristic

concentric folds of rectal prolapse and

by the painless reduction if not

incarcerated.

Anatomic abnormalities associated with

rectal prolapse

1. Deep rectovaginal or rectovesical pouch

2. Lax pelvic floor musculature

3. Failure of normal relaxation of the

external sphincter

4. Redundant sigmoids

Risk factors for rectal prolapse

• Chronic constipation

• Diarrhea

• Mental Retardation

• Female sex

Presentation

Prolapse is first noted during defecation

Discomfort during defecation

Bleeding

Mucous discharge

Irregular bowel habit --incontinence

Complications of prolapse

• Ulceration

• Infection

• Hemorrhage

• Thrombosis and edema

• Strangulation

• Urinary and fecal incontinence

• Spontaneous rupture with evisceration

SURGICAL OPTIONS

A. Abdominal approach

Rectopexy (lockhaurt)

Rectosigmoidectomy (Mikulicz’s op.)

Resection rectopexy

Ivalon sponge rectopexy (Well’s op.)

Ripstein operation

Low anterior resection

B. Perineal approach

Thiersch’s operation

Proctosigmoidectomy (Altemeier)

Delorme Operation

Choice of operation

Patient’s factors

Age

Sex

Medical condition

Extent of prolapse

Bowel function

Status of fecal continence

Choice of operation

Procedure related factors

• Extent of surgery

• Morbidity of procedure

• Recurrence rate

• Impact on bowel function

• Surgeon’s familiarity with procedure

Surgical Options

Perineal procedures

Elderly, high-risk patients

Regional or even local anesthetic

Constipated patients

resection and rectopexy

Incontinent patients

abdominal rectopexy

perineal resection with levatorplasty

Anterior rectopexy

RIPSTEIN OPERATION

Posterior rectopexy

IVALON SPONGE

Sutured posterior rectopexy

Posterior rectopexy (suture only)

N Mortality (%) Recurrence (%)

Loygue 1971 146 2 (1.3) 5 (3)

Carter 1983 32 0 0

Goligher 1984 52 0 1 (2)

Graham 1984 23 1 (4.3) 0

Blatchford 1989 42 0 2 (5)

Sayfan 1997 19 0 0

From Keighley and Williams 2001

Resection Rectopexy

Resection Rectopexy

Aims to achieve low recurrence rates and avoid long term constipation

University of Minnesota series

138 pts

Anastomotic leaks in 5 (4%)

Recurrent prolapse in 2 (1.4%)

Continence improved in all but 1 pt

Constipation improved in 56% same in 35% worse in 9%

Watts et al. Dis Colon Rectum 1985;28:96-102.

Transabdominal rectopexy

Are associated with problems with defecation and

constipation

Have a lower recurrence rate than transperineal

approaches

Require resection of the redundant sigmoid

Perineal Procedures

Perineal rectosigmoidectomy (Altemeier)

Morbidity 5-24%

Recurrence rates from 0-10%

Rectal mucosal sleeve resection (Delorme)

Morbidity 0-30%--hemorrhage, dehiscence, stricture,

diarrhea, urinary retention

Recurrence rates 7-22%

Perineal suspension-fixation (Wyatt)

Anal encirclement (Thiersch + modification)

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Thiersch Procedure

Delorme operation

Perineal rectosigmoidectomy is

appropriate for:

1. Younger patients who want to minimize

recurrence

2. Patients with a grade 3 prolapse protruding at

least 3 cm

3. Patients who are poor candidates for trans

abdominal surgery

Delorme Operation

(mucosal sleeve resection)

Described by Rene Delorme in 1900

• Stripping of the mucosa

• Plication of denuded bowel

• Re-anastomosis of the mucosa

Evaluation

• Clinical examination (DRE)

• Defecography

• Anal Manometry

• Colonoscopy/ barium enema

• Colonic transit study

Preop preparation

• Bowel preparation-PEG

• Perioperative antibiotics

• Indwelling Foley’s catheter

Position of the patient

• Lithotomy

• Prone jackknife

• Left lateral ( Simm’s)

Anesthsia

• General

• Regional

• Local with intravenous sedation

Delorme’s procedure

Only mucosa and submucosa are excised

Submucosa infiltrated with epine. solution

Mucosa incised 1cm proximal to dentate

Mucosa and submucosa dissected off

underlying muscle

Continues to apex of prolapse then

mucosa transected

Placating sutures are placed in the muscle

Mucosa is re-approximated

Delorme: T-incision

mucosal dessection

Delorme –dissected off mucosa

Delorme –plicating sutures

Delorme-reduced prolapse

within the pelvis as a bulbous plug

Complications

• Hemorrhage

• Hematoma

• Wound dehiscence

• Sepsis

• Stricture

Results