Editing Rectal prolapse (section)

=== '''Perineal     approach''' ===

** Typically reserved for more      comorbid patients
*** Less pain, earlier return       of bowel function and walking than abdo operations
*** Was thought to have higher       recurrence rates, but systematic reviews have shown similar rates
** Prolapse is resected but      without concomitant fixation
** '''Delorme's      procedure (mucosal sleeve resection)'''
*** Good for patients with a       short (<3-5cm) prolapse
*** Recurrence up to 20%
*** Technique
**** GA or spinal
**** Prone jacknife or        lithotomy position
**** Pull prolapse out and        apply lone star retractors
**** Inject a lot of adrenaline        in the submucosal plane
**** Circumferential incision        in mucosa 1cm proximal to dentate line (or as low as can be reached -        if the leadpoint is a bit higher, it's hard to pull the prolapse out        far enough to get this low).
**** Submucosa and mucosal        layers are dissected with diathermy from muscularis up to the most        proximal part of the prolapse/apex
**** Excise stripped mucosa
**** 4-8 parallel longitudinal        plicating sutures to join the two distant mucosal edges and also bunch        up the intervening muscle - use PDS, place all the circumferential        sutures, then push the prolapse back in and tie them one by one
**** Can also do separate        bunching muscularis sutures and then separate mucosal anastomosis        sutures
*** Cx:
**** Overall safe with short        hospital stay
**** Bleeding
**** Anastomotic leak
**** Stricture
**** Diarrhoea
***
** '''Stapled      transanal rectal resection'''
*** Primarily for internal       intussusception or partial thickness prolapse
*** Use circular stapler to       essentially do the same thing as Delorme's procedure
*** High rate of complications       - not recommended
** '''Perineal      proctosigmoidectomy (Altemeier's procedure)'''
*** GA/spinal
*** Lithotomy
*** Prolapse exteriorised and       grasped with Allis clamps
*** Score 1cm above dentate       line
*** Infiltrate with saline/LA       and adrenaline
*** Full-thickness       circumferential incision made through the rectum 1cm above the dentate       line - until you see external aspect of the inner layer of rectal       prolapse, including dividing mesorectum circumferentially
*** Continue dissection       proximally along the rectum, detaching it from the mesorectum and       attachments until the peritoneal cavity is entered in the pouch of       Douglas (keep pulling down - combination of blunt dissection and       LigaSure, particularly anteriorly)
*** Palpate sigmoid via the       peritoneal cavity to assess how much redundant sigmoid is present, and       identify a proximal transection margin (basically assess how much can       come down to the planned perianal anastomosis)
*** Transect at rectosigmoid       junction and hand off specimen
*** Levator muscles visualised       - can be plicated posteriorly
*** Handsewn or stapled       colo-anal anstomosis
**** Single layer, interrupted        2/0 Vicryl