Editing Rectal prolapse


A full-thickness, circumferential intussusception of the rectal wall

* Can also be partial

== '''Epidemiology''' ==

* Uncommon - 0.5% of population

== '''Risk factors''' ==

* Women >50yo (women make up     90% of patients)
* Prior pelvic surgery
* Chronic straining and     constipation
* Chronic diarrhoea
* Vaginal delivery
* Multiparity
* Pelvic floor defects
* Neurologic disease/injuries
* Men tend to get it <40yo     when they get it - uncommon
* Young patients with prolapse     often have psychiatric conditions (autism/developmental delay) and take     constipating medications

== '''Pathophysiology''' ==

* Not completely known
* Commonly-found anatomic     defects in patients with prolapse:
** Diastasis of levator ani
** Abnormally deep cul-de-sac
** Redundant sigmoid colon
** Patulous anus
** Lack of fascia attachments      of the rectum against the sacrum
* Theories:
** Sliding hernia through      defect in pelvic fascia (Moschowitz)
** Circumferential      intussusception of rectum (Broden and Snellman)
* Varies in severity from     intra-rectal or internal rectal prolapse to external rectal prolapse
* Usually has a progressive     course from transient self-reducing prolapse during defecation, to     prolapse requiring digital self-reduction, to stable prolapse that may     present with ulceration and even non-reducible incarcerated prolapse with     necrosis in some cases
* Differentiate full-thickness     vs partial-thickness. Partial thickness is just mucosa and usually looks     similar to haemorrhoids, in that it is linear rather than concentric     folds.

== '''Presentation''' ==

* Sensation of external tissue     after defecation (or continuously)
* Rectal bleeding/mucus     discharge after defecation, especially with chronically incarcerated     prolapse
* Faecal incontinence (due to     impaired anorectal sensation) - 50-75%
* Tenesmus
* Constipation
* Urinary incontinence
* Pudendal neuropathy seen in     50%
* There are case reports of     incarcerated and even strangulated rectal prolapse, but this seems to be     very rare, and occurs in the setting of a giant prolapse that has reached     venous strangulation due to being incarcerated. If it can be reduced, it's     not strangulated.
** If the prolapse cannot be      reduced or there is mucosal necrosis, need emergency resection of the      prolapsed rectum, possibly meaning Altemeier's perineal      rectosigmoidectomy

== '''Examination''' ==

* Look initially in lateral     decubitus, but best way to diagnose is with the patient sitting on a     commode and bearing down
* Often have a patulous anus     and diminished resting tone and squeeze pressures
* Differentiate from prolapsed     rectal mucosa or prolapsed haemorrhoids - radial mucosal folds, possibly     with grooves along haemorrhoid cushions. A complete prolapse has circular     folds.
* Consider proctoscopy to look     for rectal ulcer (seen in 15%). Often see erythema at 5-6cm which is the     leading edge of the prolapse.

== '''Workup''' ==

# Exclude     cancer - colonoscopy (always)
# Is it reproducible     clinically?
## Defecography      can identify occult prolapse, and document coexisting disorders      (rectocoele, cystocoele, vaginal vault prolapse, enterocoele,      sigmoidocoele)
# Constipation workup if     indicated (see separate topic)

== '''Complications''' ==

* Solitary rectal ulcer (15%)

== '''Initial management of painful, symptomatic prolapse''' ==

* Sugar (lots), either sit in     it or place gentle pressure on muscle, and it will reduce over an hour or     so
* Salt can also be used

== '''Medical''' ==

* Avoid dehydration, stool     bulking agents and softeners - but this is not a solution
* Enemas or suppositories can     help with evacuation

== '''Surgery''' ==

=== '''Goals:''' ===

** Narrowing of anal orifice
** Obliteration of the PoD
** Restoration of the pelvic      floor
** Decreased rectosigmoid      redundancy
** Fixation of rectum to sacrum

=== '''Choice of     approach''' ===

** Abdominal approach is      preferred, if the patient is a surgical candidate
*** If pre-existing       constipation: ventral mesh rectopexy +/- resection (if there is a       redundant sigmoid colon - generally the only situation where resectional       procedures are used)
*** No constipation: Ventral or       posterior rectopexy
*** Incontinence: posterior       rectopexy
** Unfit for abdominal      approach/anaesthetic
*** Short segment (1-3cm):       Delorme's
*** >3cm: Altemeier's

=== '''Abdominal     approach - lap or open rectopexy''' ===

** Rationale is to fix the      rectum to provide adequate upwards tension to prevent a recurrence, but      allow adequate evacuation during defecation
** Recurrence rate <5%
** '''Ventral      rectopexy +/- mesh:''' expose the sacral promontory just inferior to iliac vessels,      mobilise the rectum anteriorly down to pelvic floor, suture the rectum to      a mesh or suture, and suspend the suture/mesh from the sacral promontory.      Consider closing peritoneum again to prevent SBO/pelvic adhesions.

* '''Posterior     rectopexy (Wells procedure):''' Mobilise the rectum posteriorly or both posteriorly and     anteriorly. The lateral stalks are preserved to avoid constipation except     in patients with faecal incontinence. This is followed by fixation of the     rectum to the sacral promontory with sutures or mesh.
*
* '''Anterior     mesh rectopexy (modified Ripstein procedure):''' anteriorly-based mesh sling     for fixation of the rectum to the sacral hollow
* '''Resection     rectopexy:''' Mobilise     sigmoid colon and rectum, resect a segment of the sigmoid, anastomose the     remaining colon to the rectum, and suture the rectum to the sacral     promontory.
* '''Fixation:''' 
** Suture or mesh are      appropriate
** Suture: use non-absorbable      e.g. 0 Ethibond to form horizontal mattress sutures in presacral fascia,      at or just below the level of the sacral promontory, but only on one side      of the rectal mesentery
** Mesh: Can use either      non-absorbable or biologic mesh with seemingly no difference in      complication or recurrence rates

=== '''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

== Recurrence ==

* Repeat surgery is high-risk     for developing ischaemia, after having the blood supply messed with     previously
* Therefore need to know     previous operations in detail

[[Category:Colorectal]]