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Evidence Based approach to RectalProlapse
Dr T V Aditya Chowdary
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Complete rectal prolapse (procedentia) –
Circumferential full thicness descent of the
rectum outside the anus
Pathophysiology of rectal prolapse - DISTALINTUSSUSCEPTIN of the rect!m
Associated "actors
!ea levator ani and anal sphincter muscles"
A redundant rectosi#moid colon
A deep cul$de$sac
%oss of &'ation of the rectum to the sacrum
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Complete rectal prolapse (procedentia) –
Circumferential full thicness descent of the
rectum outside the anus
Pathophysiology of rectal prolapse - DISTALINTUSSUSCEPTIN of the rect!m
Associated Conditions
(ental llness *fourfold ris)
connective tissue disorders
pelvic outlet o+struction
pelvic ,oor la'ity spina +i&da
multiple sclerosis
cystic &+rosis
anore'ia and +ulimia nervosa
e'cess strainin#
Clinical "eat!res(ass PRBleedin#Constipation – -. /
Diarrhea $$ 01 /ncontinence – .2 /
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A#dominal Approach
Rectope'y
Ripstein
!ells
Resection
Resection Rectope'y
3uywan
Perineal Approach
Perineal
Proctosi#moidectomy $
Altaemeier
Anorectal (ucosectomy
!ith (uscular Plication$
Delorme
Anal Encirclement $
Therisch
(ana#ement
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Preoperative worup
Document +aseline anorectal anatomy and function prior to repairAnal manometry
4ltrasono#raphy
Pudendal nerve terminal motor latency
Dvorin %5" Chan C%" 6nowles C7" et al8 Anal sphincter morpholo#y in patients with full$thicness rectal prolapse9 Dis ColonRectum :.80;
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C@TR@VER5E5 54RCA%APPR@AC7
either the type of procedure *intra$a+dominal
versus perineal) nor the approach *open versus
minimally invasive) has +een identi&ed as optimal
• 5uture or mesh rectope'y
• Anterior or posterior mesh wrap
• Rectope'y alone or with si#moid resection
• E'tent of pelvic dissection and division of the lateral li#aments
• Anterior versus posterior mo+iliation
• Perineal approach in youn# men to spare ris of pelvic nerve
inury
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A+dominal Vs Perineal
Recurrence Rates
A+dominal 2/ to 1 / " Perineal 02/ – 01/
The perineal procedures are #enerally reserved for the most elderly
and frail" particularly those who are not candidates for either anopen or laparoscopic approach
• Clar CE" upiter DC" Thomas 5" Papaconstantinou9 Rectal Prolapse in the Elderly8 Trends in 5ur#ical(ana#ement and @utcomes from the American Colle#e of 5ur#eons ational 5ur#ical Fualitymprovement Pro#ram Data+ase9 AC5 =20=G=018.2;9
• 5ur#ical mana#ement of rectal prolapse9 (adi+a TE" Bai# (6" !e'ner 5D Arch 5ur#9 =221
anG0:2*0)8-H$.H
• Comor+id illnesses that preclude an intra$a+dominal procedure
• 3ailed previous intra$a+dominal rectal procidentia repair procedure
• Prior pelvic sur#ery
• Prior pelvic radiation therapy
• Ioun# males" in order to minimie the ris of erectile dysfunction9
There is little" if any" ris of dama#e to the hypo#astric nerves with
the perineal procedures9(ahmoud 5A" @mar !" A+del$Elah 6" 3arid (9 DelormeJs Procedure for 3ull$Thicness Rectal ProlapseGDoes it Alter Anorectal 3unction9 ndian 5ur# =20=G .:8H
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5uture Vs (esh Rectope'y
A single centre comparati$e st!dy of laparoscopic meshrectope%y $ers!s s!t!re rectope%y – & ' Sahoo A 6
Thimme#owda" (ano 5 owda (inim Access 5ur#9 =20: an$(arG 02*0)8 0
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Anterior vs PosteriorRectope'y
• Recurrence rates for anterior and posteriorrectope'y are similar9
• Rate of stricture and postoperative constipation
$ posterior < anterior rectopexy
01/ e'perience new onset constipation and 12/ have worsenin#
of constipation with rectopexy alone
"!nctional res!lts of operati$e treatment of rectal prolapse o$er an ,,-yearperiod emphasis on transa#dominal approach+Aitola PT0" 7iltunen 6(" (atiainen (9 Dis Colon Rectum9 0;;; (ayG:=*1)8-11$-29
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Resection Alone
Anterior resection alone – associated with hi#herrecurrence rates and si#ni&cant operative andpostoperative mor+idity
Recurrence rate ;/
Deterioration of continence has +een reported in 02–
=2/
Schlin.ert R T" Beart R ! r" !olK B " Pem+erton 79
Anterior resection for complete rectal prolapse9 Dis Colon
Rectum 0;
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Resection with sacral &'ation
Advanta#e of removin# e'cess +owel andrestorin# the normal rectal an#ulation9
This approach improves symptoms of +othincontinence and constipation9
&ado/ RD" !illiams " !on# !D" et al Long-termf!nctional res!lts of colon resection and rectope%y foro$ert rectal prolapse9 Am J Gastroenterol
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%ateral stal (o+iliations
Division of the lateral stalls will allow for +etter
rectal mo+iliation and &'ation and prevent
recurrence +ut at a cost of worsenin#constipation
Spea.man CT" (adden (V" icholls R" et al Lateralligament di$ision d!ring rectope%y ca!ses constipation#!t pre$ents rec!rrence 'es!lts of a prospecti$e
randomi0ed st!dy+ Br J Surg .
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%ap Vs @pen
(inimally$invasive *e#" laparoscopic" laparoscopic$
assisted" or ro+otic$assisted) colon and rectal procedures
have the advanta#es of reduced postoperative pain"
early return of +owel function" and shortened len#th of
hospital stay
()occasanta ,1123 Solomon 45546
• %ap L @pen
•
Better 3unctional results short term
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Delo'es trial st!dy protocol for arandomi0ed trial comparing t*o standardi0eds!rgical approaches in rectal prolapse -
Delorme7s proced!re $ers!s resectionrectope%y
=20= Au# =;G0H80119 doi802900