Surgical Treatment of Rectal Prolapse

Introduction

Rectal prolapse is a condition where part of the rectum is protruded out of the anus. When the rectal wall is prolapsed but not protruded, it is called internal rectal prolapse or a rectal intussusception (part of the intestine drops into an adjacent part of the intestine). When there is a protrusion of rectal mucosa, it's called mucosal prolapse. Women are most commonly affected, and 50 percent of affected women are over 70.

What Is the Etiology of Rectal Prolapse?

The etiology of rectal prolapse includes

• Rectal intussusception is where the rectal mucosa, 6 to 8 cm from the anal verge, becomes the top point, and intussusception is developed. It is aggravated by excessive straining for a long time.

• Anatomical abnormalities include redundant (loss of function) sigmoid colon, diastasis of the levator ani (a muscle that supports the pelvic visceral structures), a deep cul-de-sac, and the lack of rectal-sacral attachments.

• Perineal nerve injury, which causes the weakening of pelvic muscles, the injury can be due to excessive straining or vaginal delivery.

• Other causes such as old age, which causes the weakening of muscles.

What Are the Symptoms of Rectal Prolapse?

The symptoms of rectal prolapse are:

• Discomfort of prolapsing tissue.

• Constipation.

• Hemorrhage.

• Mucus discharge.

• Fecal incontinence.

• Tenesmus (urge to pass stool even if bowels are empty).

• Red mass, which hangs outside the anus.

• Pain in the anus or rectum.

What Are the Complications of Rectal Prolapse?

The complications of rectal prolapse are:

• Urological impairments, such as bladder stones or urethral stricture (narrowing of the tube of the urethra due to scarring).

• Bladder prolapse.

• Uterine prolapse.

What Is the Diagnosis of Rectal Prolapse?

The diagnosis includes:

• Patient’s history.

• Inspection of protrusion shape in case of complete collapse.

• Cinedefecography (diagnostic test of muscles that control bowel movement), in case of incomplete prolapse or occult prolapse.

• Anorectal physiology tests, such as anal manometry (it evaluates the function of rectal and anal muscles), electromyography (it evaluates the health of muscles and nerves), or colonic transit time measurement, are also used.

What Is the Treatment of Rectal Prolapse?

The goal is to control the prolapse, prevent constipation and restore controlling the movement of the bowel. Conservative treatment includes medications reducing edema, and constipation, electric stimulation, exercises straining the perineum(area between the genitals and anus), injection of a sclerosing agent, or rubber band ligation. Treatment of rectal prolapse can be done only by surgery, through the abdominal approach or perineal approach; the perineal approach includes:

• Thiersch Procedure: A perineal approach in which a prosthesis (sutures, nylon, teflon, or silicon rubber materials) is used to narrow down the anus. It is done under local anesthesia. In most cases, it is performed in combination with another perineal approach. It is suitable for patients with old age or high risks.

• Delorme Procedure: A perineal approach in which the inner lining of the bulged prolapsing bowel is removed, and the exposed rectal muscular layer is plicated and sutured. It has a high recurrence rate because the rectum is not attached to the sacrum. Complications can occur, such as bleeding, wound dehiscence (separation of the wound edges), stenosis (narrowing), and hematoma (collection of blood outside the vessel).

• Perineal Sigmoid Colon-Rectal Resection: Also called the altemeier procedure, is a perineal procedure in which the prolapsed or protruded rectum, along with the redundant anterior peritoneum upto sigmoid colon, is resected two centimeter above the dentate line (one-third below the surgical anal canal). Then the colon is attached to the anus with either absorbable interrupted sutures or a stapler device. Next, and simultaneously, levatorplasty (pelvic floor muscles are stitched together) is done. Complications such as bleeding and pelvic abscess due to suture failure can occur.

• Gant-Miwa Procedure: It is a perineal procedure where the protruded rectum is plicated using a nylon wire. It is sutured 20 to 40 times as a bean shape, and by using a prosthesis anal opening is narrowed. A five millimeter ligation interval is done to prevent mucosal ulcers.

The abdominal approach is used for extensive bowel dissection and fixation. It is classified according to the location or method used:

• Rectopexy: Itis the simplest abdominal procedure, in which the rectum is pulled and is fixed to the sacrum or the fascia using a nonabsorbable suture called suture rectopexy, and adhesion occurs by fibrosis. When a mesh (fascia lata polypropylene, polyvinyl alcohol, and poly tape) is used, it is called prosthetic rectopexy. If the area between the sacrum and rectum is narrowed, constipation occurs; therefore, one to two centimeters of space should exist between them, and if a part of the anterior wall of the rectum is exposed, it is called an anterior sling rectopexy (Ripstein operation). If a prosthesis (absorbable materials, such as vicryl or dexon) is inserted into the space between the sacrum and the posterior rectum, it is called a posterior prosthesis rectopexy. A surgeon should remove it in case of pelvic sepsis due to the prosthesis.

• Laparoscopic Surgery: Using laparoscopy, fixation, and dissection procedures can be done. In this procedure, a keyhole incision is made near the belly button, a laparoscope is introduced, and other small incisions are made to insert the instruments. Next, the sigmoid colon and rectum are located, the rectum is lifted and sutured to the fascia, or a mesh is used. In some cases, the surgeon may remove a part of the sigmoid colon, and after the procedure, incisions are closed.

The advantages are less postoperative pain, early recovery, low morbidity, low recurrence rate, and superior cosmetic results. Various procedures are done using laparoscopy, it includes:

• Laparoscopic Suture Rectopexy: Rectum is fixed to the sacrum using sutures.

• Mesh Rectopexy: Rectum is fixed to the sacrum using mesh. It can be placed anteriorly, called laparoscopic anterior mesh rectopexy, posteriorly called as laparoscopic lateral mesh rectopexy, laterally called laparoscopic posterior mesh rectopexy, or around the rectum.

• Laparoscopic Resection Rectopexy: After mobilization of the rectum, it is elevated, and sutures are tied before the bowel resection and attached after colorectal anastomosis. It is indicated in patients with elongated sigmoid colon with significant constipation.

Conclusion

Rectal prolapse usually occurs in aged people and should seek immediate treatment. If not treated, it can lead to ulceration, strangulation of the blood supply, or gangrene. Laparoscopic procedures have a low rate of recurrence than the perineal approach. An individualized approach is recommended considering age and underlying anatomical and functional disorders.