Open Approaches for Rectal Prolapse John Hartley Academic Surgical Unit University of Hull

Open procedures for rectal prolapse

Open operations for rectal prolapse Perineal operations inferior to abdominal procedures, but definite role Delorme’s procedure – simple but high recurrence rate, can be repeated Perineal rectosigmoidectomy – more complex but lower recurrence rate “If the patient is fit enough and life expectancy > 5yrs abdominal approach preferred” Keighley and Williams 2 nd Edition 2001

Open operations for rectal prolapse Major colorectal procedures – Consultant and higher trainees Procedures for prolapse PerinealAbdominal JH HST yr HST yr HST yr The realities – Yorkshire colon and rectal surgery

Open operations for rectal prolapse A range of possibilities: Exclusion procedures Pelvic floor repair Anterior or posterior rectopexy Resection – alone or with rectopexy

Open operations for rectal prolapse Sigmoid exclusion procedure (Lahaut’s operation) Rectum fully mobilised in pelvis Rectosigmoid sutured to posterior rectus sheath Sigmoid extra-peritonealised behind rectus muscle

Open operations for rectal prolapse Lahaut’s operation 33 pts 1 death (3%) No recurrences 11 of 12 pts improved continence One faecal fistula (?ischaemic) One obstruction Mortensen et al Ann R Coll Surg Engl 1984:66:17 18

Open operations for rectal prolapse Pelvic floor repair via the abdomen Full anterior and posterior mobilisation of the rectum Repair of pelvic floor posterior (originally ant and post) to rectum Difficult access Pelvic floor thin and attenuated Largely replaced by rectopexy

Pelvic floor repair for prolapse

Results of abdominal pelvic floor repair for prolapse AuthorsProcedureNMortalityRecurrence (%) Comments Snellman 1961Ant. repair4204 (10) Porter 1962Ant. Repair46023 (50) Kupfer and Goligher 1970 Post. Repair6315 (8)Mucosal recurrence Klaaborg et al 1985 Post. repair2303 (13) Hughes and Gleadell 1962 Ant and post. Repair 8415 (6) From Keighley and Williams 2001

Open procedures for rectal prolapse Rectopexy Probably the operation of choice Recurrence rates approx. 2% Continence restored in 60-80% with rectopexy alone How should rectum be fixed? When should resection be added?

Open operations for rectal prolapse Anterior rectopexy (Ripstein procedure) Full mobilisation of rectum Fixation to sacral promontary by sling (polypropylene, teflon or fascia) Principle complication – fibrous stricture

Anterior rectopexy

NMortality (%) Recurrence (%) Comments Gordon and Hoexter (0.3)26 (2)Impaction 14, stricture 20 (1.8%) Morgan (1.6)2 (3)Stenosis Launer (7)Stricture 9 (17%) Holmstrom (2.8)5 (4)Stricture 4 Tjandra (0.1)10 (8)1/3 recurrences >10 yrs post op From Keighley and Williams 2001

Open operations for rectal prolapse Posterior rectopexy Posterior aspect of fully mobilised rectum attached to sacrum Lateral peritoneum divided, posterior mobilisation to tip of coccyx, division of lateral ligaments No anterior restriction, distensible rectum Mesh to sacrum and lateral aspects rectum

Posterior rectopexy

Method of fixation Teflon Polypropylene (marlex) Polyvinyl alcohol sponge (Well’s procedure) - infection (recurrence) Vicryl Gore-Tex SIMPLE SUTURES

Sutured posterior rectopexy

Posterior rectopexy (suture only) NMortality (%)Recurrence (%) Loygue (1.3)5 (3) Carter Goligher (2) Graham (4.3)0 Blatchford (5) Sayfan From Keighley and Williams 2001

Prosthetic vs suture posterior rectopexy (no resection) Ivalon sponge (n=31)Sutures alone (n=32) Hospital stay (days)14 (8-52)14 (8-50) Mortality00 Complications6 (19%)3 (9%) Recurrent prolapse1 (3%) Late postop incontinence6/102/10 Postop constipation15 (48%)10 (31%) Novell et al. Br J Surg 1994;81:

Division of lateral ligaments in mesh posterior rectopexy Lateral ligaments divided (n=14) Lateral ligaments preserved (n=12) PreopPostopPreopPostop Continence score 3242 Time straining (%) No. constipated Rectal prolapse Speakman et al. Br J Surg 1991;78:

Open operations for rectal prolapse Resection alone Sigmoid or partial rectal resection (n=113) Incontinence: - Improved 23 (20%) - Same 13 (11%) - Worse 10 (9%) Sepsis morbidity: 52% after “low” and 19% after high anastomosis Recurrence at 10 yrs 14% after “high” and 9% after “low” resections Schlinkert et al Dis Colon Rectum 1985:28:

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:

Rectopexy +/- Resection Preop status and outcomeMarlex rectopexy (n=16) Rectopexy and sigmoidectomy (n=13) Incontinent preop129 Unchanged or worse33 Continence restored96 Constipated preop35 Unchanged or worse31 Constipation improved04 Normal bowel habit preop138 Unchanged98 Became constipated40 Sayfan et al. Br J Surg 1990;77:

Rectopexy +/- Resection Constipation (%)Incontinence (%) PreopPostopPreopPostop Rectopexy (n=129) 47 (36)42 (33)48 (37)25 (19) Resection rectopexy (n=18) 12 (67)2 (11)5 (28)3 (17) Tjandra et al. Dis Colon Rectum 1993:36;

Open Approaches for Rectal Prolapse Summary Lower recurrence rates but higher morbidity than perineal procedures Fixation superior to pelvic floor repair, or resection alone Posterior fixation superior results Sutures alone comparable to mesh fixation Less constipation with concomitant resection

Open Approaches for Rectal Prolapse Conclusions Sigmoid resection with sutured rectopexy offers: Low risk of recurrence The long term avoidance of constipation PROCEDURE OF CHOICE (why not laparoscopically?)