A Prof of colorectal surgery Prof/ Walid Elshazly A Prof of colorectal surgery

Classification of rectal prolapse: Partial: prolapse of rectal mucosa only

Classification of rectal prolapse: Complete: prolapse with all layers Grade 1: occult prolapse

Classification of rectal prolapse: Complete: prolapse with all layers Grade 2: prolapse to but not through anus

Classification of rectal prolapse: Complete: prolapse with all layers Grade 3: any protrusion through anus

Complications of prolapse include: Ulceration

Complications of prolapse include: Strangulation

Complications of prolapse include: Urinary and fecal incontinence Spontaneous rupture with evisceration

Partial Rectal Prolapse 1-4 cms PROTRUSION of rectal mucous membrane and submucosa outside the anus. Common in Extremes of life Children Elderly

Partial Rectal Prolapse Predisposing Factor- Infants Underdeveloped Sacral Curve low Anal Sore Predisposing Factor- Children Diarrhoea Whooping Cough Loss of Weight Predisposing Factor- Adults Haemorrhoids Prolonged straining Perineal Tears  Females Secondary to Surgery  Damage to Sphincter

Investigation in Elective Case Finding ppt. factor At least a flexible sigmoidoscopy Assessment of surgical risk (no effective nonoperative treatment) Anorectal manometry, pudendal nerve test Predicts functional outcome after surgery

Treatment In children (partial or complete) Alleviate straining due to constipation or diarrhea (tenesmus) Construct regular bowel habits Strap the buttocks together after defecation after spontaneous or manual reduction Build up the body of the child and fat reservoirs Use sclerosant injection (phenol in almond oil for submucous injection in partial prolapse and alcohol for retrorectal injection in complete prolapse) In case of failure one of the operations described is resorted to

Treatment In partial prolapse mucosal hemorroidectomy will often suffice to deal with the condition, recently Longo’s procedure (PPH stapler is used to induce anal lift and refixation of the prolpased mucosa back to the rectum and anal canal)

Operations of prolpase The choice of the operation depends on Degree of prolapse present Associated disorders (cystocele, rectocele, incontinence or constipation) Co-morbid conditions (spinal cord lesion, mental or psychic problems or vital system problems) The main symptoms of presentation Goals are Resection of redundant colon Fixation of the rectum to the sacrum Improving symptoms of fecal incontinence and constipation

Aim of treatment Primary objective Secondary gain Eradicate the prolapse improve the quality of life Secondary gain Improvement in continence and bowel function

Elective Presentation : Operative Treatment

Perineal Procedures Thiersch Procedure Delorme Procedure Considered obsolete nowadays! Delorme Procedure The minimum you should do! Altemeier Operation (Perineal Proctosigmoidectomy)

Perineal Procedures : Delorme Procedure Mortality 0-4% Recurrence 4-38% (St Marks 12.5%) Good for short prolapse Can be repeated if necessary

Perineal Procedures : Delorme Procedure

Perineal Procedures : Delorme Procedure

Perineal Procedures : Delorme Procedure

Perineal Procedures : Delorme Procedure

Perineal Procedures : Delorme Procedure

Perineal Procedures : Perineal Proctosigmoidectomy (Altemeier Procedure)

Perineal Procedures : Perineal Proctosigmoidectomy (Altemeier Procedure) Mortality 0-5%; complication: pelvic sepsis, leakage Recurrence 0-16% Best if combined with posterior levatorplasty Ideal for incarcerated and strangulated ones Difficult to perform for small prolapse Deen KL Br J Surg 1994:81: 302-304 Wexner, Cleveland Clinic Florida; Archieves of Surgery; Jan 2005; 140,1

Abdominal Procedure Rectopexy Laparoscopic Vs Open Sutured Rectopexy Prosthesis or Mesh Rectopexy Anterior ventral rectopexy Posterior rectopexy Wells operation Resection rectopexy (Frykman-Goldbery procedure) Laparoscopic Vs Open

Sutured Rectopexy

Abdominal Procedure : Sutured Rectopexy No reported mortality Recurrence (majority 0-8%; ranges 0-27%) Variable response to constipation Posterior mobilization to tip of coccyx Division of lateral ligaments on either sides

Anterior ventral rectopexy

Posterior Rectopexy Wells operation

Abdominal Procedure : Prosthesis or Mesh Rectopexy Makes use foreign material to evoke more fibrous tissue reaction, examples Anterior Sling Rectopexy Ripstein Procedure Posterior Mesh repair e.g. Wells Operation Problems: Increased pelvic sepsis and rectal strict

Resection rectopexy (Frykman-Goldbery procedure)

Abdominal Procedure : Resection Rectopexy Add 1% to mortality Recurrence 0-5% Majority has improved constipation

Abdominal Procedure : A Comparison Sutured Rectopexy Mesh Resection Recurrence 0-8% 0-13% 0-5% Mortality 0% 0-2.8% 1-4% Complication rare 8-52% Up to 30% Continence improve Constipation variable Up to 42%

Laparoscopic Approach Rectopexy (sutured, stapled, posterior mesh, resection) Recurrence 0-10% As effective as open ( no long term difference) Benefit Shorter post-op hospitalization Overall reduction in cost Earlier recovery Less morbidity Earlier return to work Laparoscopic approach is desirable because of Benign nature of the condition Patients are often at high surgical risk for laparotomy

Choice of Operation : Individualized Abdominal procedures are ideal for young fit patient and provide best chance of cure Sutured rectopexy gives good result Combination of a resection reduce constipation Laparoscopic approach provides similar results with less morbidity Perineal procedure for frail patients with extensive co-morbidity, not fit for major abdominal surgery Perineal rectosigmoidectomy, combined with levatorplasty gives better result than Delorme’s operation