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

2. Open procedures for rectal prolapse

3. 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

4. Open operations for rectal prolapse Major colorectal procedures – Consultant and higher trainees Procedures for prolapse PerinealAbdominal JH 2002-2004281101 HST yr 619864 HST yr 619181 HST yr 48731 The realities – Yorkshire colon and rectal surgery

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

6. 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

7. 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

8. 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

9. Pelvic floor repair for prolapse

10. 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

11. 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?

12. 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

13. Anterior rectopexy

14. NMortality (%) Recurrence (%) Comments Gordon and Hoexter 1978 11114 (0.3)26 (2)Impaction 14, stricture 20 (1.8%) Morgan 1980642 (1.6)2 (3)Stenosis Launer 19825404 (7)Stricture 9 (17%) Holmstrom 19861083 (2.8)5 (4)Stricture 4 Tjandra 19931421 (0.1)10 (8)1/3 recurrences >10 yrs post op From Keighley and Williams 2001

15. 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

16. Posterior rectopexy

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

18. Sutured posterior rectopexy

19. Posterior rectopexy (suture only) NMortality (%)Recurrence (%) Loygue 19711462 (1.3)5 (3) Carter 19833200 Goligher 19845201 (2) Graham 1984231 (4.3)0 Blatchford 19894202 (5) Sayfan 19971900 From Keighley and Williams 2001

20. 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;81:904-906.

21. Division of lateral ligaments in mesh posterior rectopexy Lateral ligaments divided (n=14) Lateral ligaments preserved (n=12) PreopPostopPreopPostop Continence score 3242 Time straining (%) 54 1256 No. constipated 31067 Rectal prolapse 140126 Speakman et al. Br J Surg 1991;78:1431-1433

22. 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 1985:28:409-412

23. Resection Rectopexy

24. 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;28:96-102.

25. 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;77:143-145.

26. 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;501-507

27. 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

28. 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?)