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

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

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

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

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

6. Complications of prolapse include:
Ulceration

7. Complications of prolapse include:
Strangulation

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

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

10. 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

11. 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

12. 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

13. 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)

14. 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

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

16. Elective Presentation : Operative Treatment

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

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

19. Perineal Procedures : Delorme Procedure

20. Perineal Procedures : Delorme Procedure

21. Perineal Procedures : Delorme Procedure

22. Perineal Procedures : Delorme Procedure

23. Perineal Procedures : Delorme Procedure

24. Perineal Procedures : Perineal Proctosigmoidectomy (Altemeier Procedure)

25. 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:
Wexner, Cleveland Clinic Florida; Archieves of Surgery; Jan 2005; 140,1

26. 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

27. Sutured Rectopexy

28. 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

29. Anterior ventral rectopexy

30. Posterior Rectopexy Wells operation

31. 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

32. Resection rectopexy (Frykman-Goldbery procedure)

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

34. 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%

35. 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

36. 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