Abdominal Approaches to Rectal Prolapse

Abstract

In his 1890 description of operative repair of complete rectal prolapse, Caddy used the following words to describe the physical appearance of his patient's rectal prolapse: "A complete prolapse of the rectum, six inches in length, and eleven inches in circumference. The mucous membrane, which was in numerous circular folds, was covered with slimy mucus, and was bleeding slightly at several small points." 1 With that description, it is easy to see that rectal prolapse, or rectal procidentia, is a morbid condition characterized by protrusion of the rectal wall through the anus. 2 Definition and AssociationsTrue rectal prolapse is the protrusion of all rectal layers through the anal sphincters. 3 The prolapse is classified by the degree of severity. The categories in order of decreasing severity include complete full-thickness rectal prolapse, mucosal prolapse, and internal or occult prolapse. 4 The leading clinical sign is the protrusion itself, with additional symptoms including constipation, sensation of incomplete evacuation, rectal bleeding, rectal pain, incontinence, urgency, and tenesmus. 5 Multiple associated findings on history and physical exam are seen in patients with rectal prolapse. A history of obstetric trauma or previous anorectal surgery is often present. Other associated abnormalities include spina bifida, prior back injury or surgery, psychiatric illness, old age, and female gender. Symptoms of fecal incontinence and constipation are reported in up to 75% and 25-50%, respectively, of patients with prolapse. 3 Patients often have other pelvic floor derangements including rectocele, cystocele, enterocele, and uterine prolapse, and a complete evaluation of constipation and prolapse should be performed. 6 Solitary rectal ulcer syndrome is directly related to rectal prolapse and is caused by injury and ischemia of the mucosa after internal prolapse of the rectal wall. 7 EtiologyThe cause of rectal prolapse is not completely understood and, like many poorly understood diseases, many procedures (more than 100) have been described for its treatment. The two accepted theories regarding the etiology of rectal prolapse involve either a sliding hernia that protrudes through a defect in the pelvic floor 7 or a circumferential intussusception of the upper rectum and rectosigmoid colon. 6 These theories are based on the anatomic defects associated with rectal prolapse: diastasis of the levator ani muscles, deep pouch Keywords ► rectal prolapse ► rectopexy ► mesh repair ► laparoscopy AbstractRectal prolapse is a debilitating condition with a complex etiology. Symptoms are most commonly prolapse of the rectum and pain with bowel movements or straining, with worsening fecal incontinence over time due to progressive stretching of the anal sphincters. Physical findings are fairly consistent from patient to patient-most notably diastasis of the levator ani muscles, deep pouch of Douglas, redundant sigmoid colon, a mobile mesorectum, and occasionally a solitary rectal ulcer. Evaluation includes a physical exam or im...

" Surgical options for full-thickness rectal prolapse: current status and institutional choice"

“…Ripstein’s procedure has been performed worldwide but has a significant morbidity rate [ 1 ]. Ways of modifying the mesh fixation, such as posterior wrapping and using a laparoscopic approach, have been described [ 86 ], but mesh-related postoperative complications, such as tissue erosion, infection, and mesh migration, are critical problems [ 75 ]. Abdominal rectopexy with sigmoid colectomy was developed by Frykman and Goldberg [ 34 , 35 ] and subsequent studies have evaluated the usefulness of sigmoidectomy [ 1 ].…”

“…Laparoscopic rectopexy is the most popular treatment in Europe. Surgeons in North America favored laparoscopic resection rectopexy in 2013 [ 74 ] and laparoscopic ventral rectopexy is currently far more likely to be performed in 2017 [ 75 ].…”

Tension-free vaginal mesh operation for concomitant rectal and uterine prolapse: A case report

“…The benefit of the abdominal methods is a lower recurrence rate; however, they require general anesthesia and are suitable for low-risk patients. 2 Perineal methods have a higher recurrence rate, but are minimally invasive surgeries, have lower operative morbidity, and (in men) present minimal to no risk of erectile dysfunction. 3 There is much debate over whether abdominal methods or peritoneal methods are best, but there is no consensus.…”

Assessment of incidence of recurrence and constipation in patients of rectal prolapse undergoing rectal mobilization only with division of lateral stalks

“…8 Theirsch's anal encirclement operation was described in 1891, In 1900, Delorme's mucosal sleeve resection was described and later in 1933, Miles performed rectosigmoidectomies. 9 Perineal approaches have lower morbidities but have higher recurrence rate and high incidence of postoperative incontinence. Novel abdominal approaches to rectal prolapse repair also began to proliferate during the first half of his century.…”