Prolaps Recti

= intussusception of the rectum

- May be categorized as:
Mucosal:

protrusion of the mucosa only the muscular layers of the rectum remaining in place.

Complete:
= procidentia full-thickness protrusion of the rectum through the anus

Classification of rectal prolapse:

Partial: prolapse of rectal mucosa only Complete: prolapse with all layers Grade 1: occult prolapse Grade 2: prolapse to but not through anus Grade 3: any protrusion through anus

RECTAL PROLAPSE VS HEMORRHOIDS

Rectal prolapse can be distinguished from prolapsed incarcerated internal hemorroids by the characteristic concentric folds of rectal prolapse and by the painless reduction if not incarcerated.

ASSOCIATED SYMPTOMS/ETIOLOGIES
Rectal bleeding, underwear wetting, incarceration

Fecal incontinence 50 75% Chronic constipation 30 67% Obstructed defecation 33% Solitary rectal ulcer 12% Colonic inertia
10%

ASSOCIATED FACTORS
Diastasis of the levator ani Abnormally deep cul-de-sac/loss of the rectal sacral attachments Redundant sigmoid colon Sphincter dysfunction

Complications of prolapse include:

Ulceration Strangulation Urinary and fecal incontinence Spontaneous rupture with evisceration

DIAGNOSIS
History & Physical exam If/ not seen on physical exam, ask patient to strain in squatting or sitting position Colonoscopy r/o mass Defecography Anal manometry & pudendal N terminal motor latencies

DIAGNOSTIC TOOLS : DEFECOGRAPHY

Barium paste placed in the vagina and the rectum after the patient ingests water-water soluble contrast to opacify the small bowel the patient evacuates the rectal barium paste, defecation is recorded with fluoroscopic videotaping Detects occult intussusception and rectal prolapse with a sensitivity of 100% and a specificity of 93% Can also detect: paradoxical puborectalis contraction and pelvic floor weakness such as rectocele, enterocele, and cystocele

DIAGNOSTIC TOOLS : ANAL MANOMETRY

Measurement of anal canal pressures : involves using waterfilled, filled balloons attached to catheters and transducers placed in the anal canal Normal resting and squeeze values are 40 to 80 mm Hg Resting pressure reflects the function of the internal sphincter, squeeze pressure measures external sphincter (voluntary muscle) contributions. balloon expulsion test: balloon catheter is inflated with 50 to 100 ml of water ; without obstructed defecation the balloon should expel easily

DIAGNOSTIC TOOLS : PUDENDAL NERVE TERMINAL MOTOR LATENCY (PNTML)

times are measured with a special transducer attached to a glove like apparatus designed to be worn on the finger and hand A digital rectal exam is required with application of the finger electrode to the right and left levator ani complex Values between 1.8 and 2.2 msec are normal Prolonged values are seen in traumatic injuries of the vagina or anal canal (obstetric in etiology), sacral nerve root damage, or in chronic diseases such as diabetes.

DIAGNOSTIC TOOLS : SITZ MARKER STUDY

radiopaque markers are ingested by patient plain abdominal films are performed to demonstrate the movement of stool throughout the colon Patients with total colonic inertia will retain at least 80% of the markers equally distributed throughout the colon at 5 days Patients with obstructed defecation will have markers concentrated near the rectosigmoid junction Failure to recognize and treat a dysfunctional colon or obstructed defecation may result in continued straining and ultimately recurrent prolapse

OPERATIVE MANAGEMENT
Perineal
Thiersch wire procedure : anal encirclement
Delorme procedure : mucosal sleeve resection
Altemeier procedure : perineal rectosigmoidectomy

Advantages: use of spinal anesthesia, shorter hospita stay, lower risk of injury to pelvic nerves, reduced pain, concomitant repair of other anorectal problems, can be performed multiple times
Disadvantages: higher recurrence (5-20%), inferior functional outcomes, reduced improvement of incontinence

OPERATIVE MANAGEMENT

Abdominal
rectopexy
Frykman & Goldberg: Sigmoid resection w/ suture rectopexy
Ripstein & Lantern : anterior fixation using a sling
Wells procedure : mesh placement posterior to rectum

Pts w/ perineal Sx:
Older, higher ASA scores, decreased physical ability
Less procedural blood loss, operative time, hospital stay, and dietary restriction Rate of recurrence 26.5% perineal Sx vs 5.2% abdominal Sx (p: <0.001)

ANAL ENCIRCLEMENT
Described in 1981 2 small lateral incisions, wire is introduced into one and out the other & repeated The wire is tied and buried laterally Silver wire, stainless steel wire, mesh, silastic bands, nylon suture, polypropylene Reserved for pts of highest surgical risk, can be done under local Disadvantages: doesn t resolve incontinence, recurrence >30%, erosion of wire, fistula formation, impaction, incarceration

DELORME
Evert Inject local anesthesia 1-1.5cm above dentate to minimize bleeding Circumferential incision of mucosa Mucosa is dissected away from the underlying muscle until resistance prevents further dissection Plicate the remaining muscular tube circumferentially Resection of mucosa w/ anastomosis one quadrant at a time Anastomosis spontaneously reduces

Perineal Rectosigmoidectomy
/ALTEMEIER
Evert & give local Circumferential incision 1-1.5cm above dentate through full thickness rectal wall until perirectal fat encountered & mesorectum identified Rectal mobilization & division of the mesentery Ligation of the hernia sac Levatorplasty Proximal transection of the rectum & anastomosis Rectopexy from scarring Recurrence ~10%

Perineal rectosigmoidectomy is appropriate for:

1.

Better suited for elderly patients that are poor candidates for abd surgery due to high recurrence rate

2. Patients with a grade 3 prolapse protruding at least 3 cm 3. Patients who are poor candidates for trans abdominal surgery

ABDOMINAL APPROACH
Rectopexy: the lateral preserved attachments of the rectum is tacked to the presacral fascia at S2/S3; 4-6 sutures from distal to proximal

W/ mesh: Teflon, Gortex, Marlex; secured to sacrum & wrapped around rectum anchoring it to the muscularis propria leaving a 1cm separation

ABDOMINAL APPROACH
Mobilize the sigmoid starting ~5cm proximal to the pelvic brim Mobilization of the rectum to the coccyx will minimize recurrence but increase likelihood of nerve damage The splenic flexure provides additional fixation => it is not mobilized Care must be taken to preserve the lateral pelvic nerves The redundant sigmoid colon is resected & primary anastomosis is made

RIPSTEIN / RECTAL SLING

Sling of Teflon or Marlex to wrap the fully mobilized rectum anteriorly and attach it to the presacral fascia

WELL S PROCEDURE
Marlex or Teflon mesh sutured to the presacral fascia, then wrapped the rectum posteriorly to three fourths of circumference

LAPAROSCOPIC ABDOMINAL APPROACH

Port placement: p 10mm infra or supraumbilical, 10mm x2 lateral to R. rectus in R midabdomen & R. iliac fossa Mobilization of the sigmoid down to the rectum Transection of the redundant bowel which is removed through a hand port Anastomosis is made Rectopexy is performed more easily through the hand port given the significant force to penetrate the sacral bone

LAPAROSCOPIC ABDOMINAL APPROACH

A) Benefits similar to those mentioned for lap cholecystectomyshorter hospital stay; less post op pain; earlier return of bowel function B) Most colon and rectal diseases are amenable to lap approach except can not do for sigmoid resection for diverticulitis C) Port site recurrence appears equivalent to recurrence of cancer in incision of patients treated by conventional operation D) Post operative recovery of lap colectomy is prolonged on average if hand assisted techniques are used or if anastamosis has to be performed extracorporeally