CLINICAL MEET- GS I

13.03.23

Moderator Presenter

Dr Cherring Tandup Dr Deepika Sharma

Associate professor Junior resident

Demographics Details

• Name : Mr BS
• Age : 27 YR/Male
• CR NO : 202104113707
• Address : Maloya Chandigarh
• DOA : 08/02/2022
• DOSX1 : 08/02/2022, DOSX2 : 11/02/2022, DOSX3 : 26/07/2022
DOSX4 : 22/09/2022, DOSX5 : 10/02/2023
Clinical History

Presented with chief complaint :

• Mass protruding per rectum x 10 months
• Tenesmus x 9 months
History of present illness

• H/O mass protruding per rectum x 10 months

- initially 1-2 cm below anal verge, present on straining,
reduced after manual reduction, progressed to 4-5
cm beyond anal verge , non reducible
• H/O tenesmus
• H/O constipation, NO/H/O fecal incontinence
• H/O pain lower abdomen
• NO/H/O bleeding per rectum , obstipation, fever , jaundice
• NO/H/O difficulty in micturition
• NO/H/O loss of weight /loss of appetite
• Past history :
No/H/O HTN/DM/Asthma/TB/Psychiatric illness
No/H/O Previous surgery

• Personal History :
Consume mixed diet
Normal bladder habits and Chronic constipation
Normal sleep pattern
Non smoker, Non alcoholic

• Family History:
No significant family history
Examination

• General physical examination: normal

• Systemic examination : normal
• Per abdomen : soft and non tender
• Per rectal examination
- Grade V rectal prolapse present
- Visualized mucosa normal
- No mass / growth palpable
- Finger stained with normal stool
 Hematological Investigations

DATE 07/02/22 DATE 19/02/22

Hemogram 15.3 TB/CB 1.2/0.5

TLC 5800 AST/ALT 29/33
PLT 144K
ALP 49

TP/ALB 7.9/4.65
DATE 19/02/22
NA/K 133/4.05
PT/INR 98/1.1
UREA/CREATNINE 30/0.8
APTT 37
Surgery -1(8/2/2022)

• Procedure- Laparoscopic converted to open resection of redundant

sigmoid colon + hand sewn end to end anastomosis + ventral mesh
rectopexy
• Intraoperative findings:
Laparoscopic phase –
• Visualized small bowel and solid organ normal, no ascites
• Redundant sigmoid , rest of large bowel normal
• Converted to open due to difficulty in mobilization of redundant
sigmoid colon
Open phase :
• Deep sacral curvature with narrow pelvis present
• Sigmoid colon and rectum fully mobilized till the level of coccyx
• Left ureter and gonadal vessels identified and preserved
• Sigmoid vessels identified , ligated and divided close to the sigmoid
colonic wall , Superior rectal artery preserved
• Resection of 30 cm of redundant sigmoid colon done
• End to end handsewn colorectal anastomosis done
• Ventral mesh rectopexy done using prolene mesh
• Mesh placed in presacral plane and overlying peritoneum closed with 2-0
vicryl
Postoperative Events

• Persistent tachycardia with low grade fever

• Per abdomen - distended , purulent discharge from midline wound
• CECT abdomen was done- mild circumferential thickening of rectum
(6.5cm) at colorectal anastomotic site approximately 6mm thickness
with minimal contrast extravasation through medial wall
extensive fat stranding in pelvis and mesorectal fat

• Re-explored on POD 2 in view of anastomotic leak

SURGERY -2 (11/2/2022)

Operative procedure-
• Minimal feculent contamination in pelvis
• Small bowel loops, Omentum normal
• 1.5x1.5 cm anastomosis site leak present at right lateral site and 1x1
cm anastomotic leak present anteriorly at anastomotic site
• Primary repair done with PDS 4-0 single layer
• Loop of sigmoid colon proximal to anastomosis site brought out as
diversion loop sigmoidostomy in left iliac fossa
• Pelvic drain placed
Postoperative events

• Postoperative period was uneventful

• Discharged on POD13/16
• Readmitted on 13/7/2022 for restoration of bowel continuity
Surgery 3(26/7/2022)

• Operative procedure : Restoration of bowel continuity

• Loop colostomy taken down by gun site incision
• Dense adhesions present between bowel loops and surrounding structure
– adhesiolysis done
• Hand sewn continuous, single layer, closure of loop stoma done
Postoperative Event

• Postoperative period was uneventful

• Discharged on post operative day 7
Follow up

• During follow up period after 2 month presented with

- H/O feeling of incomplete evacuation
- H/O mild pain abdomen
- NO/H/O fever , fecal incontinence bleeding per rectum, loss of
appetite , loss of weight, difficulty in micturition
Examination

• General physical examination: normal

• Systemic examination : normal
• Per abdomen : soft and non tender, midline scar healthy
• Per rectal examination:
- normal perianal skin
- normal anal tone
- visualized mucosa normal
- No mass / growth palpable , finger stained with normal stool
Investigation

• Colonoscopy done
(2/9/2022) (PGIMER)–
15 cm from anal verge,
ulcerated mucosa with stricture
present , scope not negotiable,
mesh like structure was present
in anterior rectal wall involving
30% circumference, pinworm
present in rectum
• CECT abdomen + pelvis (3/9/2022)(E42170/22) –
- proctitis with surrounding inflammation
- circumferential mural thickening of rectum wall 16mm
- multiple perirectal lymph node present
- mesh like structure present anterior to rectum close to right
anterolateral wall
Surgery – 4 (23/9/2022)

• Operative procedure – EL+ Adhesiolysis + Mesh explant from rectal

wall + sigmoid colorectal anastomosis + covering loop ileostomy
• Intraoperative findings –
• Dense adhesions present between bowel and anterior abdominal wall,
scar and interbowel – adhesiolysis done
• Mesh found to be firmly adhered to posterior wall of upper rectum just
below sacral promontory, eroding posterior wall
• On mesh removal, 3 x 3 cm defect in posterior rectal wall present
• Rectum and sigmoid colon dismantled at defect site
• Dense perirectal adhesions present , rectum mobilised
• Sigmoid colorectal anastomosis done
• Covering loop ileostomy done
Postoperative events

• Postoperative period was uneventful

• Discharged on postoperative day 7
• Readmitted on Jan 2023 for restoration of bowel continuity
 Surgery 5 (10/2/2023)

Operative Procedure – Restoration of bowel continuity

Operative findings-
• Stoma site approached via local site
• Peristomal incision given
• Loop stoma closed
Postoperative events

• Postoperative period was uneventful

• Discharged on postoperative day 7
• During follow up period – doing well
DISCUSSION
RECTAL PROLAPSE AND
MANAGEMENT
 PELVIC FLOOR ANATOMY
• Components :
• Superficial and deep muscles
• Levator ani muscles
(Puborectalis, pubococcygeus ,
ileococcygeus )
• Coccygeus muscles
• Fascia covering of the muscle
Functions:
• Support abdominopelvic viscera
• Resistance to increased in intra
abdominal pressure
• Urinary and fecal continence
Introduction

Definition
• Pelvic floor disorder
• Circumferential , full thickness intussusception of rectal wall
• Intra-rectal to intra-anal
Epidemiology
• Uncommon- 0.5% overall and 1% after the age of 65 years
• Female> male
• Bimodal – children with in 3 years of age and after 7th decade
Bordeianou et al. J Gastrointest [Link];18(5):1059-69
Classification

• Occult rectal prolapse or rectal

intussusception

• Partial procidentia or rectal mucosal

prolapse.

• Complete rectal procidentia or full-

thickness rectal prolapse
Risk factor

•Age >40 years

•Female gender
•Prior pelvic surgery
•Chronic straining and constipation
•Anatomical defect
•Neurological and psychiatric illness
Anatomical defect
• Diastasis of levator ani muscle
• Abnormal deep cul-de-sac
• Pelvic floor dysfunction – pelvic floor atony and patulous anus
• Pelvic floor anatomic defects - wide pelvic floor inlet
• Redundant and nonfixed rectosigmoid
• Physiologic abnormalities
- atonic levator ani muscles
- external anal sphincter weakness
- pudendal nerve injury

Fischer’s master of surgery (6th edition)

Children –
• Diarrhoeal illness
• Cystic fibrosis , Hirschsprungs disease
• Rectal polyp
• Pelvis maldevelopment

Female gender
• Multiparity, Vaginal delivery
• Prior pelvic surgery
• Chronic straining, Chronic constipation
Fischer’s mastery of surgery (7th edition)
Etiology

• Two theories-
1. Sliding hernia through a defect in pelvic fascia
2. Intussusception

Fischer’s master of surgery (6th edition)

 Degree of rectal prolapse
OXFORD GRADING SYSTEM FOR RECTAL PROLAPSE

Rectal Intussusception GRADE 1 Descends no lower than the proximal limit of rectocele

GRADE 2 Descends in to the level of a rectocele, but not in to anal canal

Rectoanal Intussusception GRADE 3 Descends to the top of anal canal

GRADE 4 Descends in to anal canal

External Rectal Prolapse GRADE 5 Protrudes from the anus

 Clinical presentation
Symptom Prevalence

Faecal incontinence 50–75 %

Constipation 25–50 %

Rectal bleeding 75–100 %

Urinary incontinence 25–30 %

Vaginal vault prolapse 15–30 %

Pain 100 %

Decreased quality of life 100 %

Diagnosis and workup
1. History and physical examination
2. Proctoscopic examination
3. Colonoscopy
4. Radiological imaging-
- MRI defecography (traditional fluoroscopy or dynamic MRI)
- Endoanal ultrasound
5. Pelvic physiology test
- Anorectal manometry
- Balloon expulsion test
- Pudendal nerve latency
- Electromyography
6. Colonic transit study Sabiston Textbook of surgery(21st edition)
• History and physical examination – differentiate between true rectal
prolapse, mucosal prolapse and prolapsed hemorrhoid
• Proctoscopic examination- redundant tissue, solitary rectal ulcer
• MRI defecography- confirm the diagnosis , rectocele, cystocele,
vaginal vault prolapse, enterocele, sigmoidocele
• Endoanal ultrasound- shows thickening of internal anal sphincter
• Colonoscopy- to look for colorectal cancer and other colonic pathology
• Colonic transit study- to look for slow colonic transit

Sabiston Textbook of surgery, The biological basis of modern surgical practice(21 st edition)
Management

RECTAL PROLAPSE

OPERATIVE
OPERATIVE
NONOPERATIVE MANAGEMENT BY
MANAGEMENT BY
MANAGEMENT ABDOMINAL
PERINEAL APPROACH
APPROACH
Nonoperative management

• Medical management is offered to

• Minimize fecal incontinence, pain, and constipation.
• Comorbid illness
• Refuse a surgical repair
• Dietary modification-
- Adequate fluid intake
- High fiber diet
• Pharmacological management-
- Stool softners
- Enema
• Topical sugar and salt application to decrease mucosal edema
• Encompassing the rectum with an elastic compression wrap
• Hyaluronidase injection - results in breakdown of extracellular matrix
Sabiston Textbook of surgery (21st edition)
Surgical management

•Surgical repair is the strategy of choice.

•Early repair is ideal –

-Persistent externalization of the rectal mucosa
-Weakening of the sphincter complex
-Risk of rectal incarceration  strangulation  surgical emergency

•Any treatment must be tailored-

•Patient’s overall medical condition
•History of previous procedures
•Patient’s willingness to undergo an operation
• Goal of surgical repair –
- Eliminate prolapse
- Correct anatomical and functional abnormalities
• Choice of procedure is based upon
- Patient’s comorbidities
- Patients age
- Bowel function
- Surgeons preference
• Types of surgical procedure
- Trans abdominal
- Transperineal
Management of rectal prolapse in emergency

• Resuscitation with IV fluids , IV antibiotics and IV analgesics , Optimization

of comorbidities

• Look for evidence of gangrene or ulcer

• Attempt for non operative reduction – Sugar application, Hyper tonic saline ,
elastic compression

• Failure to reduce prolapse with 24 hours

• Attempt to reduce the prolapse under GA in emergency.

• Failure to reduce under GA, If no signs of systemic toxicity or
gangrenous changes.

• Non operative management was given for 7 days with watchful

observation and attempted to reduce the prolapse again under GA

• Systemic toxicity or gangrenous changes – Indication for operative

management.
Abdominal procedure

• Procedure of choice in patients with acceptable risk.

• The intra-abdominal repair involve two basic tenets:
• Adequate mobilization of the rectum.
• Appropriate fixation of the rectum.

• Rectopexy can be performed with

• Suture v/s mesh
• Posterior v/s anterior approach
• Open v/s minimal invasive
• Resection vs no resection
Fischer’s master of surgery (6th edition)
Abdominal procedure
NO PROCEDURE NAME DESCRIPTION
1. Suture rectopexy Complete mobilization to level of levators
(Sudeck) Suture of rectum to presacral fascia

2. Anterior sling rectopexy Complete rectal mobilization to level of levators

(Ripstein) Circular wrapping of mesh around rectum and attachment to promontory

3. Lateral mesh rectopexy Anterior + posterior complete rectal mobilization

(Orrlogue) Two lateral mesh strips to promontary

4. Ventral mesh rectopexy Anterior rectal mobilization to level of levators

(D’ Hoore) Fixation of mesh strip om distal rectum and promontary

5. Posterior mesh rectopexy Complete rectal mobilzation to level of levators

(Wells) Semicircular mesh around rectum posterior, fixation to promontory

6. Resection rectopexy Complete rectal mobilization to level of levators

(Frykman-Goldberg) Sigmoid resection and suture fixation of rectum to promontory

7. Only rectal mobilization Rectal mobilization without rectopexy, complete rectal mobilization to level of levators,
(Goligher) no fixation
 Posterior suture rectopexy (Sudeck’s)
• Mobilization of rectum- anterior and
posterior
• Elevated to straighten any redundant
bowel distal
• Rectum must be dissected, retracted
intra abdominally
• sutured to the periosteum of the sacral
promontory
• Resection of redundant sigmoid can be
performed
• Recurrence rates - 3% to 9% at 2 years.
 Anterior sling rectopexy
(RIPSTEIN PROCEDURE)

• Mesh completely encircled the

rectum anteriorly.
• Recurrence rates ranged from 4% to
10%,
• Complication rates were high.

Sabiston Textbook of surgery, The biological basis of modern surgical practice(21 st edition)
 POSTERIOR MESH RECTOPEXY
(Modified Ripstein procedure)
• Rectum – anterior and posterior mobilization
• Prosthetic or biologic mesh- secured to the periosteum of the sacral
promontory.
• The rectum is straightened
• Fixing it laterally to the mobilized rectum.
• Recurrence rates - 2% to 5% with a 20% postoperative morbidity rate.
 WELLS PROCEDURE

• Similar to posterior mesh rectopexy.

• Mesh is secured to the sacrum between the posterior rectum and sacral
promontory.
• Recurrence rate – 3% to 5%

• Mullholland ,Operative techniques in surgery

Mullholland ,Operative techniques in surgery
 FRYKMAN-GOLDBERG PROCEDURE

• Abdominal posterior rectopexy with concomitant sigmoid Resection

• Patients with redundant sigmoid colon and/or constipation symptoms
• Distal transection margin
• Just at or below the level of the rectosigmoid junction.
• Proximal transection margin
• Based on where the remaining sigmoid colon can be anastomosed
without tension.
• Recurrence rate – 2% to 5%
• Risk of anastomotic leak 2-5%
Mullholland ,Operative techniques in surgery
 Anterior rectopexy

• Ventral mesh rectopexy

• D’Hoore Procedure – laparoscopic ventral rectopexy
• Rectum – mobilized anteriorly only
• Anterior wall of the rectum is sutured to mesh that is affixed to sacral
promontory
• Avoiding posterior rectal dissection
• Reported an 84% improvement in postoperative constipation

• Reported recurrence rate 3.4%.

 ROLE OF MINIMALLY INVASIVE SURGERY

• Equivalent recurrence rates (4%–8%) and morbidity (10%–33%)

• Frequently cited problems with laparoscopy include
- Longer operating times
- High learning curve
- The need for specialized equipment
- Limited patient eligibility.
• Advantages-
- good pain control
- less hospital stay
• 3 D laparoscopic equipment or robotic technology- Emerging
- improved visualization of deep pelvis
Laparoscopic ventral mesh rectopexy
D’Hoore procedure

Mullholland ,Operative techniques in surgery

Mullholland ,Operative techniques in surgery
 PERINEAL APPROACHES
• Perineal approaches to rectal prolapse are reserved for
• Patients with significant comorbidities
• Elderly patient
• High risk for general anesthesia
• Previously undergone transabdominal repair of rectal prolapse
• Pelvic surgery and radiation in the past
• Associated with
• Lower operative morbidity and mortality
• Higher recurrence rate.
• Commonly used perineal procedures are
• Perineal proctectomy or proctosigmoidectomy ( Altemeier
Procedure )
• Levatorplasty ( Parks postnatal repair}
• Perineal mucosal stripping and muscle plication (Delorme
Procedure)
• Stapled transanal rectal resection (STARR)
 ALTEMEIER PERINEAL RECTOSIGMOIDECTOMY
• Most frequently performed perineal procedure
• Typically for rectal prolapse with length > 3 cm
• Recurrence rate is reported to be 16-30%.
• Performed under regional or general anesthesia in
prone jackknife or lithotomy position
• Components of this procedure include:
• Redundant rectum is prolapsed.

• Epinephrine is injected in to submucosa

• Full thickness circumferential incision is performed

approximately 1 to 2 cm above the dentate line
• The rectum is then dissected proximally

• Redundant and floppy bowel is delivered and transected.

• A handsewn coloanal anastomosis - suturing the

proximal margin to the anal canal.

• Levatorplasty is performed - improve support by the

pelvic floor and lengthen the anal canal.

• Recurrence rate was reported to be lower than 10% -

with levatorplasty
 DELORME PROCEDURE

• Delorme procedure is the most commonly

performed perineal approach to rectal prolapse
repair in Europe.
• For rectal prolapse < 3 cm.
• The principle components of this procedure
includes:
• Circumferential incision is made through
mucosal and sub mucosal layer.

• Submucosal layer is dissected along the length

of prolapse
• Sleeve resection of mucosa until reduntant
mucosa is resected

• The exposed muscularis propia is plicated

• Hand-sewn anastomosis is between the

proximal mucosal layer at the level of
transection and the anal canal.
Reported recurrence rate – 10 % to 15%.
 THIERSCH PROCEDURE
• Rectal prolapse in high risk patients.
• 2 or 4 incision were performed beside the
anus
• Dissecting the subcutaneous tunnel, a
silicon tube or mesh was inserted to
encircle the anus
• Mechanically narrowing the anus +
proliferation of circumferential
connective tissue
• Infection, anal stenosis and foreign body
erosion are critical complications.
Stapled transanal rectal resection (STARR)

• Alternative procedure for symptomatic intrarectal prolapse

• Full thickness rectal resection including internal prolapse with circular
stapler or specific curved stapler
• Complication-
- staple line bleeding
- staple line disruption and rectovaginal fistula
- chronic proctalgia
- stool urgency
• Morbidity -7%-21%
 Outcomes and Algorithmic
Approach

Patient with rectal prolapse

Young & Old &

healthy comorbid

Abdominal Perineal
Approach Approach

Incontinence Constipation incontinence constipation

Ventral or Ventral or Reduntant

Posterior posterior <3cm >3cm colon
rectopexy rectopexy with
sigmoid
resection Delorme Altemeier Altemeier with
procedure procedure sigmoid resection
MORTALITY AND MORBIDITY

• Abdominal procedures - high mortality and morbidity than perineal approaches.

• Mortality : 0-7%, morbidity : 0-52%
• Major complication:
• Faecal incontinence
• Pelvic sepsis
• Pelvic hematoma
• Stenosis
• Obstruction
• Mesh related complication (infection , erosion , fistula)(2-4%)
 RECURRENCE
• Abdominal procedures generally have lower recurrence compared to perineal
procedures
Procedure Recurrence rate Complication rate
Abdominal procedures
Suture rectopexy 3 to 9% 14%
Resection rectopexy 2 to 5% 0-20%
Posterior mesh rectopexy 2 to 5% 20%
(modified Ripstein)
Ventral mesh rectopexy 2 to 4.8% 14 %
Perineal procedure
Altemeier 16 to 30 % <10%
Delorme Procedure 10 to 15% 4 to 12%

Varma M et al. Dis Colon Rectum 2011, Novell JR et al. Br J Surg 1994, Madbouly KM
et al. Surg Endosc 2003.
 POST OPERATIVE BOWEL FUNCTION
• Fetal incontinence
• Suture rectopexy – Improvement in 15 to 82 % of patients.
• Mesh Rectopexy -- Improvement 3 to 92% of patients.

• Perineal procedure – Complete resolution in 20 to 50%.

• Constipation
• New onset or worsening constipation - abdominal procedure
• Preservation of lateral stalks and concomitant sigmoid resection reduce
the rate of constipation
Mesh related complication

• Mesh infection
• Mesh migration
• Mesh erosion- rectal/ vaginal/bladder
• Pain/dyspareunia
• Rectal stricture
• Rectovaginal fistula

D’Hoore A, Cadoni R,Pennickx F. Laparoscopic ventral rectopexy for rectal prolapse;long term [Link] Jsurg2004;91
Management of mesh migration after mesh rectopexy

• Mesh migration and erosion are rare complication -2-4%

• Present month or years after surgery

Clinical features
• Presented with discharge or bleeding per rectum ,
• Tenesmus
• Constipation
Risk factors

1. Type of mesh used -

- small pore size vs larger pore size mesh
- synthetic vs biological
- size of mesh bigger size vs small size (ideal 6cmx4cm)
2. Surgical technique-
- unrecognized rectal injury
- deeper stitches through rectum
3. Patient associated -
- H/O smoking, tabaco use, alcoholic, DM
- H/O pelvic irradiation , previous surgery
 Management-
• Evaluated by flexible sigmoidoscopy- look for ulcerated lesion at the
site of erosion with visualization of mess
• CECT abdomen + pelvis with contrast – localization of mess /pelvic
collection
Treatment-
Complete excision of mesh - laparoscopic or open
- transabdominal or transperineal
Mathew MJ, Parmar AK, Reddy PK. mesh erosion after laparoscopic posterior rectopexy;a rare complication.J
Minim Access Surg.2014 jan;10(1);40-1
 POST OPERATIVE MANAGEMENT

• Early ambulation and initiation of enteral feeding after both perineal and
abdominal repair.
• Pelvic floor muscle exercises (Kegel)
• Biofeedback therapy
• Patient with constipation :
• Aggressive bowel regimen for at least 2 weeks
• High fiber diet
• Fiber supplements
• 1-2 liters pf water / day
• Enemas and suppositories for severe constipation
Ternent CA et al. Dis Colon Rectum. 2007 Dec.
Take home message

• Tailored approach needed

• Perineal approach is preferred for patient with significant co
morbidities.
• No significant difference in recurrence rate between abdominal and
perineal approach.
• Mesh related complications occur in 2-4% of cases
• Complete excision is the treatment of choice in case of mesh migration
or erosion after mesh rectopexy
•

THANK YOU