Rectal prolapse: a 10-year experience

Abstract

Purpose: To compare perineal to abdominal procedures for rectal prolapse over a 10-year period at a single tertiary care institution.

Methods: Between May 1, 1995, and January 1, 2005, 75 patients underwent surgical intervention for primary rectal prolapse at a tertiary referral center. Surgical techniques included perineal-based repairs (Altemeier and Delorme procedures) and abdominal procedures (open and laparoscopic resection and/or rectopexy). Medical records were abstracted for data pertaining to patient characteristics, signs and symptoms at presentation, surgical procedure, postoperative length of hospitalization, morbidity and mortality, and recurrence of rectal prolapse.

Results: Seventy-five patients underwent surgical intervention for rectal prolapse during the study period. The average patient age was 60.8 years. Sixty-two patients (82.7%) underwent perineal-based repair (Altemeier n = 48, Delorme n = 14); eight patients (10.7%) underwent open abdominal procedures (resection and rectopexy n = 4, rectopexy only n = 4); and five patients (6.7%) underwent laparoscopic repair (laparoscopic LAR n = 3, laparoscopic resection and rectopexy n = 2). Average hospitalization was shorter with perineal procedures (2.6 days) than with abdominal procedures (4.8 days) (p < 0.0031). Postoperative complications were observed in 13.3% of cases. With a median follow-up of 39 months (range 6-123 months), there was no mortality for primary repair, a postoperative morbidity occurred in 13% of patients, and the overall rate of recurrent prolapse was 16% (16.1% for perineal-based repairs, 15.4% for abdominal procedures).

Conclusion: Perineal resections were more common, performed in significantly older patients, and resulted in a shorter hospital stay. Their minimal morbidity and similar recurrence rates make perineal procedures the preferred option.

Keywords: Altemeier; Delorme; Rectal prolapse; procedentia; recurrence.

Figure 1.

Sagittal view of full-thickness rectal prolapse. (From Beck DE, Whitlow CB. Rectal prolapse and intussusception. In Beck DE, ed. Handbook of Colorectal Surgery, 2nd ed. New York: Marcel Dekker, 2003:301–324. With permission)

Figure 2.

Physical examination. A. Concentric folds of prolapsed rectum. B. Radial folds of hemorrhoids (mucosal prolapse). (From Beck DE, Whitlow CB. Rectal prolapse and intussusception. In Beck DE, ed. Handbook of Colorectal Surgery, 2nd ed. New York: Marcel Dekker, 2003:301–324. With permission)

Figure 3.

Ivalon sponge rectopexy (Wells). A. Ivalon sponge being fixed to the sacrum. B Sponge in place before fixation to the rectum. C. Incomplete encirclement of the rectum anteriorly with the sponge sutured in place. (From Beck DE, Whitlow CB, Rectal prolapse and intussusception. In Beck DE, ed. Handbook of Colorectal Surgery, 2nd ed. New York; Marcel Dekker, 2003:301–324. With permission)

Figure 4.

Mesh rectopexy (Ripstein). A. Posterior fixation of sling on one side. B. Sling brought anteriorly around mobilized rectum. C. Sling fixed posteriorly on the opposite side. D. Sagittal view of the completed rectopexy. (From Beck DE, Whitlow CB. Rectal prolapse and intussusception. In Beck DE, ed. Handbook of Colorectal Surgery, 2nd ed. New York: Marcel Dekker, 2003:301–324. With permission)

Figure 5.

Abdominal rectopexy and sigmoidectomy. A. Rectum is fully mobilized in the posterior avascular plane. B. Redundant sigmoid colon is resected. C. Anastomosis is completed and rectopexy sutures are placed. (From Vernava AM, III, Beck DE. Rectal prolapse. In Wolff BG, Fleshman JW, Beck DE, Pemberton JH, Wexner SD, eds. The ASCRS Textbook of Colon and Rectal Surgery. New York: Springer, 2006:665–677. With permission)

Figure 6.

Perineal rectosigmoidectomy (Altemeier). A, B. Incision of rectal wall. C. Division of vessel adjacent to bowel wall. D. Mesenteric vessels ligated. Stay sutures previously placed in distal edge of outer cylinder are placed in cut edge of inner cylinder. E. Anastomosis of distal aspect of remaining colon to the short rectal stump. (From Beck DE, Whitlow CB. Rectal prolapse and intussusception. In Beck DE, ed. Handbook of Colorectal Surgery, 2nd ed. New York: Marcel Dekker, 2003:301–324. With permission)

Figure 7.

Mucosal proctectomy (Delorme). A. Subcutaneous infiltration of dilute epinephrine solution. B. Circumferential mucosal incision. C. Dissection of mucosa off muscular layer. D. Plicating stitch approximating cut edge of mucosa, muscular wall, and mucosa just proximal to dentate line. E. Plicating stitch tied. F. Completed anastomosis. (From Beck DE, Whitlow CB. Rectal prolapse and intussusception. In Beck DE, ed. Handbook of Colorectal Surgery, 2nd ed. New York: Marcel Dekker, 2003:301–324. With permission)