Rectal prolapse repair

Definition

Rectal prolapse repair surgery treats a condition in which the rectum falls, or prolapses, from its normal anatomical position because of a weakening in the surrounding supporting tissues.

Purpose

A prolapse occurs when an organ falls or sinks out of its normal anatomical place. The pelvic organs normally have tissue (muscle, ligaments, etc.) holding them in place. Certain factors, however, may cause those tissues to weaken, leading to prolapse of the organs. The rectum is the last out of six divisions of the large intestine; the anus is the opening from the rectum through which stool exits the body. A complete rectal prolapse occurs when the rectum protrudes through the anus. If rectal prolapse is present, but the rectum does not protrude through the anus, it is called occult rectal prolapse, or rectal intussusception. In females, a rectocele occurs when the rectum protrudes into the posterior (back) wall of the vagina.

Factors that are linked to the development of rectal prolapse include age, repeated childbirth, constipation, ongoing physical activity, heavy lifting, prolapse of other pelvic organs, and prior hysterectomy . Symptoms of rectal prolapse include protrusion of the rectum during and after defecation, fecal incontinence (inadvertent leakage of feces with physical activity), constipation, and rectal bleeding. Women may experience a vaginal bulge, vaginal pressure or pain, painful sexual intercourse, and lower back pain.

Demographics

The overall incidence of rectal prolapse in the United States is approximately 4.2 per 1,000 people. The incidence of the disorder increases to 10 per 1,000 among patients older than 65. Most patients with rectal prolapse are women; the ratio of male-to-female patients is one in six.

Description

Surgery is generally not performed unless the symptoms of the prolapse have begun to interfere with daily life. Because of the numerous defects that can cause rectal prolapse, there are more than 50 operations that may be used to treat the condition. A perineal or abdominal approach may be used. While abdominal surgery is associated with a higher rate of complications and a longer recovery time, the results are generally longer lasting. Perineal surgery is generally used for older patients who are unlikely to tolerate the abdominal procedure well.

Abdominal and laparoscopic approach

Rectopexy and anterior resection are the two most common abdominal surgeries used to treat rectal prolapse. The patient is usually placed under general anesthesia for the duration of surgery. During rectopexy, an incision into the abdomen is made, the rectum isolated from surrounding tissues, and the sides of the rectum lifted and fixed to the sacrum (lower backbone) with stitches or with a non-absorbable mesh. Anterior resection removes the S-shaped sigmoid colon (the portion of the large intestine just before the rectum); the two cut ends are then reattached. This straightens the lower portion of the colon and makes it easier for stool to pass. Rectopexy and anterior resection may also be performed in combination and may lead to a lower rate of prolapse recurrence.

As an alternative to the traditional laparotomy (large incision into the abdomen), laparoscopic surgery may be performed. Laparoscopy is a surgical procedure in which a laparoscope (a thin, lighted tube) and various instruments are inserted into the abdomen through small incisions. Rectopexy and anterior resection have been performed laparoscopically with good results. A patient's recovery time following laparoscopic surgery is shorter and less painful than following traditional abdominal surgery.

Perineal approach

Perineal repair of rectal prolapse involves a surgical approach around the anus and perineum. The patient may be placed under general or regional anesthesia for the duration of surgery.

The most common perineal repair procedures are the Altemeier and Delorme procedures. During the Altemeier procedure (also called a proctosigmoidectomy), the prolapsed portion of the rectum is resected (removed) and the cut ends reattached. The weakened structures supporting the rectum may be stitched into their anatomical position. The Delorme procedure involves the resection of only the mucosa (inner lining) of the prolapsed rectum. The exposed muscular layer is then folded and stitched up and the cut edges of mucosa stitched together.

A rarely used procedure is anal encirclement. Also called the Thiersch procedure, anal encirclement involves the insertion of a thin circular band of non-absorbable material under the skin of the anus. This narrows the anal opening and prevents the protrusion of the rectum through the opening. This procedure, however, does not address the underlying condition and therefore is generally reserved for patients who are not good candidates for more invasive surgery.

Diagnosis/Preparation

Physical examination is most often used to diagnose rectal prolapse. The patient is asked to strain as if defecating; this increase in intra-abdominal pressure will maximize the degree of prolapse and aid in diagnosis. In some instances, imaging studies such as defecography (x rays taken during the process of defecation) may be administered to determine the extent of prolapse.

Before surgery, an intravenous (IV) line is placed so that fluid and/or medications may be easily administered to the patient. A Foley catheter will be placed to drain urine. Antibiotics are usually given to help prevent infection. The patient will be given a bowel prep to cleanse the colon and prepare it for surgery.

Aftercare

A Foley catheter may remain for one to two days after surgery. The patient will be given a liquid diet until normal bowel function returns. The recovery time following perineal repair is faster than recovery after abdominal surgery and usually involves a shorter hospital stay (one to three days following perineal surgery, three to seven days following abdominal surgery). The patient will be instructed to avoid activities for several weeks that will cause strain on the surgical site; these include lifting, coughing, long periods of standing, sneezing, straining with bowel movements, and sexual intercourse. High-fiber foods should be gradually added to the diet to avoid constipation and straining that could lead to prolapse recurrence.

Risks

Risks associated with rectal prolapse surgery include potential complications associated with anesthesia, infection, bleeding, injury to other pelvic structures, recurrent prolapse, and failure to correct the defect. Following a resection procedure, a leak may occur at the site where two cut ends of colon are reattached, requiring surgical repair.

Normal results

Most patients undergoing rectal prolapse repair will be able to return to normal activities, including work, within four to six weeks after surgery. The majority of patients will experience a significant improvement in symptoms and have a low chance of prolapse recurrence if heavy lifting and straining is avoided.

Morbidity and mortality rates

The approximate recurrence rates for the most commonly performed surgeries as reported by several studies are as follows:

• Altemeier procedure: 5–54%
• Delorme procedure: 5–26%
• anal encirclement: 25%
• rectopexy: 2–10%
• anterior resection: 7–9%
• rectopexy with anterior resection: 0–4%
• laparoscopic rectopexy

Abdominal surgeries are associated with a higher rate of complications than perineal repairs; rectopexy, for example, has a morbidity rate of 3–29%, and anterior resection a rate of 15–29%. The complication rate for combined rectopexy and anterior resection is slightly lower at 4–23%. Approximately 25% of patients undergoing anal encirclement will eventually require surgery to treat complications associated with the procedure.

Alternatives

There are currently no medical therapies available to treat rectal prolapse. In cases of mild prolapse where the rectum does not protrude through the anus, a high-fiber diet, stool softeners, enemas, or laxatives may help to avoid constipation, which may make the prolapse worse.

Resources

BOOKS

Feldman, Mark, et al. Sleisenger & Fordtran's Gastrointestinal and Liver Disease. 7th edition. Philadelphia: Elsevier Science, 2002.

Walsh, Patrick C., et al. Campbell's Urology. 8th edition. Philadelphia: Elsevier Science, 2002.

PERIODICALS

Felt-Bersma, Richelle J. F., and Miguel A. Cuesta. "Rectal Prolapse, Rectal Intussusception, Rectocele, and Solitary Rectal Ulcer Syndrome." Gastroenterology Clinics 30, no. 1 (March 1, 2001): 199–222.

ORGANIZATIONS

American Society of Colon and Rectal Surgeons. 85 W. Algonquin Rd., Suite 550, Arlington Heights, IL 60005. (847) 290-9184. http://www.fascrs.org .

OTHER

Flowers, Lynn K. "Rectal Prolapse." eMedicine, July 30, 2001. [cited April 9, 2003]. http://www.emedicine.com/emerg/topic496.htm .

Poritz, Lisa S. "Rectal Prolapse." eMedicine, February 6, 2003. [cited April 9, 2003]. http://www.emedicine.com/med/topic3533.htm .

Stephanie Dionne Sherk

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Rectal prolapse repair is usually performed in a hospital operating room . The surgery may be performed by a general surgeon, a colon and rectal surgeon (who focuses on diseases of the colon, rectum, and anus), or a gastrointestinal surgeon (who focuses on diseases of the gastrointestinal system).

QUESTIONS TO ASK THE DOCTOR

• What defect is causing the rectal prolapse?
• What surgical procedure is recommended for treatment?
• What are the risks and complications associated with the recommended procedure?
• Are any non-surgical treatment alternatives available?
• How soon after surgery may normal activities be resumed?