1989 - Surgical Technique in Prolapso or the Rectum

8/3/2019 1989 - Surgical Technique in Prolapso or the Rectum

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Langenbecks Arch Ch i r (1989) 374 :370-376

L a n g e n b e c k sA iv C hi l rg ie Spr inge r -Ver lag 1989

Surgical techn iqu e in prolapse of the rectumJ.A. Solla, D. A. Rothenberger and S.M. GoldbergDivision of Colon and Rectal Surgery, Universityof Minnesota, 1721 Medical Arts Building,Minneapolis, MN 55402, USA

Selection of the most appropriate surgical proce-dure in the management of rectal prolapse contin-ues to be a problem for the surgeon. Few clinicalconditions have generated such a large number ofsurgical techniques with varying degrees of success.Over 100 procedures have been described for thetreatment of the many distressing symptoms ofprocidentia. It has been our experience that the vastmajority of patients with rectal prolapse can bemanaged by two procedures. The good risk patientis best managed by sigmoid resection with abdom-inal rectopexy without foreign material. The elderlyor poor-risk patient is better management by per-ineal rectosigmoidectomy and generally toleratesthis so well that there is only a limited place for theanal encirclement procedures. Each procedure hasits own merits and disadvantages. Ideally, an oper-ation for the repair of rectal prolapse should cor-rect the pathologic anatomy of the prolapse, re-store fecal continence, and be associated with a lowmortality, morbidity and recurrence rates. We be-lieve these two operations to be the procedures ofchoice for the treatment of rectal prolapse. Thisreport will describe our surgical technique in detailas well as our results with these two surgical proce-dures.

TerminologyComplete prolapse or procidentia of the rectumdescribes the circumferential extrusion of the entirethickness of the rectal wall through the anus. In-complete prolapse or hidden prolapse represents anearly stage of complete prolapse, in which intussus-ception of some degree of the rectum has occur red[13]. Patients present with symptoms of rectal pro-lapse but the actual prolapse cannot be demon-strated to protrude through the anal orifice. Mu-

cosal prolapse or false prolapse involves onlymucosa. Mucosal prolapse is due to laxity of theconnective tissue between the submucosa of thebowel and the underlying muscle. This usuallystarts at the anus and in its earliest form is repre-sented by prolapsing hemorrho ids. Some degree ofmucosal prolapse frequently coexists with proci-dentia, but the two conditions are completely dif-ferent and mucosal prolapse usually does not pro-gress into the true rectal prolapse.

Surgical optionsOnce the diagnosis of rectal prolapse is establishedin an adult, conservative management is useless,and some type of surgical therapy should beplanned. Repeated episodes of complete rectal pro-lapse usually occur more frequent ly with time andmay result in loss of sphincter tone, ulceration,herniation of the small bowel, and occasionalstrangulation of the protruding bowel. The pa-tient's age and medical risk factors generally deter-mine the choice between an abdominal or perinealapproach. Perineal procedures overall have re-sulted in higher recurrence rates and less improve-ment in the associated incontinence than the trans-abdominal operations but their advantage is thatthey are better tolerated by patients whose medicalcondition is suboptimal. The abdominal proce-dures with their much lower recurrence rates areusually reversed for the younger and healthier pa-tients.Abdominal procedureOf the myriad of abdominal procedures, we prefersigmoid resection with abdominal rectopexy(Fig. 1). As opposed to rectopexy with mesh, this


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A B CFig . 1A -C . P resac ra l r ec topexy and s igm oid r e sec t ion . Th i s appr oach favo red by the au tho r s in mos t cases , dea l s wi th the r edun dan ts igmoid (A) , by r e sec t ion (B) , in add i t ion to f ix ing the r ec tum to the sac ru m (C) . (F rom: [13] wi th pe rm iss ion )

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Fig . 2 . Mo di f i ed Trende lenburg pos i t ion wi th the pa t i en t ' s legs in s t i r rups

procedu re avo id s the u s e o f f o r e ign ma te r i a l andthe concomi tan t inc r eas ed r a t e o f s ep t i c compl ica -t ions. The inc iden ce o f obs t ruc t ive com pl ica t ions i sa l s o lower . I n ou r expe r i ence r e s ec t ion o f the r e -d u n d a n t s i g m o id c o l o n l o w e r s t h e r e c u r r e n c e r a t ewi thou t incu r r ing the r i s k en ta i l ed by a low-an te -r ior resect ion . I t i s ideal for pat ien ts wi th chronicd ive r t i cu la r d i s ease and ch ron ic cons t ipa t ion w h ichf r equen t ly coex i s t wi th r ec ta l p ro laps e . S igm oid r e -s e c t i o n m a y i m p r o v e b o w e l m a n a g e m e n t i n t h e s epa t i en t s. The re i s a l so a s m a l l s ubg roup o f pa t i en t swi th co lon ic ine r t i a a s s oc ia ted wi th p roc iden t i aw h o a r e b e st m a n a g e d b y a b d o m i n a l r e c t o p e x y a n ds ub to ta l co lec tomy bu t they mus t be fu l ly con t i -nen t .P reopera t ive p r epa ra t ion cons i s t s o f a f u l l me-chan ica l bowe l p r epa ra t ion wi th o r a l po lye thy lene

g lyco l s o lu t ion . P rophy lac t i c an t ib io t ic s a r e ad min -i s t e red by the o r a l and in t r aven ous rou tes . The op -e r a t ion i s pe r fo rm ed und er gene ra l anes thes ia , andthe pa t i en t i s p l aced in the mod i f i ed Trende lenb u rgpos i t ion with the pat ien t ' s legs in s t i r rups (F ig . 2) .Th i s pos i t ion a l lows pe r inea l acces s to the r ec tumand conven ien t s pace fo r a s econd as s i s t an t . AF o ley ca the te r i s in s e r t ed and the abdomen i sp r e p a r e d w i t h p o v i d o n e - i o d i n e . T h e s u r g e o n a n ds omet imes h i s f i rs t a s s is t an t w ear s a hea d l igh t du r -ing al l abdo min a l and pe r inea l p rocedu res . F o r th i sp roce du re we f avo r an in t r aum bi l i ca l tr an s ve r s e in-c i s ion , wh ich p rov ides exce l len t expos u re and i swe l l to l e r a ted by pa t i en t s . Af te r a s t anda rd exp lo -r a t ion o f the abdomen the l e f t co lon i s mob i l i zedf rom the mid -des cend ing l eve l to the s ac r a lp romon to ry . The p r es ac ra l s pace i s en te r ed and


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F i g . 3 . T h e p r e s a c r a l s p a c e , a n a v a s c u l a rp l a n b e t w e e n t h e s a c r u m a n d r e c t u m , i se n t e r e d a n d b l u n t l y d i s s e c t e d d o w n t othe r e t ros acra l f as c ia . Th i s f as c ia l a t t ach-m e n t i s s h a r p l y d i v i d e d , a n d t h e p o s t e r i -o r m o b i l i z a t i o n i s c a r r i e d d o w n t o t h el e v a t o r a n i . T h e p r e s a c r a l f a s c i a p r o t e c t sthe p res acra l ves s e l s , which l i e deep to i t .D i s s e c t i o n i n t h e w r o n g p l a n e a t t h i ss t a g e o f t h e p r o c e d u r e c a n c a u s e m a j o rb l e e d i n g f r o m t h e s e v e s s e l . ( F r o m : G o l d -b e r g S M , L o w r y A C , S m i t h L E : S i m g o i dr e s e c t i o n w i t h r e c t o p e x y f o r p r o c i d e n t i a lo f t h e r e c t u m . S u r g e r y I l l u s t ra t e d : A p i c -t o r i a l r e v ie w . U p j o h n 1 9 88 ; w i t h p e r m i s -s ion)

p o s t e r i o r m o b i l i z a t i o n o f t h e r e c t u m i s c a r r i e d o u tto t h e l e ve l o f t he l e v a to r a n i m usc l e ( F ig . 3 ) . I n t hepe lv i s, t he pe r i t o ne um i s i nc i s e d 1 c m l a t e r a l t o e i -t h e r s i d e o f t h e r e c t u m a n d d i s s e c t i o n i s c a r r i e dd i s t a ll y w i t h p r e s e r v a t i o n o f t h e l a t e r a l r e c t a ls t a lk s . The r e c tum i s e l e va t e d a nd i t s l a t e r a l pe r i -t o n e a l a t t a c h m e n t s s u t u r e d t o t h e p r e s a c r a l f a s c i ab e g i n n i n g j u s t b e l o w t h e s a cr a l p r o m o n t o r y( F ig . 4 ). G e n e r a l l y , t w o s u t u r e s o f 2 - 0 s il k o n e i -t h e r s i d e o f th e r e c t u m a r e a ll t h a t a r e n e c e s s a r y .T h e s u t u r e s a r e p l a c e d i n a h o r i z o n t a l m a t t n e s sf a s h i o n w i t h t h e f i r s t s u t u r e b e i n g p l a c e d t h r o u g hthe l a t e r a l r e c t a l s t a lk . The su tu r e s a r e p l a c e dt h r o u g h t h e p r e s a c r a l f a s c i a l a t e r a l t o t h e m i d l i n e .U s e o f th i s s it e a v o i d s b l e e d i n g f r o m t h e m i d d l es a c r al a r t e r y . A s t h e s u t u r e s a r e t i e d , c a r e s h o u l d b et a k e n t o a v o i d f o r m a t i o n o f t h e c o n s t r ic t i n g b a n da c r o s s t h e a n t e r i o r w a l l . I f a b a n d d o e s d e v e l o p , t h eo f f e n d i n g s u t u r e m u s t b e r e m o v e d . T o a v o i d t h i sc o m p l i c a t i o n , s u t u r e s m a y b e p l a c e d o n t h e r i g h ts i de o n l y . O n c e t h e r e c t o p e x y is c o m p l e t e a s e g m e n -t a l r e s e c t i o n i s p e r f o r m e d , e l i m i n a t i n g r e d u n d a n c yi n th e l e ft c o l o n , a n d t h e a n a s t o m o s i s i s p e r f o r m e da t a c o n v e n i e n t l ev e l w i t h o u t t e n s i o n . N o a t t e m p t i sm a d e t o o b l i t e r a t e t h e d e e p c u l - d e - s a c o r t o r e p a i rt h e l e v a t o r h i a t u s . N o d r a i n i s n e e d e d . T h e a b d o -m e n i s c l o s e d w i t h t w o l a y e r s o f c o n t i n u o u s s u t u r e .P o s t o p e r a t i v e l y , t h e p a t i e n t i s m a i n t a i n e d o n i n t r a -v e n o u s f l u id s u n t i l b o w e l f u n c t i o n r e t u r n s , u s u a l l yo n t h e t h i r d o r f o u r t h p o s t o p e r a t i v e d a y . L i q u i d s

a r e o f f e r e d a t t h a t p o i n t a n d i f w e l l t o l e r a t e d t h ed i e t is g r a d u a l l y a d v a n c e d . T h e p a t i e n t r e c e iv e s t w op o s t o p e r a t i v e d o s e s o f i n t r a v e n o u s a n t i b i o t i c s, a n dt h e F o l e y c a t h e t e r is u s u a ll y r e m o v e d o n t h e f o u r t ho r f i f th d a y . T h e u s u a l p o s t o p e r a t i v e s t a y in h o s p i -t a l is s e v en t o t e n d a y . P o s t o p e r a t i v e c a r e o f t h e s ep a t i e n t s i s r o u t i n e . F o r p a t i e n t s w i t h l o n g s t a n d i n gc o n s t i p a t i o n , b u l k l a x a t i v e s h o u l d b e c o n s i d e r e d .A n y i n c o n t i n e n c e m u s t b e c a r e fu l l y m o n i t o r e d .Perineal proceduresT r a n s a b d o m i n a l p r o c e d u r e s r e q u i r e t h e p at i e n t t ob e a b l e t o t o l e r a t e a m a j o r a n e s t h e t i c a n d a m a j o ro p e r a t i v e p r o c e d u r e s . F o r t h i s r e a s o n t h e s e o p e r a -t i o n s a r e r e s e r v e d f o r t h e g e n e r a l l y h e a l t h y l o w - r i s kp a t i e n ts . V e r y o f te n , h o w e v e r , p a t i e n t s a f f e c t e dw i t h r e c t a l p r o l a p s e a r e e l d e r l y a n d i n f i rm . F o r t h isr e a s o n p e r i n e a l a p p r o a c h e s h a v e b e e n d e s c r i b e da n d u t i li z e d . T h e p e r i n e a l r e c t o s i g m o i d e c t o m y iso u r o p e r a t i o n o f c h o i c e f o r t h e e ld e r l y , o f t e n d e b i l-i t a t e d , pa t i e n t ( F ig . 5 ) .P r e o p e r a t i v e p r e p a r a t i o n c o n s i s ts o f a m e c h a n i -c a l a n d a n t i b i o t i c b o w e l p r e p a r a t i o n a n d p e r i o p e r -a t i v e i n t r a v e n o u s a n t i b i o t ic s a s u s e d i n o u r i n t r a a b -d o m i n a l c o l o n i c s u r g e r y . P e r i n e a l r e c t o s i g m o i d -e c t o m y c a n b e p e r f o r m e d i n e i th e r t h e p r o n e j a c k -k n i f e o r d o r s a l l i t h o t o m y p o s i t i o n , u s u a l l y u n d e rr e g i o n a l a n e s t h e s i a . A F o l e y c a t h e t e r i s i n s e r t e di n t o t h e b l a d d e r . T h e r e c t a l p r o l a p s e i s r e p r o d u c e d


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Fig . 4 . The re c topexy i s com ple te , w i tht h e r e c t u m f i x e d i n a m o r e c e p h a l a dp o s i t i o n . I f a c o n s t r i c t i n g b a n d f o r m sacross the an te r io r rec ta l wa l l ( i n s e t ) , th eo f f e n d i n g s u tu r e ( s ) m u s t b e r e m o v e d a n dr e t i e d . ( F r o m : G o l d b e r g S M , L o w r y A C ,S m i t h L E : S i g m o i d r e s e c t i o n w i t h r ec -t o p e x y f o r p r o c i d e n t i a o f t h e r e c t u m .Surgery I l lus t ra ted : A p ic to r ia l rev iew .U p j o h n 1 9 8 8 ; w i t h p e r m i s s i o n )

": 1 ~ 1o " . :) : . $ l ~ : . : o l ~ ll ~ .

F i g . 5 A - I . P e r i n e a l r e c t o s i g m o i d e c t o -m y . W i t h t h e r e c t u m p r o l a p s e d , t h e o u t -e r rec ta l tube i s inc ised c i rcu la r ly (A) andu n f o l d e d ( B ) . T h e m e s o r e c t u m i s s er i a l lyl i g a t e d a n d d i v i d e d ( C ) . W h e n a l l r e d u n -d a n c y h a s b e e n r e m o v e d , t h e i n n e r t u b eis d iv ided , com ple t ing the resec t ion ( ! ) ) .T h e a n a s t o m o s i s m a y b e p e r f o r m e d b yh a n d o r w i t h t h e i n t r a l u m i n a l s ta p l in gdev ice as shown (E to I ) . (F rom : [13]w i t h p e r m i s s i o n )


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374b y g e n tl y , f o u r - q u a d r a n t t r a c ti o n o n t h e p r o l a p s i n gr e c ta l w a l l w i t h B a b c o c k c l a m p s . T h i s u s u a l l y re -s u l ts in e v e r s i o n o f t h e d e n t a t e l i n e. A m i n i m u m o f5 c m o f p r o l a p s e d r e c t u m t h r o u g h t h e a n a l v e r g e i sr e q u i r e d . 2 - 3 c m p r o x i m a l t o t h e d e n t a t e l i n e, th em u c o s a a n d s u b m u c o s a a r e i n f i l t r a t e d w i t h a s 6 1 u -t i o n c o n t a i n i n g 1 : 2 0 0 0 0 0 u n i ts o f e p i n e p h r i n e , t om i n i m i z e b l e e d i n g . A c i r c u m f e r e n t i a l , f u l l - t h i c k -n e s s i n c i s i o n i s m a d e c o m p l e t e l y i n c i s i n g t h e o u t e rc y l i n d e r o f b o w e l 3 c m p r o x i m a l t o t h e d e n t a t e l in e .U s e o f e l e c t r o c a u t e r y f u r t h e r d e c r e a s e s t h e b l e e d -i n g. T h e 4 q u a d r a n t s o f th e d i s ta l e n d o f t h e r e c t u ma r e t a g g e d w i t h 4 s ta y s u t u r e s . T h e m e s e n t e r i c v e s -s el s b e t w e e n t h e o u t e r a n d i n n e r w a l l s o f t h e r e c t u ma r e c a r e f u l ly l ig a t e d . T h i s p r o c e d u r e i s c o n t i n u e du n t il t h e r e d u n d a n t b o w e l c a n n o t b e p u l le d d o w na n y f a r t h e r . T h i s c a n b e p u r s u e d f o r a c o n s i d e r a b l el e ng t h o n t h e b o w e l , b e f o r e a m p u t a t i n g t h e in n e rt u b e . A p p r o x i m a t e l y 2 c m d i s t a l t o th e a n u s , t h ei n n e r c y l i n d e r o f b o w e l is t r a n s e c t e d . T h u s , a r e -d u n d a n t s e g m e n t o f 6 t o 2 5 c m o f r e c to s i g m o i d i sr e s ec t e d a n d t h e a n a s t o m o s i s i s p e r f o r m e d 1 t o2 c m a b o v e t h e d e n t a t e l in e e i th e r w i t h i n t e r r u p t e ds u t u r e s o r w i t h a n i n t r a l u m i n a l s t a p l in g d e v i c e [1 2] .W h e n s t a p l in g d e v i c e s a r e u s e d , t h e b o w e l s h o u l db e t r a n se c t e d 1 c m l o n g e r t o a l l o w f o r p l a c e m e n t o ft h e p u r s e - s t r in g s u t u r e . W e d o n o t r e p a i r t h e l e v a-t o r a n i o r p u b o r e c t a l i s m u s c l es . A n o t h e r i n d i c a ti o nf o r t h i s p r o c e d u r e i s a n u l c e r a t e d , g a n g r e n o u s p r o -l a p s e d r e c t u m . P o s t o p e r a t i v e l y , t h e p a t i e n t i ss t a r t e d o n a c le a r l iq u i d d i e t t h e n e x t d a y a n d g r a d -u a l l y a d v a n c e d t o a so f t d i e t. P a t i e n t s a r e a m b u -l a t e d o n e d a y a f t e r s u r g e r y a n d t h e F o l e y c a t h e t e ri s r e m o v e d i n 4 8 h . T h e p a t i e n t r e c e iv e s t w o p o s t -o p e r a t i v e d o s e s o f i n t r a v e n o u s a n t i b i o t ic s . R e -m a r k a b l y l it tl e p a i n , w h i c h c a n b e c o n t r o l l e d e a s i lyw i t h o r a l a n a l g e s i c s , i s a s s o c i a t e d w i t h t h i s p r o c e -d u r e . P a t i e n t s u s u a l l y l e a v e t h e h o s p i t a l i n f o u r t os e v e n d a y s .

Resu l t s

W e h a v e r e v i e w e d a n d p u b l i s h e d 3 0 y e a r s ' e x p e r i -e n c e in t h e m a n a g e m e n t o f re c ta l p r o l a p s e a t t h eU n i v e r s i t y o f M i n n e s o t a A f f i l i a te d H o s p i t a l s [1 4] .T h i s r e tr o s p e c t i v e s t u d y e n c o m p a s s e d 1 3 8 p a t i e n t sw h o u n d e r w e n t a s i g m o i d r e s e c t i o n a n d a b d o m i n a lr e c t o p e x y w i t h o u t a n o p e r a t iv e d e a t h . 9 p a ti e n tsu n d e r w e n t a b d o m i n a l r e c t o p e x y a n d s u b t o t a lc o l e c t o m y b e c a u s e o f d o c u m e n t e d c o l o n i c in e r ti ac a u s i n g s e v e r e c o n s t i p a t i o n . 3 6 o f t h e 1 3 8 p a t ie n t st r e a te d b y s i g m o i d r e se c t io n a n d a b d o m i n a l r e c-t o p e x y w e r e l o s t to f o l l o w - u p , l e v i n g 1 0 2 p a t i e n t sf o r e v a lu a t i o n . O f th i s g r o u p , 8 1 % w e r e f o l lo w e d

f o r 2 o r m o r e y e a r s , 7 0 % f o r 3 o r m o r e y e a r s a n d5 7 % f o r 4 o r m o r e y e a r s , w i t h f o l l o w - u p r a n g i n gf r o m 6 m o n t h s t o 3 0 y e a r s . T h e a v e r a g e i n th i sg r o u p w a s 5 2 y e a r s , a n d t h e a v e r a g e h o s p i t a l s t a yw a s 1 0 d a y s . 2 p a t ie n t s ( 1 . 9 % ) d e v e l o p e d r e c u r -r e n ce , o n e 6 m o n t h s a n d t h e o t h e r 2 . 5 y e a r s p o s t o p -e r at iv e l y. T h e m o r b i d i t y w a s 4 % . O n e w a s m a n -a g e d b y p e r in e a l r e c t o s i g m o i d e c t o m y , a n d t h eo t h e r b y l o w a n t e r io r r e se c t io n , w i t h o u t s u b s e q u e n tr e c u r r e n c e . 6 1 o f t h e 1 0 2 p a t i e n t s w e r e r e a c h e d f o ri n t e rv i e w . 7 2 % c o n s i d e r e d t h e i r r e su l t s t o b e e xc e l-l e n t, 8 % g o o d , a n d 2 0 % f a i r o r p o o r . T h o s e d i s s a t-i s fi e d w i t h t h e i r r e s u l ts c o m p l a i n e d o f i n c o n t i n e n c eo r s e v e r e c o n s t i p a t i o n .

T h e 9 p a t i e n ts w h o u n d e r w e n t a b d o m i n a l r ec -t o p e x y a n d s u b t o t a l c o l e c t o m y f o r c o r re c t i o n o fp r o l a p s e a s s o c i a t e d w i t h c o l o n i c i n e r t i a w e r e f o l -l o w e d f r o m 1 t o 6 y e a r s w i t h a n a v e r a g e o f 2 y e a r s .A l l w e r e c o n t a c t e d f o r i n t e rv i e w . S e v e n p a t i e n t s( 7 8 % ) f e l t th e i r r e s u l ts w e r e e x c e l l e n t t o g o o d , w h i l et w o p a t i e n t s ( 2 2 % ) f e lt r e s u lt s w e r e p o o r b e c a u s e o fi n c o n t i n e n c e .

W e h a v e p e r f o r m e d a p e ri n e a l r e c t o si g m o i d e c -t o m y o n 6 6 p a ti e n t s o f w h ic h 4 4 w e r e a v a i l ab l e f o rf o l l o w - u p a f t e r 3 m o n t h s t o 6 y e a r s , w i t h a m e a nf o l l o w - u p o f 2 - 6 y e a r s [ 9 ]. T h e a v e r a g e a g e i n t h isg r o u p w a s 7 8 y e a rs ( as o p p o s e d t o 5 2 in t h e a b d o m -i n a l r e c t o p e x y s i g m o i d r e s e c t i o n g r o u p ) . T h i s e x -p l a i n s i n p a r t t h e s h o r t e r f o l l o w - u p a v a i l a b l e i n th i sg r o u p . T h e r e w e r e n o o p e r a t i v e d e a t h s o r r e c u r -r e nc e s. T h e m o r b i d i t y w a s 1 5 % . O f t h e 4 4 p a t i en t sc o n t a c t e d f o r i n t e r v i e w 3 2 % c o n s i d e r e d t h e i r r e -s u l ts to b e e x c e ll e n t a n d 5 7 % g o o d . T h e r e m a i n i n g1 1 % c o n s i d e r e d t h e ir r e su l ts p o o r b e c a u s e o f w o r s -e n i n g i n c o n t i n e n c e .

Di scu s s i on

A m y r i a d o f s u rg i c al p r o c e d u r e s , u s u a l l y b a s e d o nt h e p r e s u m e d e t i o l o g i c f a c t o r s , h a s b e e n p r o p o s e df o r t h e t r e a t m e n t o f r e c ta l p r o l a p s e . A t p r e s e n t i t i sg e n e r a l l y a c c e p t e d t h a t r e c t a l p r o l a p s e i s a n i n t u s -s u s c e p t i o n [ 2, 11 ]. T w o o f t h e a n a t o m i c a b n o r m a l i -t ie s c o m m o n t o p a t ie n t s w i t h r e c t a l p r o l a p s e a r e 1 )a r e d u n d a n t r e c t o s ig m o i d , a n d 2 ) l os s o f h o r i z o n t a lp o s i t i o n o f t h e r e c t u m w i t h l o s s o f it s sa c r a l a t t a c h -m e n t s . A s a b e tt e r u n d e r s t a n d i n g o f p r o la p s e h a se v o l v e d , s o h a s i ts m a n a g e m e n t , w h i c h e n t a i l s p r e -v e n t i o n o f i n t u s s u s c e p t i o n b y f i x a ti o n , r e s e c t i o n , o ra c o m b i n a t i o n o f th e t w o .O u r p r e f e r r e d p r o c e d u r e f o r t h e g o o d - r i s k p a -t i e n t i s a b d o m i n a l r e c t o p e x y w i th s i g m o i d r e s e c ti o nb e c a u s e i t a v o i d s f o r e i g n m a t e r i a l , e l i m i n a t e s t h er is k o f v o l v u l u s, i m p r o v e s b o w e l m a n a g e m e n t


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375p r o b l e m s , a n d h a s l o w m o r b i d i t y a n d m o r t a l i t yw i t h a l o w r e c u r r e n c e s r a t e s . F r y k m a n a n d G o l d -b e r g , t h e o r i g i n a t o r s o f th i s a p p r o a c h , f e l t t h a t " o fa ll t h e w e a k n e s s e s o r a b n o r m a l i t i e s r e q u i r e d t o p r o -d u c e r e c t a l p r o l a p s e , t h e o n l y f a c t o r t h a t c a n b ec o n t r o l l e d w i t h c e r t a i n t y i s t h e l e n g t h o f t h e c o l o n "[3] . Re se c t i on o f t he r e du nd a n t l e f t c o l on i s c ons i d -e re d t o be a n a i d i n c on t ro l o f t he p ro l a pse , s i nc e as t r a i g h t , s h o r t l e f t c o l o n p r e v e n t s d e s c e n t o f t h er e c t u m a n d h e n c e r e c u r re n c e o f p r o l a p s e . F u r t h e r -mo re , s e g me n t a l r e se c t i on is ide a l l y su i t e d fo r t hos epa t i e n t s wi t h s i gn i f i c a n t s i gmoi d d i ve r t i c u l a r d i s -e as e . R e s e c t io n c o m b i n e d w i t h a n a n a t o m i c c o rr e c -t i on o f t he p ro l a pse i s be ne f i c i a l fo r i mprov i ngp o s t o p e r a t i v e b o w e l h a b i ts . 6 3 % o f t h e p a t i e n t s ino u r s e ri es w h o u n d e r w e n t a t r a n s a b d o m i n a l p r o c e -d u r e f o r r e ct a l p r o l a p s e c o m p l a i n e d p f p r e o p e r a t i v ec o n s t i p a t i o n [ 1 4 ] . A f t e r a b d o m i n a l r e c t o p e x y a n ds i g m o i d re s e c ti o n , 5 6 % e x p e r i e n c ed im p r o v e m e n ti n b o w e l h a b it s , 3 5 % r e m a i n e d u n c h a n g e d , a n d 9 %h a d p r o g r e s s iv e l y i n c r e as i n g p r o b l e m s . I n o u rse ri e s o f 102 pa t i e n t s t r e a t e d by re c t ope xy a nd s ig -m o i d r e s e c ti o n , t h e re w e r e n o d e a t h s , a n d o n l y 4 %m o r b i d i t y d i r e c tl y r e la t e d t o t h e a n a s t o m o s i s . A f t e ra m e a n f o l l o w - u p p e r i o d o f 4 y e a rs , t h e r e c u r r e n c er a t e w a s 1 . 9 % . R e v i e w o f t h e l it e r a tu r e w o u l d c o n -f i r m t h a t t h e m a j o r i t y o f r e c u r re n c e s , r e g ar d l e ss o ft ype o f r e pa i r , w i l l p re se n t wi t h i n t wo t o t h re e ye a r s[141.T h e t r a n s a b d o m i n a l s u s p e n s i o n - f i x a t io n a n dre se c t i ona l p roc e d ure s y i e l d the be s t r e su l t s , bu t a rel i m i t e d t o p a t i e n t s w h o a r e g o o d s u r g i c a l r i s k .T h o s e p r o c e d u r e s c o m b i n i n g s u s p e n s i o n - f i x a t i o nwi t h r e se c t i on a re a s soc i a t e d wi t h r e c u r re nc e ra t e so f 0 t o 3 .6% [2, 8 , 14 ] , wh i l e t hose w i t ho u t r e se c t i onvary f rom 0 to 18 .9% [2 , 7 , 14] .Re c t ope xy wi t h syn t he t i c ma t e r i a l s i s some -t i me s c ompl i c a t e d by i n fe c t i on , wh i c h re qu i re s r e -o p e r a t i o n a n d r e m o v a l o f t h e im p l a n t i n 1 .5 t o 2 . 6o f t h e p a t i e n t s [ 5 ]. I n a d d i t i o n , c o m p l e t e w r a p p i n gof t he r e c t um, i n pa r t i c u l a r wi t h a s l i ng , ha s be e nr e p o r t e d t o r e s u l t i n o b s t r u c t iv e s y m p t o m s a n d f e -c a l i m pa c t i on i n 6 .7 t o 18% o f t he pa t i e n t s [5] .R e o p e r a t i o n w i t h d i v i s i o n o r r e m o v a l o f t h e p r o s -t h e ti c m a t e r ia l m a y t h e n b e n e c es s ar y . A b d o m i n a lr e c t o p e x y b y m e a n s o f s u t u r e u s u a l l y a v o i d s t h e s ep r o b l e m s .P e r i n e al r e c t o s i g m o i d e c t o m y , o r ig i n a ll y a d v o -c a t e d b y M i l es [ 1 0 ] , w a s p o p u l a r i z e d i n N o r t hA m e r i c a b y A l t e m e i e r [ 1] . T h i s is o u r p r o c e d u r e o fc ho i c e fo r t he poo r - r i sk , e l de r l y de b i l i t a t e d pa t i e n t sw i t h r e c t a l p r o l a p s e i n w h o m a n a b d o m i n a l a p -p r o a c h is n o t j u s ti f ie d . W e h a v e p e r f o r m e d t h is p r o -c e dure on 66 pa t i e n t s a nd ha ve be e n s a t i s f i e d wi t ht h e ze r o m o r t a l i t y , m i n i m a l m o r b i d i t y , a n d n o r e -

c u r re nc e [9 ]. Re v i e w o f t he li t e ra t u re wou l d c on f i rmt ha t de sp i t e t he pa t i e n t popu l a t i on , t he re i s l i t t l ea s s o c i a t e d m o r t a l i t y a n d m i n i m a l m o r b i d i t y . R e -c u r r e n c e r a te s v a r y c o n s i d e r a b l y f r o m 2 . 8 t o m o r et ha n 60% [1, 4 , 6 , 11 ]. W e a re un a b l e t o e xp l a i n t h i sd i s c re pa nc y . Th e l a c k o f r e c u r re nc e i n o u r s e ri e s i sp r o b a b l y a m a n i f e s t a t i o n o f t h e s h o r t e r f o l l o w - u pi n t he se e l de r l y , de b i l i t a t e d pa t i e n t s who ma y no ts u r v iv e l o n g e n o u g h f o r a r e c u r r en c e t o d e v e l o p .P roc e dure s t ha t n a r ro w t he a na l o r i f ic e , suc h a st h e T h i e r s c h a n a l e n c i r c l e m e n t p r o c e d u r e o r i t sm o d i f i c a t i o n s , c o n t i n u e t o b e a s s o c i a t e d w i t h ah i g h i n c i d e n ce o f c o m p l i c a t io n s , d o n o t h i n g f o r t h eu n d e r l y i n g p r o b l e m , a n d h a v e a l i m i t e d p l a c e in t h ec u r r e n t m a n a g e m e n t o f r ec ta l p r o la p s e . I n m a n yp o o r - r i s k p a t i e n t s , w h o w o u l d h a v e o t h e r w i s e u n -d e r g o n e a n a n a l e n c i r c l e m e n t p r o c e d u r e w e h a v eha d g ra t i fy i ng re su l t s wi t h pe r i ne a l r e c t os i gm oi de c -t o m y .F o l l o w i n g p e r i n e a l r e c t o s i g m o i d e c t o m y , o n l y1 4 p a ti e n t s ' i n c o n t i n e n c e i m p r o v e d , w h i l e 5 p a -t i e n t s f e l t t ha t i t ha d worse ne d . I t i s obv i ous f romo u r p a t i e n t i n t e r v ie w s t h a t p e r s i st e n t i n c o n t i n e n c ei s t he m a j o r c a use o f pa t i e n t s ' d i s s a t i s fa c t ion . Th i so p e r a t i o n i s n o t a n o p e r a t i o n a d v o c a t e d f o r g o o dr i sk pa t i e n t s .F i n a ll y , w e h a v e r e s e r v ed a b d o m i n a l r e c t o p e x ya n d s u b t o t a l c o l e c t o m y f o r a s el ec t s u b g r o u p o fp a t i e n t s w i t h r e c t a l p r o l a p s e w i t h d o c u m e n t e dse ve re c o l on i c ine r t i a . The se pa t i e n t s u sua l l y c om -p l a i n o f i n t r a c t a b l e c o n s t i p a t i o n w h i c h i s n o t r e -l ie v e d w i t h l a x a ti v e s a n d / o r e n e m a s . T h i s s u b g r o u po f p a t i e n t s i s id e n t if i e d b y m e a n s o f p r e o p e r a t i v emo t i l i t y a nd t r a ns i t t i me s t ud i e s . Onc e i de n t i f ie d ,t h e y ar e f u r t h e r s t u d i e d b y a n a l m a n o m e t r y . T h o s ew h o h a v e n o r m a l s p h i n c t e r p r e s s u r e s a n d p r o v e nc o l on i c i ne r t i a a s soc i a t e d wi t h r e c t a l p ro l a pse a rem a n a g e d b y a b d o m i n a l r e c t o p e x y a n d s u b t o t a lc o l e c t o m y . I n o r d e r t o b e a c a n d i d a t e f o r s u b t o t a lc o l e c t o m y , t h e p a t i e n t m u s t b e p e r f e c t ly c o n t i n e n tw i t h n o r m a l s p h i n ct e r m a n o m e t r y ; t h o s e w h o a r eno t wi l l ha ve unsa t i s fa c t o ry r e su l t s .

Conc lus i on

T h e v a s t m a j o r i t y o f p a t ie n t s w i t h r e c t al p r o l a p s ec a n b e m a n a g e d b y e i t h e r a b d o m i n a l F e c to p e x y a n ds i g m o i d r e s e ct i o n o r p e r i n e a l r e c t o s i g m o i d e c t o m y .Bo t h p roc e dure s i nvo l ve p r i nc i p l e s f a mi l i a r t o a l la b d o m i n a l s u r g e o n s a n d a v o i d t h e u s e o f f o r ei g nma t e r i a l . P e r i ne a l r e c t os i gm oi de c t om y i s r e se rve df o r t h e e l d e r l y o r d e b i l i ta t e d p a t i e n t b e c a u s e o f o u ro w n c o n c e r n o f h ig h r e c u r r e n ce s r a te s r e p o r t e d b yo t h e r s a n d t h e o c c a s io n a l a l t e r at i o n o f c o n t i n e n c e


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376s e e n i n a s s o c i a t i o n w i t h t h i s p r o c e d u r e . F o r t h eh e a l t h y , l o w - r i s k p a t i e n t , a n a b d o m i n a l r e c t o p e x yw i t h s i g m o i d r e s e c t i o n o f r e d u n a n t b o w e l p r o v i d e sa s a t i s f a c t o r y o u t c o m e . T h i s o p e r a t i o n d o e s n o tp r e s e n t t h e r is k o f r e c t o s i g m o i d o b s t r u c t i o n s e c-o n d a r y t o s l in g p l a c e m e n t . T h e s i g m o i d r e s e c t io n i sp e r f o r m e d s o t h a t t h e a n a s t o m o s i s c a n b e c o n -d u c t e d a t a c o n v e n i e n t l e v el a l l o w i n g t e c h n i c a l e a s ea n d a v o i d i n g t h e ri sk o f l o w c o l o r e c t a l a n a s t o m o -s i s . A b d o m i n a l r e c t o p e x y a n d s i g m o i d r e s e c t i o n i sm o r e l ik e l y t o r es u l t i n im p r o v e m e n t o f c o n t i n e n c et h a n i s p e r i n e a l r e c t o s i g m o i d e c t o m y .

R e f e r e n c e s1. Altemeier WA, Gauseth J, Hoxworth PI (1952) Treatment ofextensive prolapse of rectum in aged and debilitated pa-tients. Arch Surg 65:72-802. Broden B, Snellman B (1968) Procidentia of the rectumstudied with cineradiography: a contribut ion to the dis-cussion of causative mechanism. Dis Colon Rectum 11:330-3473. Frykman HM, Goldberg SM (1969) The surgical treatmentof rectal procidentia. Surg Gynecol Obstet 129:1225-1230

4. Gopal KA, Amshel AL, Shonberg IL (1984) Rectal proci-dentia in elderly and debilitated patients: Experience withthe Altemeier procedure. Dis Colon Rectum 27:3765. Gor don PH, Hoexter B (1978) Complicat ions of the Rip-stein procedure. Dis Colon Rectum 21:277-2806. Hughes ESR (1949): In discussion on rectal prolapse. Pro fR Soc Med 42:10077. Keighley MR, Fielding JW, Alexander-Williams J (1983)Rectopexy for rectal prolapse in 100 consecutive patients.Br J Surg 70:229-2328. Khubchandani IT, Bacon HE (1965) Complete prolapse ofthe rectum and its treatment. Arch Surg 90:337-3409. Lowry AC, Goldberg SM (1987) Internal and overt rectalprocidentia. Gastroenterol Clin North Am 16:47-7010. Miles WE (1933) Recto-sigmoidectomy as a method oftreatment for procidentia recti. Proc R Soc Med 26:1445-145211. Theuerkauf F J, Beahrs OH, Hill JR (1970) Rectal prolapse:causation and surgical treatment. Ann Surg 171:819-83512. Vermeulen FD, Nivatvongs S, Fang DT, Balcos EG, Gold-berg SM (1983) A technique for perineal rectosigmoidec-tomy using autosuture devices. Surg Gynecol Obstet

156:85-8613. Wassef R, Rothenberger DA, Goldberg SM (1986) Rectalprolapse. Curr Probl Surg 23:402-45114. Watts JD, Rothenberger DA, Buls JG, Goldberg SM,Nivatvongs S (1985) The management of procidentia: 30years' experience. Dis Colon Rectum 28:96-102

1989 - Surgical Technique in Prolapso or the Rectum

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