ELLIS : WRAP OPERATION FOR RECTAL PROLAPSE 675

DONE, M. J., GOULD, L. V., and BROZIN, I. H. (1962),

FIDDIAN, R. V. (1959), Post-grad. med. J., 35, 673. GREY TURNER, G. (1932), Br. J . Surg., 20, 26. HOYER, A. (1960), Acta chir. scand., suppl. 129. JENKINS, H. P., EVANS, R., and KOLLERT, W. (1961),

KIRKLAND, K. C., and CROCE, E. J. (1961), 3. Am. med.

Br. J . Surg., 49, 660.

Surg. Clins N . Am., 41, 71.

have been extruded and the cholecyst-enteric fistula may close spontaneously.

It is our submission that a conservative attitude should be adopted and that gall-bladder surgery should be underaken only if there are further symp- toms referable to that organ.

S U M W R Y The clinical features, investigations, and operative

findings in 13 cases of gall-stone obstruction of the small bowel are described. The treatment is discussed and the literature reviewed.

REFERENCES BROCKIS, J. G., and GILBERT, M. C. (1957), Br. J. Surg.,

DECKOFF, S . L. (1955), Ann. Surg., 142, 52. 44, 461.

Ass., 176, 494.

J . Surg., 81, 424. MCLAUGHLIN, G. W., jun., and RAINES, M. (IggI), Am.

MORLOCK. C. G.. SHOCKET, E., and REMINE, W. H. (1956), *Gastroenterology, 30, 462.

ROUTLEY, E. F., and MAYO, C . W. (I952), Post-grad. med. J., 12, 503.

VICK, R. M. (1932), Br. med. J., 2, 546. WAKELEY, CECIL P. G., and WILLWAY, F. W. (I935),

Br. J . Surg., 23, 377.

THE POLYVINYL SPONGE WRAP OPERATION FOR RECTAL PROLAPSE

BY HAROLD ELLIS PROFESSOR OF SURGERY, WESTMINSTER HOSPITAL, LONDON

THE large number of operations which have been described for rectal prolapse are a tribute to the difficulties of its cure. In 1959 Wells described the use of a polyvinyl alcohol sponge prosthesis wrapped round the mobilized rectum in order to secure the bowel against the sacral hollow by firm fibrous adhesions. The procedure is simple and the results to date have been most promising. Naunton Morgan (1962) reported a combined series of 52 patients from Professor Wells’s Unit in Liverpool and from St. Mark’s Hospital. There were 2 postoperative deaths (3.8 per cent) and in 26 patients followed up for 2 years or more there was only I complete recurrence. Calne (1966) has recently published the figures from Westminster Hospital and the Gordon Hospital. Thirty patients have been operated upon with I post- operative death (mortality 3.3 per cent) and I complete recurrence. Although incontinence, particu- larly if severe preoperatively, cannot always be abolished it is usually much improved, and the patient is nearly always delighted with the relief from the discomfort and embarrassment of this unpleasant disease.

Wells (1962) has published a brief account of the polyvinyl wrap operation. Since this useful pro- cedure is passing rapidly into the armamentarium of general surgery, it might be opportune to give a detailed description of the operation together with some modifications which we have found of value.

PREOPERATIVE CARE The patient is admitted to hospital 4 or 5 days

preoperatively so that a careful clearing of the colon can be obtained by means of a lubricant aperient and colonic lavage. A non-residue diet is ordered. Since the majority of these patients are frail elderly ladies, it is essential to check for, and if necessary treat, any anaemia and to ensure a high vitamin-(= intake. Anti- biotic sterilization of the bowel is not necessary since

its lumen is not to be opened at operation. Anal sphincter exercises are taught by the ward physio- therapist and are encouraged by the medical and nursing staff.

THE OPERATION A Foley self-retaining catheter is introduced into

the bladder and the patient placed in a moderate Trendelenburg tilt. The abdomen is opened through a midline incision from the umbilicus to the pubic symphysis. After full laparotomy the small intestine is packed into the upper abdomen and a self-retaining retractor inserted. In the female the uterus is con- veniently held forward by stay sutures passed through the broad ligament and looped around the tube on either side. The sigmoid colon is freed from its left lateral peritoneal attachments by scissors dissection along the avascular white line which is readily seen when the bowel is placed on stretch. Peritoneal incisions are made on either side of the base of the pelvic mesocolon and the mesorectum, and are carried down from the aortic bifurcation to the bottom of the recto-uterine (or, in the male, recto- vesical) pouch. These incisions are joined distally in front of the rectum. Quite typical of this condi- tion is the very deep peritoneal basin of the pelvic cavity; long scissors are required to complete the lower reaches of these incisions. Where there has been a previous unsuccessful rectosigmoidectomy or other perineal procedure, there are often filmy adhesions in the pouch of Douglas which require division at this stage, and the pelvic peritoneum will be found to be rather thickened and adherent.

Peritoneal flaps are then raised on either side and also anteriorly onto the back of the vagina, using pledgets of gauze held in long artery forceps. Stay sutures are placed through the edge of each lateral flap and clipped in artery forceps, whose weight conveniently retracts them. The ureters are identified,

676 BRIT. J. SURG., 1966, Vol. 53, No. 8, AUGUST

mobilized, and pushed well laterally and out of harm. The mesorectum, with its contained superior haemorrhoidal plexus, is then freed from its attach- ment to the sacrum by gentle blunt dissection until

FIG. I.-The peritoneal flaps have been widely raised. The rectum and its mesorectum are mobilized from the sacrum and tapes are passed around the bowel so that it can be held con- veniently forwards and to the right. (Note in this and all the subsequent figures that the pelvic floor is at the top of the diagram.)

1 FIG. 3.-Both ends of each suture are threaded through a sheet

of polyvinyl alcohol sponge which is then ‘rail-roaded’ down into the sacrum.

the whole length of the hollow of the sacrum is exposed. Two tapes are passed around the rectum, which greatly assist in its retraction over to the right side of the wound during the subsequent stages of the operation (Fig. I).

Four or five long lengths of 30 linen thread, each on a small, preferably fish-hook, needle, are now

firmly inserted into the sacral periosteum in the mid- line, commencing from below and progressing up- wards. Each is tied, the two ends kept equal in length and held seriatim in artery forceps (Fig. 2).

FIG. 2.-A row of linen sutures IS inserted in the midline through the sacral periosteum. Each stitch is tied and held long.

-../

FIG. 4.-The sponge is held by tying

firmly against the sacral hollow the sutures.

A sheet of polyvinyl sponge, 3 inches wide and 5 inches long, is soaked in sterile saline and wrung dry. Rethreading both ends of each suture with a straight needle, these are passed in line along the middle of the sponge sheet and again held serially in artery forceps to avoid tangling the threads (Fig. 3). The sheet can now be eased down into the sacral

ELLIS : WRAP OPERATION FOR RECTAL PROLAPSE 677

hollow by ‘rail-roading’ it along this line of sutures, which are then tied firmly down upon the sponge, commencing with the lowermost stitch (Fig. 4).

Difficulties in attempts to lay the polyvinyl sponge in the pelvis and then to suture it into place-in- adequate anchoring stitches, some bleeding from small vessels hit by blind suturing through the

FIG. 5.-The polyvinyl alcohol sponge is wrapped round four- fifths of the circumference of the rectum and the edges of the sheet tacked to the bowel by a series of interrupted thread sutures.

sponge, tangling of the ligatures-have convinced us of the value of this more methodical technique which enables the sponge to be anchored accurately, safely, and securely into the pelvis.

The sides of the sheet are now smoothly wrapped around the rectum so that about four-fifths of its circumference is covered; an anterior strip of bowel is left exposed to prevent the perhaps theoretical risk of stricture formation. Any excess of sponge is trimmed away and its edges are tacked to the sides of the rectum by a series of interrupted fine thread sutures (Fig. 5).

The stay sutures through the peritoneal flaps are then removed, enabling peritoneum to be sutured meticulously over the rectum, completely hiding the sponge from view (Fig. 6), since there must be a very real risk of a loop of small bowel becoming adherent and kinked to any exposed piece of the sponge. For this reason it is well worth while at the early stages of the operation to ensure that good wide wings of peritoneum are mobilized on each side.

Now an important final step before closing the abdomen: the rectosigmoid is pulled well up out of the pelvis and tacked to the left lateral peritoneal wall by a series of four or five thread sutures (Fig. 6). These will hold the bowel snugly in place during the immediate postoperative period and will allow firm fibrous tissue to be laid down around the sponge so that the rectum becomes bound to the sacrum in the fully reduced position. These sutures also relieve us of any anxiety that early mobilization of the patient

and the straining at stool in the first week or two after surgery might allow some degree of prolapse to occur before dense fibrosis has taken place.

Postoperatively the catheter is left in situ for 24- 48 hours and the patient is then allowed to get up out of bed. A lubricant aperient is prescribed daily to ensure soft motions and to avoid undue straining,

FIG. 6.-The peritoneal flaps are sutured back so that the sponge is completely hidden. Four or five thread sutures tack the rectosigmoid firmly onto the left lateral pelvic wall to allow the rectum to become fixed to the sacral hollow in the fully reduced position.

and the anal sphincter exercises are also continued. Because of the potential danger of infection of the sponge it has been our practice to order a 5-day course of tetracycline, although we now consider that this may well be an unnecessary precaution. The patient is allowed home 2 weeks after operation.

RESULTS We have carried out the last ten consecutive opera-

tions exactly according to the technique described above. The patients were all elderly females. There have been no operative difficulties or any post- operative complications in this group.

SUMlMARY The polyvinyl sponge wrap operation for prolapse

of the rectum has been shown to provide satisfactory results in follow-up studies from this and other centres. A detailed description is given of a tech- nique for this procedure.

I should like to thank Miss Jill Hassell of the Department of Medical Illustration, Westminster Hospital, for the illustrations. ~~~

REFERENCES CALNE, R. Y . (1966)~ Proc. R. SOC. Med., 59, 127. NAUNTON MORGAN, C. (1962), Ibid., 55, 1084. WELLS, C. (1959)~ Zbid., 52, 602. -- (1962), Zbid., 55, 1083.