rectal prolapse. SYED OBAID PROFESSOR OF SURGERY

rectal prolapse. SYED OBAID PROFESSOR OF SURGERY

1. RECTAL PROLAPSE DR SYED UBAID Associate professor of surgery

2. FULL THICKNESS PROLAPSE/ PROCIDENTIA F ull -thickness protrusion of the rectum through the anal sphincters ● Protrussion consists of all layers of rectal wall ● 4-15 cm in length ● More common in females . Female to male ratio 6:1 ● Commonly associated with prolapse of uterus ● A “ falling down ” of the rectum so that it ’ s out of the body

3. FULL THICKNESS PROLAPSE/ PROCIDENTIA

4. FULL THICKNESS PROLAPSE/ PROCIDENTIA

5. INTERNAL PROLAPSE/INTUSSUSCEPTION ● Occult rectoanal intussusception ● Prolapse does not protude from the anus

6. MUCOSAL PROLAPSE Protusion of the rectoanal mucosa

7. MUCOSAL VS FULL RECTAL PROLAPSE

8. MUCOSAL VS FULL RECTAL PROLAPSE

9. Difference Between Rectal Prolapse and Hemorrhoids Rectal Prolapse Hemorroids Tissue Folds Circumferential Radial Abnormality on Palpation Double Rectal Wall Hemorrhoidal Plexus Resting and Squeeze Pressures Decreased Normal

10. Difference Between Rectal Prolapse and Hemorrhoids

11. Rectal prolapse can be distinguished from prolapsed incarcerated internal hemorroids by the characteristic concentric folds of rectal prolapse and by the painless reduction if not incarcerated.

12. PATHOPHYSIOLOGY INFANTS Undeveloped sacral curve CHILDREN Attack of diarrhoea ADULTS Constipation (component of colonic dysmotility ) Weakening/malfunctioning of pelvic floor/sphincters spastic pelvic floor Pudendal neuropathy (obstetric injuries, aging) Sphincter dysfunction (trauma, aging)

13. Clinical Features ♦ Mucus Discharge ♦ Rectal Bleeding ♦ Soilage ♦ Feeling of incomplete evacuation ♦ Diarrhea ♦ Itching

14. Clinical Features ♦ Children: first three years (male=female) ● Cystic fibrosis , malnutrition , diarrhea , severe cough , parasites ♦ Adults: majority are eldery female ● Females >50 – 6 times more likely than males ● 2/3 are multiparous ● Mental illness ( depression , autism ) ● Neurologic disorder ● Connective tissue disorder ● Constipation and straining

15. Clinical Features ♦ Constipation is associated with prolapse in 30%-70% of pts ♦ Chronic straining, sensation of anorectal blockage, need of digital evacation ♦ 60% have coexisting incontinence ● Stretching of anal sphincters ● Impaired rectal compliance ♦ 20-35% have associated urinary incontinence

16. NON OPERATIVE MANAGMENT Treat constipation Fiber supplements Stool softeners Digital repositioning in infants and young children Sub mucosal injection of 5% phenol in almond oil Reduce incarcerated rectal prolapse Table sugar

17. Surgical Treatment ♦ Mainstay in treatment of rectal prolapse ♦ Over 100 procedures ♦ In infants and young children rectum is sutured to sacrum in prone jack-knife position. ♦ In adults with unilateral prolapse, redundant mucosa is excised or, if circumferential, an endoluminal stapling technique can be used. Full thickness prolapse: ♦ Perineal procedures ● Resection , reefing, and e ncirclement ♦ A bdominal procedures ● F ixation , colon resection or combination of both

18. Choosing Type of Surgery ♦ Abdominal ● Recurrence low (<10%) ● ↑ constipation 50% ● Higher M & M esp. with anastomosis ● Mesh placement – stricture, migration, erosion, infection ♦ Perineal ● Recurrence (20%) ● Constipation rate unchanged ● Persistent incontinence worse rate due to removal of rectal resevoir ● Correction of associated abnormalities ( rectoceole , sphincter) ● No pelvic dissection – preserves sexual function

19. Perineal Procedures ♦ Perineal Proctosigmoidectomy – Altemeier ♦ Mucosal Sleeve Resection - Delorme ♦ Anal Encirclement - Thiersch Wire Technique ♦ Perineal suspension/fixation - Wyatt

20. Altemeier Procedure

21. Delorme’s procedure Only mucosa and submucosa are excised Submucosa infiltrated with epine . solution Mucosa incised 1cm proximal to dentate Mucosa and submucosa dissected off underlying muscle Continues to apex of prolapse then mucosa transected Placating sutures are placed in the muscle Mucosa is re-approximated

22. Delorme: T-incision mucosal dessection

23. Delorme –dissected off mucosa

24. Delorme –plicating sutures

25. Delorme-reduced prolapse within the pelvis as a bulbous plug

26. Complications Hemorrhage Hematoma Wound dehiscence Sepsis Stricture

27. Delorme Procedure

28. Delorme Procedure

29. Delorme Procedure

30. Thiersch Procedure

31. Abdominal Procedures ♦ Anterior rectopexy or Ripstein procedure/ sutured rectopexy ● Anterior wrapping of the rectum and fixation to sacrum ♦ Goldberg rectopexy / resection rectopexy : (Ant rectopexy+sigmoid resection) ♦ Posterior rectopexy - Wells procedure ● Synthetic mesh ● Sutures alone ♦ Sigmoid colectomy with sutured rectopexy ● Low recurrence ● Low morbidity ● Improves constipation

32. Ripstein Procedure

33. Ripstein Procedure

34. Laparoscopic Rectopexy ♦ Largely replacing open abdominal procedures ♦ Ease of performing rectopexy and colon resection simultaneously with shorter hospital stay ♦ Morbidity and mortality no different than open controls ♦ Recurrence rate lower but not statistically significant

35. Lap ventral m esh Rectopexy Purpose of surgery : to correct prolapse, protect or restore continence and avoid constipation Correct middle compartment prolapse too

36. Dissection from sacral promontory avoiding nerves

37. Deep part of fold of Douglas retracted and incised

38. Polypropylene mesh sutured to anterior aspect of rectum and fixed to sacral promontory (Loosely)

39. Posterior vaginal suture

40. Further rectal sutures

41. Closure of peritoneum

42. Rectopexy +/- Resection ♦ Rectopexy with resection - Multiple papers ● Improvement in continence and constipation ● Mortality – 0-6.7% ● Recurrence – 0-5% ♦ Rectopexy without resection - Wilson et. Al ● 9% recurrence at 48 month f/u ● 17% severe constipation managed by laxatives

43. Conclusions ♦ Consider surgery when conservative therapy fails ♦ Careful pt selection is crucial to satisfactory outcome ♦ Tailor surgery to the specific pt ♦ Laparoscopic rectopexy allows for quicker recovery and shorter LOS but similar recurrence ♦ Regardless of material used, correct suture and tack placements are crucial ♦ If severely constipated, perform sigmoidectomy ♦ Pts care as much about continence and constipation

44. Thank you!!