Download - Prolapse of Rectum
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Rectal prolapse, surgical options: An overview
and Delorme’s operation
Ashok kumar
Department of Surgical Gastroenterology, Sanjay Gandhi Post Graduate Institute of
Medical Sciences, Lucknow
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RECTAL PROLAPSE
• It is a full thickness rectal intussuception ~3inches above dentate line and extending beyond anal verge
• Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of
age and elderly people. More common
in female than male
• Young male patients tend to have psychiatric disorders
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Types of rectal prolapse
Partial or incomplete prolapse when the mucous
membrane lining the anal canal protrudes through
the anus only
Complete prolapse in which the whole thickness
of the bowel protudes through the anus
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Grading of rectal prolapse:
• Grade 1: occult prolapse
• Grade 2: prolapse to but not through anus
• Grade 3: any protrusion through anus
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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.
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Anatomic abnormalities associated with
rectal prolapse
1. Deep rectovaginal or rectovesical pouch
2. Lax pelvic floor musculature
3. Failure of normal relaxation of the
external sphincter
4. Redundant sigmoids
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Risk factors for rectal prolapse
• Chronic constipation
• Diarrhea
• Mental Retardation
• Female sex
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Presentation
Prolapse is first noted during defecation
Discomfort during defecation
Bleeding
Mucous discharge
Irregular bowel habit --incontinence
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Complications of prolapse
• Ulceration
• Infection
• Hemorrhage
• Thrombosis and edema
• Strangulation
• Urinary and fecal incontinence
• Spontaneous rupture with evisceration
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SURGICAL OPTIONS
A. Abdominal approach
Rectopexy (lockhaurt)
Rectosigmoidectomy (Mikulicz’s op.)
Resection rectopexy
Ivalon sponge rectopexy (Well’s op.)
Ripstein operation
Low anterior resection
B. Perineal approach
Thiersch’s operation
Proctosigmoidectomy (Altemeier)
Delorme Operation
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Choice of operation
Patient’s factors
Age
Sex
Medical condition
Extent of prolapse
Bowel function
Status of fecal continence
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Choice of operation
Procedure related factors
• Extent of surgery
• Morbidity of procedure
• Recurrence rate
• Impact on bowel function
• Surgeon’s familiarity with procedure
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Surgical Options
Perineal procedures
Elderly, high-risk patients
Regional or even local anesthetic
Constipated patients
resection and rectopexy
Incontinent patients
abdominal rectopexy
perineal resection with levatorplasty
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Anterior rectopexy
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RIPSTEIN OPERATION
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Posterior rectopexy
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IVALON SPONGE
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Sutured posterior rectopexy
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Posterior rectopexy (suture only)
N Mortality (%) Recurrence (%)
Loygue 1971 146 2 (1.3) 5 (3)
Carter 1983 32 0 0
Goligher 1984 52 0 1 (2)
Graham 1984 23 1 (4.3) 0
Blatchford 1989 42 0 2 (5)
Sayfan 1997 19 0 0
From Keighley and Williams 2001
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Resection Rectopexy
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Resection Rectopexy
Aims to achieve low recurrence rates and avoid long term constipation
University of Minnesota series
138 pts
Anastomotic leaks in 5 (4%)
Recurrent prolapse in 2 (1.4%)
Continence improved in all but 1 pt
Constipation improved in 56% same in 35% worse in 9%
Watts et al. Dis Colon Rectum 1985;28:96-102.
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Transabdominal rectopexy
Are associated with problems with defecation and
constipation
Have a lower recurrence rate than transperineal
approaches
Require resection of the redundant sigmoid
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Perineal Procedures
Perineal rectosigmoidectomy (Altemeier)
Morbidity 5-24%
Recurrence rates from 0-10%
Rectal mucosal sleeve resection (Delorme)
Morbidity 0-30%--hemorrhage, dehiscence, stricture,
diarrhea, urinary retention
Recurrence rates 7-22%
Perineal suspension-fixation (Wyatt)
Anal encirclement (Thiersch + modification)
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A
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E
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Thiersch Procedure
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Delorme operation
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Perineal rectosigmoidectomy is
appropriate for:
1. Younger patients who want to minimize
recurrence
2. Patients with a grade 3 prolapse protruding at
least 3 cm
3. Patients who are poor candidates for trans
abdominal surgery
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Delorme Operation
(mucosal sleeve resection)
Described by Rene Delorme in 1900
• Stripping of the mucosa
• Plication of denuded bowel
• Re-anastomosis of the mucosa
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Evaluation
• Clinical examination (DRE)
• Defecography
• Anal Manometry
• Colonoscopy/ barium enema
• Colonic transit study
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Preop preparation
• Bowel preparation-PEG
• Perioperative antibiotics
• Indwelling Foley’s catheter
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Position of the patient
• Lithotomy
• Prone jackknife
• Left lateral ( Simm’s)
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Anesthsia
• General
• Regional
• Local with intravenous sedation
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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
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Delorme: T-incision
mucosal dessection
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Delorme –dissected off mucosa
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Delorme –plicating sutures
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Delorme-reduced prolapse
within the pelvis as a bulbous plug
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Complications
• Hemorrhage
• Hematoma
• Wound dehiscence
• Sepsis
• Stricture
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Results
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