Complete:
= procidentia fullthickness protrusion of the rectum through the anus
distinguished from
prolapsed incarcerated internal hemorroids by the characteristic concentric folds of rectal prolapse and by the painless reduction if not incarcerated.
ASSOCIATED SYMPTOMS/ETIOLOGIES
Rectal bleeding, underwear wetting, incarceration Fecal incontinence 5075% Chronic constipation 3067% Obstructed defecation 33% Solitary rectal ulcer
12%
Colonic inertia 10%
ASSOCIATED FACTORS
Diastasis of the levator ani
Ulceration Strangulation Urinary and fecal incontinence Spontaneous rupture with evisceration
DIAGNOSIS
History & Physical exam If/ not seen on physical exam, ask patient to strain in squatting or sitting position Colonoscopy r/o mass
Defecography
Anal manometry & pudendal N terminal motor latencies
balloon expulsion test: balloon catheter is inflated with 50 to 100 ml of water ; without obstructed defecation the balloon should expel easily
and hand
A digital rectal exam is required with application of the finger electrode to the right and left levator ani complex
OPERATIVE MANAGEMENT
Perineal
Thiersch wire procedure : anal encirclement
Delorme procedure : mucosal sleeve resection Altemeier procedure : perineal rectosigmoidectomy
Advantages: use of spinal anesthesia, shorter hospita stay, lower risk of injury to pelvic nerves, reduced pain, concomitant repair of other
OPERATIVE MANAGEMENT
Abdominal
rectopexy Frykman & Goldberg: Sigmoid resection w/ suture rectopexy Ripstein & Lantern : anterior fixation using a sling Wells procedure : mesh placement posterior to rectum
Pts w/ perineal Sx: Older, higher ASA scores, decreased physical ability Less procedural blood loss, operative time, hospital stay, and dietary restriction Rate of recurrence 26.5% perineal Sx vs 5.2% abdominal Sx (p: <0.001)
ANAL ENCIRCLEMENT
Described in 1981
2 small lateral incisions, wire is introduced into one and out the other & repeated
DELORME
Evert
Inject local anesthesia 11.5cm above dentate to minimize bleeding Circumferential incision of mucosa Mucosa is dissected away from the underlying muscle until resistance prevents further dissection Plicate the remaining muscular tube circumferentially Resection of mucosa w/ anastomosis one quadrant at a time Anastomosis spontaneously reduces
Perineal Rectosigmoidectomy
/ALTEMEIER
Evert & give local
1.
Better suited for elderly patients that are poor candidates for abd surgery due to high recurrence rate
2. Patients with a grade 3 prolapse protruding at least 3 cm 3. Patients who are poor candidates for trans abdominal
surgery
ABDOMINAL APPROACH
Rectopexy: the lateral preserved attachments of
the rectum is tacked to the presacral fascia at
separation
ABDOMINAL APPROACH
Mobilize the sigmoid starting ~5cm proximal to the pelvic brim Mobilization of the rectum to the coccyx will minimize recurrence but increase likelihood of nerve damage The splenic flexure provides additional fixation => it is not
mobilized
Care must be taken to preserve the lateral pelvic nerves The redundant sigmoid colon is resected & primary
anastomosis is made
presacral fascia
WELLS PROCEDURE
Marlex or Teflon mesh sutured to the presacral fascia,