Rectal Prolapse

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Dr. Sharjeel iqbal p.g.2 surgical unit 2 services hospital:

Dr. Sharjeel iqbal p.g.2 surgical unit 2 services hospital Rectal Prolapse

Definition :

Definition Rectal prolapse ( procidentia ) Full Thickness Protrusion of full thickness of rectal wall through anus. Mucosal Prolapse Only rectal mucosa not the entire wall protrudes from the anus. Internal intussusception May be a full thickness or a partial rectal wall disorder but the prolapse tissue does not pass beyond the anal canal and does not pass out of the anus. It is important to distinguish full thickness prolapse from mucosal prolapse because treatment of the two conditions is very different.

Epidemiology :

Epidemiology Rectal prolapse is uncommon Mostly in fourth and seventh decade in life Females(multiple pregnancies due to pelvic floor descent)

Etiology :

Etiology Constipation Pregnancy Previous surgeries Neurological diseases

Differential diagnosis :

Differential diagnosis Specifically the folds between the mucosal layers in hemorrhoidal prolapse are radial whereas in rectal prolapse they are circumferential.

Presentation:

Presentation Something coming out of the anus by coughing and sneezing and any other type of stress and retract by standing.

Investigations:

Investigations Diagnosed on the basis of clinical examination. No specific lab investigations Barium studies and colonoscopy required for excluding colonic leisions . Videodefecography is used to differentiate rectal prolapse from mucosal prolapse .

Preoprative preparation:

Preoprative preparation Gut preparation I/V antibiotics

Transabdominal :

Transabdominal Rectal fixation Rectal resection combination of resection and fixation Attachment of the rectum to the sacrum can be performed using foreign material or sutures although the lateral rectal attachments can be achieved to the sacral periosteum without foreign material. Advantages lower recurrence rates associated improvements in incontinence preservation of a rectal reservoir. Disadvantages more invasive procedures risk of postoperative sexual dysfunction in males.

Anterior rectopexy (Ripstein procedure) :

Anterior rectopexy ( Ripstein procedure) The rectum is completely mobilized posteriorly Loose sung of mesh is wrapped around the anterior wall of the rectum and sutured to the sacrum. Results: Recurrence varies form 0 to 10%.

Posterior sling rectopexy (Wells procedure) :

Posterior sling rectopexy (Wells procedure) Posterior rectal mobilization and fixation of a mesh to the sacral hollow the mesh is wrapped around the lateral aspects Anterior rectal wall is left free to prevent stricture. Results: Recurrence rates for anterior and posterior rectopexy are similar Rate of stricture and therefore postoperative constipation may be lower after posterior than after anterior rectopexy .

Anterior resection without fixation :

Anterior resection without fixation After anterior resection the rectum becomes secondarily scarred and therefore adherent to the sacrum. Advantages: removal of the redundant colon may prevent volvulus and torsion and may ameliorate some bowel complaints, especially constipation. Disadvantages: Risk for anastomotic leak. Results: Recurrence rate 9%. Deterioration of continence has been reported in 10–20% of patients.

Resection with sacral fixation :

Resection with sacral fixation Fixation of the distal rectal segment to the sacrum with redundant sigmoid extirpation. Results: Initial reports stated recurrence rates of 2–9%. Bowel control is more likely to be improved when compared to other methods The procedure is comparable to rectopexy with respect to operative morbidity Postoperative constipation is less likely Division of the lateral ligaments decrease recurrence rates but increase the incidence of postoperative constipation.

Suture Rectopexy :

Suture Rectopexy Perhaps the simplest abdominal approach is rectopexy . The rectum is mobilized distally down to the levator ani muscles. The mesentery of the rectum and the muscularis are secured to the sacral fascia or bone. Results: Recurrence rates are reported in 2–5% . However a redundant sigmoid colon may at least theoretically cause the onset of or exacerbate preexisting constipation.

Laparoscopy :

Laparoscopy Sutured rectopexy , mesh rectopexy , and anterior resection or resection rectopexy are all technically feasible laparoscopic approaches.

Perineal procedures :

Perineal procedures Perineal procedures are associated with a higher recurrence rate than abdominal procedures. In addition postoperative incontinence may be exacerbated . Benefits avoiding laparotomy very low morbidity negligible disability. These operations can be done under general, regional or occasionally local anesthesia.

Altemeier operation (perineal proctosigmoidectomy) :

Altemeier operation ( perineal proctosigmoidectomy ) Perineal resection of the full thickness of the prolapsed segment with coloanal anastomosis . Results: Recurrence rates can reach up to 50% Additional plication of the levator ani muscles seems to be associated with a lower incidence of recurrence and better functional outcome

Delorme Procedure :

Delorme Procedure Unlike the perineal rectosigmoidectomy the dissection is within the submucosal layer The mucosa and the submucosa are excised Denuded muscularis is longitudinally pleated prior to effecting the anastomosis . Results: Recurrence varies from 7 to 22%.

Conclusion :

Conclusion The treatment of choice is an abdominal procedure (preferably resection rectopexy ) due to the fact that the recurrence rates are lower and continence is more likely to be restored than after other operations.

Complications:

Complications Bleeding Anastomotic Leakage Bowel injury Constipation Bladder dysfunction Sexual dysfunction

Thank You :

Thank You 