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RECTAL PROLAPSE
DR ANAS AHMAD
PGR – SURGICAL UNIT 2
SHALAMAR HOSPITAL- LAHORE
RECTAL
PROLAPSE
FULL THICKNESS
PROLAPSE
INTERNAL
INTUSSUCEPTION
MUCOSAL
PROLAPSE
FULL THICKNESS PROLAPSE/ PROCIDENTIA
● Full-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
INTERNAL PROLAPSE/INTUSSUSCEPTION
● Occult rectoanal
intussusception
● Prolapse does not protude
from the anus
MUCOSAL PROLAPSE
 Protusion of the rectoanal mucosa
MUCOSAL VS FULL RECTAL PROLAPSE
MUCOSAL VS FULL RECTAL PROLAPSE
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
Difference Between Rectal Prolapse
and Hemorrhoids
PATHOPHYSIOLOGY
 INFANTS
 Undeveloped sacral curve
 CHILDREN
 Attack of diarrhoea
 ADULTS
 Constipation (component of colonic dysmotility)
 Weakening/malfunctioning of pelvic floor/sphincters
 Anismus – spastic pelvic floor
 Pudendal neuropathy (obstetric injuries, aging)
 Sphincter dysfunction (trauma, aging)
Clinical Features
♦ Mucus Discharge
♦ Rectal Bleeding
♦ Soilage
♦ Feeling of incomplete evacuation
♦ Diarrhea
♦ Itching
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
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
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
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 encirclement
♦ Abdominal procedures
● Fixation, colon resection or combination of both
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
Perineal Procedures
♦ Perineal Proctosigmoidectomy – Altemeier
♦ Mucosal Sleeve Resection - Delorme
♦ Anal Encirclement - Thiersch Wire Technique
♦ Perineal suspension/fixation - Wyatt
Altemeier Procedure
Delorme Procedure
Delorme Procedure
Delorme Procedure
Thiersch Procedure
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
Ripstein Procedure
Ripstein Procedure
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
Lap ventral mesh Rectopexy
 Purpose of surgery : to correct prolapse, protect or restore
continence and avoid constipation
 Correct middle compartment prolapse too
Dissection from sacral promontory
avoiding nerves
Deep part of fold of Douglas retracted
and incised
Polypropylene mesh sutured
to anterior aspect of rectum and
fixed to sacral promontory
(Loosely)
Posterior vaginal suture
Further rectal sutures
Closure of peritoneum
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
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
Any questions??
THANK YOU

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Rectal prolapse

  • 1. RECTAL PROLAPSE DR ANAS AHMAD PGR – SURGICAL UNIT 2 SHALAMAR HOSPITAL- LAHORE
  • 3. FULL THICKNESS PROLAPSE/ PROCIDENTIA ● Full-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
  • 4. INTERNAL PROLAPSE/INTUSSUSCEPTION ● Occult rectoanal intussusception ● Prolapse does not protude from the anus
  • 5. MUCOSAL PROLAPSE  Protusion of the rectoanal mucosa
  • 6. MUCOSAL VS FULL RECTAL PROLAPSE
  • 7. MUCOSAL VS FULL RECTAL PROLAPSE
  • 8. 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
  • 9. Difference Between Rectal Prolapse and Hemorrhoids
  • 10. PATHOPHYSIOLOGY  INFANTS  Undeveloped sacral curve  CHILDREN  Attack of diarrhoea  ADULTS  Constipation (component of colonic dysmotility)  Weakening/malfunctioning of pelvic floor/sphincters  Anismus – spastic pelvic floor  Pudendal neuropathy (obstetric injuries, aging)  Sphincter dysfunction (trauma, aging)
  • 11. Clinical Features ♦ Mucus Discharge ♦ Rectal Bleeding ♦ Soilage ♦ Feeling of incomplete evacuation ♦ Diarrhea ♦ Itching
  • 12. 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
  • 13. 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
  • 14. 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
  • 15. 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 encirclement ♦ Abdominal procedures ● Fixation, colon resection or combination of both
  • 16. 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
  • 17. Perineal Procedures ♦ Perineal Proctosigmoidectomy – Altemeier ♦ Mucosal Sleeve Resection - Delorme ♦ Anal Encirclement - Thiersch Wire Technique ♦ Perineal suspension/fixation - Wyatt
  • 23. 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
  • 26. 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
  • 27. Lap ventral mesh Rectopexy  Purpose of surgery : to correct prolapse, protect or restore continence and avoid constipation  Correct middle compartment prolapse too
  • 28. Dissection from sacral promontory avoiding nerves
  • 29. Deep part of fold of Douglas retracted and incised
  • 30. Polypropylene mesh sutured to anterior aspect of rectum and fixed to sacral promontory (Loosely)
  • 34. 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
  • 35. 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

Notes de l'éditeur

  1. This perhaps sheds some light on etiology of hemorrhoidal disease and opens doors to future research into prevention and treatment of hemorrhoids.
  2. This perhaps sheds some light on etiology of hemorrhoidal disease and opens doors to future research into prevention and treatment of hemorrhoids.
  3. This perhaps sheds some light on etiology of hemorrhoidal disease and opens doors to future research into prevention and treatment of hemorrhoids.
  4. This perhaps sheds some light on etiology of hemorrhoidal disease and opens doors to future research into prevention and treatment of hemorrhoids.
  5. This perhaps sheds some light on etiology of hemorrhoidal disease and opens doors to future research into prevention and treatment of hemorrhoids.
  6. This perhaps sheds some light on etiology of hemorrhoidal disease and opens doors to future research into prevention and treatment of hemorrhoids.
  7. This perhaps sheds some light on etiology of hemorrhoidal disease and opens doors to future research into prevention and treatment of hemorrhoids.
  8. This perhaps sheds some light on etiology of hemorrhoidal disease and opens doors to future research into prevention and treatment of hemorrhoids.
  9. This perhaps sheds some light on etiology of hemorrhoidal disease and opens doors to future research into prevention and treatment of hemorrhoids.
  10. This perhaps sheds some light on etiology of hemorrhoidal disease and opens doors to future research into prevention and treatment of hemorrhoids.
  11. This perhaps sheds some light on etiology of hemorrhoidal disease and opens doors to future research into prevention and treatment of hemorrhoids.