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
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
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
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