Plate 223
###### Figure 5

Operative correction of complete rectal prolapse in children is rarely indicated. However, in adults (especially in older groups) effective operative repair is worthwhile. Relatively commonly, rectal prolapse is found to be associated with or related to neurologic and psychiatric disorders as well as degenerative arteriosclerotic diseases. True prolapse of the rectum involves a herniation of the pouch of Douglas through the dilated and incompetent sphincter muscles. To correct this defect, the hernial pouch must be eliminated and the weakened pelvic floor strengthened. Obliteration of the pouch of Douglas and fixation of the rectum can be accomplished by the perineal, abdominal, or combined approach.

True prolapse of the rectum starts as an internal intussusception at the level of the levator muscles anteriorly. The rectum slides from this weak point through the anal canal. A true prolapse can be identified by circular rings of the prolapsed rectum as all layers of the bowel are present. In a first-degree prolapse, only the mucosa of the bowel is prolapsed, which is usually identified by three radial folds rather than circumferential folds. Rectal prolapse, if allowed to persist, can result in dilatation and incompetent anal sphincters. Prolapse is often present in elderly women who have perineal descent and weakness of the pelvis floor muscles. Perineal descent may often be associated with either a retocele or a cystocele. There is often an antecedent history of multiple pregnancies and pelvis surgery including hysterectomy. Operative correction by the perineal approach is usually reserved for individuals who are elderly and would otherwise be unable to tolerate a sigmoid colectomy and rectopexy, which is the ideal repair for this problem.

Colonoscopy or a barium enema and sigmoidoscopic examination are essential. The use of a low-residue diet, cathartics, and enemas is necessary to obtain a clean and empty large bowel. The prolapse is reduced and reduction sustained by the application of a T-binder to minimize the associated edema and encourage the healing of any superficial ulcerations. The procedure requires a complete bowel prep including both mechanical cleansing and oral and preoperative intravenous antibiotics.

General or spinal anesthesia is satisfactory; however, general is usually preferred.

The patient is placed in a lithotomy position with the legs widely separated. The table is in a slight Trendelenburg position to decrease the venous ooze and enhance the anatomic dissection.

The prolapse is reduced and the rectum irrigated ...

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