Chapter 25. Operative Management of Rectal Prolapse

• Symptomatic rectal prolapse with or without fecal incontinence.

Resection Rectopexy

• Elderly patients with limited life expectancy.
• Patients with severe comorbidities or those unable to tolerate general anesthesia or major abdominal surgery.

Perineal Rectosigmoidectomy (Altemeier Procedure)

• None.

Resection Rectopexy

Expected Benefits

• Resection rectopexy is more durable than perineal rectosigmoidectomy and can often be performed via a laparoscopic approach.

Potential Risks

• Bleeding or hematoma development requiring reoperation.
• Wound infection.
• Injury to one or both ureters requiring repair.
• Sexual dysfunction, including impotence or retrograde ejaculation in men.
• Incisional hernia.
• Possible temporary or permanent colostomy.

Perineal Rectosigmoidectomy (Altemeier Procedure)

Expected Benefits

• Preferred over an abdominal approach in high-risk patients.

Potential Risks

• Infection, most notably perirectal abscess.
• Bleeding, primarily from the sacral venous plexus but also potentially from the mesenteric vascular supply divided as part of the procedure.
• Anastomotic dehiscence.
• Recurrence of rectal prolapse.
• Loss of or failure to regain fecal continence.

Resection Rectopexy

• Standard general surgery set used in gastrointestinal surgery.

Perineal Rectosigmoidectomy (Altemeier Procedure)

• Lone Star retractor.

• Complete colonoscopy (preferable) or barium enema and sigmoidoscopy to rule out malignancy or other colonic disease.
• Bowel preparation according to surgeon preference.

Resection Rectopexy

• The patient should be supine on the operating table.
• A Foley catheter is placed to decompress the bladder.
• Either a nasogastric or an orogastric tube is placed to decompress the stomach.

Perineal Rectosigmoidectomy (Altemeier Procedure)

• The patient may be positioned either in the lithotomy position or in the prone jackknife position.
• A Foley catheter is inserted to decompress the bladder.
• A Lone Star retractor is used for exposure.

Resection Rectopexy

• Figure 25–1: As the normal rectal attachments become lax, the rectum intussuscepts through the pelvic floor, telescoping through the anus.
• Figure 25–2: The redundant sigmoid colon is resected in the usual manner, down to the peritoneal reflection.
  • The peritoneum is incised posteriorly and laterally to mobilize the rectosigmoid out of the pelvis, but the lateral attachments of the rectum are left intact.
  • Redundant rectosigmoid is resected.
  • The proximal colon is then anastomosed to the rectum to provide intestinal continuity and the rectum is sutured to the presacral fascia to fix it in place.
• Figure 25–3: The completed procedure is shown, with the anastomotic line at or below the peritoneal reflection and tacking sutures between the rectum and the presacral fascia fixing the colon in place.