Plate 223

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 with sterile saline. The skin about the perineum is cleansed in a routine manner. The area may be dried and a plastic drape used if desired. The bladder is catheterized, and the catheter left in place.

The prolapse tends to present without difficulty (Figure 1), and Babcock or Allis forceps are applied for traction purposes to determine the extent of the prolapse. The relationship of the prolapse to the pouch of Douglas and the sphincter muscles of the anus is shown in Figure 2. The protruding mass is palpated to make certain the small intestine is not entrapped in the hernia sac anteriorly. Absorbable 000 sutures are placed in midline (Figure 3, A) anteriorly, posteriorly, and at the halfway point on either side (Figure 3, B and B1) near the anal margin, not only to serve as a retractor but for subsequent landmarks at the completion of the procedure. The identification of the pectinate line is important, since the incision through the presenting rectal mucosa will be made 3 mm proximal to this anatomic landmark. This minimal amount of mucosa is adequate for the final anastomosis and is short enough to prevent postoperative protrusion. A sharp knife or electrocautery can be used (Figure 3). This area tends to be quite vascular, and meticulous hemostasis by electrocoagulation or individual ligation is essential (Figure 4). The incision through the outer sleeve should divide the full thickness of bowel wall, including mucosa as well as the muscularis. The pouch of Douglas is not entered. The dissection is facilitated if the surgeon inserts his index finger in a developed cleavage plane between the two layers of prolapsed bowel wall (Figure 5).

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