Plate 225

In some instances, especially when the prolapse is not particularly marked, the pouch of Douglas may be developed from the anterior rectal wall similar to a direct hernial sac (Figure 12). The peritoneum is then carefully incised and the margins held apart by traction with two or three forceps (Figure 13). The surgeon's index finger should be inserted to ascertain that the pouch of Douglas is free from attachments to either the small bowel or the adnexa in the female. It may be necessary to enlarge such an opening and insert a small retractor to accomplish this with good visualization. The pouch of Douglas should be closed as high as possible with a purse-string 00 absorbable suture (Figure 14). Considerable time may be required to make certain that the pouch of Douglas has been obliterated as high as possible. If the obliteration cannot be done satisfactorily, it may be judicious to obliterate the pouch of Douglas by a transabdominal approach as part of a plan for a second-stage or a two-stage procedure. After the peritoneum has been closed, the redundant peritoneum is amputated, and additional sutures are taken to control bleeding and reinforce the pouch of Douglas (Figure 15).

The next step involves identification of the levator muscles, since the reinforcement of the pelvic floor is essential to prevent recurrence. The procedure to be followed is not unlike the approximation of the levator muscles in the performance of a posterior perineorrhaphy. A small narrow retractor can be inserted anteriorly as the surgeon inserts the index and middle fingers of the left hand to better define the levator ani muscles on the left side. An Allis or Babcock clamp grasps the levator muscles to better define their margins, and a deep 00 absorbable suture is inserted (Figure 16). The first suture can be applied at either the top or the bottom of the proposed closure, depending on which is easier. In Figure 17, the first suture shown is placed in the bottom of the approximation, and a right-angle clamp depresses the bowel wall to provide a snug approximation by the levators. An additional three or four sutures are required to approximate the levators farther up in the midline (Figure 18).

Only after the levators are approximated should the prolapsed bowel be prepared for amputation. It is essential that the normal anatomic position of the bowel be retained. For this reason it has been found judicious to split the anterior as well as the posterior wall of the prolapsed large intestine almost up to the region where the bowel will be divided. This should be done carefully so that sufficient bowel is available for approximation to the pectinate line, yet a sufficient amount is removed to prevent recurrence (Figure 18). After the bowel has been divided, the surgeon should insert a finger into the lumen of the bowel to again check snugness of the approximation of the levator muscles. Enough room should be available to admit the index and middle fingers easily. If the approximation of the levators seems to be too snug and the blood supply to the bowel compromised, one of the sutures may be removed, or, if too large, an additional approximation of the levators should be considered.

Before the bowel wall is divided up as high as eventually required, the midline anteriorly should be tested for length. The bowel wall is divided up to a point where a retraction suture can be placed in the midline approximating the mucosa with the pectinate line without tension (Figure 19). A quadrant of the mucosa is then divided, and the mucosa is approximated to the pectinate line with either the continuous lock or interrupted 00 absorbable sutures. The mucosa can be approximated more accurately if a planned quadrant anatomic fixation is carried out as shown in Figures 19 and 20. The importance of the traction sutures in the midline and at the halfway point on either side readily becomes apparent as the satisfactory approximation of the mucosa to the pectinate line is finally accomplished (Figure 20). There should be an easy approximation of the mucosa to the pectinate line, and it should have a nice pink color. The sutures should not be tied so tight as to produce bleaching of the mucosa. After completion of the procedure the surgeon should introduce a well-lubricated finger carefully through the anastomosis to make certain of its patency as well as its adequacy (Figure 21). No drainage is indicated.

Antibiotic therapy should be considered for about 3 or more days. Fluid balance is maintained by intravenous administration of water, glucose, and electrolytes. A liquid diet is gradually progressed to a low-residue diet. Mineral oil in doses of 1 oz two times per day is given. Digital examination is delayed unless undue distress develops about the site of operation. The possibility of development of a perirectal abscess, which may require incision and drainage, is an ever-present threat.