Presentation by Yossef Nasseri, M.D. Yosef Nasseri, M.D., is a founding member of The Surgery Group of Los Angeles, a Los Angeles based physician group providing a comprehensive approach to surgical care through advanced technology, long-term patient follow-up, and direct physician access. Dr. Nasseri is double board-certified in general and colorectal surgery and specializes in cutting-edge robotic and minimally invasive techniques for the treatment of colon and rectal cancers, inflammatory bowel disease, benign anorectal diseases, a variety of hernias, and general surgery.

1. Yosef Nasseri M.D.Yosef Nasseri M.D.
Rectal Prolapse
Cedars Sinai Medical CenterCedars Sinai Medical Center
Medicine Resident TalkMedicine Resident Talk

2. Introduction
♦ Rectal prolapse or procidentia:
● Full-thickness protrusion of the rectum through the
anal sphincters
● A “falling down” of the rectum so that it’s out of the
body

3. Introduction
♦ Internal prolapse or intussusception:
● Occult rectoanal intussusception
● Prolapse does not protude from the anus
● Not always pathologic/symptomatic
● Occurs in 50% of defograms
♦ Rectal mucosal prolapse:
● Protusion of the rectoanal mucosa

4. Mucosal vs Full Rectal Prolapse
♦ To compare the quality of collagen in
patients with hemorrhoidal disease versus
normal controls
♦ To compare the quality of collagen
between different genders and age groups

5. Mucosal vs Full Rectal Prolapse

6. Difference Between Rectal
Prolapse and Hemorrhoids
Rectal Prolapse Hemorroids
Tissue Folds Circumferential Radial
Abnormality on
Palpation
Double Rectal
Wall
Hemorrhoidal
Plexus
Resting and
Squeeze
Pressures
Decreased Normal

7. Difference Between Rectal
Prolapse and Hemorrhoids

8. Pathophysiology
♦ Result from
● Constipation (component of colonic dysmotility)
● Weakening/malfunctioning of pelvic floor/sphincters
● Anismus – spastic pelvic floor
● Pudendal neuropathy (obstetric injuries, aging)
● Sphincter dysfunction (trauma, aging)
♦ Chronic straining – progression of disease
● Intussusception -> prolapse
● OR rectocoele w/ or w/out rectal ulcer

9. Pathophysiology
♦ Rectum passes through opening in pelvic floor
funnel
♦ With BMs, intussusception occurs much like
what happened with hiatal hernia
♦ Lateral & rectosigmoid attachments relax
♦ Mesorectum lengthens
♦ Anal sphincters stretch
♦ Rectal prolapse

10. Method

11. Pathophysiology
♦ Associated pelvic anatomic abnormalities
● Deep anterior cul de sac
● Redundant sigmoid colon
● Patulous anal sphincter
● Loss of posterior rectal fixation

12. Clinical Features
♦ Mucus Discharge
♦ Rectal Bleeding
♦ Soilage
♦ Feeling of incomplete evacuation
♦ Diarrhea
♦ Itching

13. Clinical Features
♦ Extreme of age
♦ 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

14. 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

15. Take Home Message
♦ USUALLY BOTH A FUNCTIONAL AND
ANATOMIC COMPONENT TO THIS PROBLEM
♦ IMPORTANT WHEN CHOOSING SURGERY AND
POST-OP TREATMENT
● Surgical intervention may worsen either the
incontinence or constipation
● Post-op biofeedback therapy often needed

16. Evaluation
♦ Ask patient to produce the prolapse
♦ If not obvious
● straining in sitting position (toilet)
● phosphate enema or glycerine suppositories
(children) to induce strain
♦ Look for associate vaginal prolapse (15-30%)

17. Evaluation
♦ Concentric rings and grooves
♦ Perianal skin excoriation and maceration
♦ Chronic prolapse
● Inflamed, edematous and irregular surface
● Biopsies to rule out neoplasia
♦ Digital examination
● Sphincter pressures
♦ Colonoscopy or barium enema
● Exclude tumor
● Biopsy of ulcers and mass lesions

18. Evaluation
♦ Defecography
● Rectocele
● Internal intussusception
♦ Anal manometry can help assess sphincters
● Longstanding prolapse may damage internal sphincter
♦ EMG for patients with history of severe straining
♦ Colonic transit times with severe constipation
● May need colon resection

19. Nonoperative management
♦ Treat constipation
● Fiber supplements
● Stool softeners
♦ Reduce incarcerated rectal prolapse
● Table sugar

20. Surgical Treatment
♦ Mainstay in treatment of rectal prolapse
♦ Over 100 procedures
♦ Perineal procedures
● Resection, reefing, and encirclement
♦ Abdominal procedures
● Fixation, colon resection or combination of both

21. Choosing Type of Surgery/
Perineal
♦ High-risk or eldery patients
♦ Advantages
● Low morbidity and pain
● Low mortality
♦ Disadvantages
● Higher recurrence rate
● Risks coloanal leak

22. Choosing Type of Surgery/
Abdominal
♦ Overall better results than perineal
approaches
♦ Full mobilization of the rectum, sacral fixation
with or without resection
♦ Younger patients
♦ Most common procedures
● Rectopexy
● Resection and rectopexy

23. 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

24. Perineal Procedures
♦ Perineal Proctosigmoidectomy – Altmeier
♦ Mucosal Sleeve Resection - Delorme
♦ Anal Encirclement - Thiersch Wire Technique
♦ Perineal suspension/fixation - Wyatt

25. Altmeier Procedure

26. Delorme Procedure

27. Delorme Procedure

28. Delorme Procedure

29. Thiersch Procedure

30. Perineal Procedures - Advocates
♦ Pts suffer mainly from incontinence,
constipation and decreased quality of life
♦ Pts are not mainly threatened from recurrence
♦ Surgery should be verified in priority to its effect
on post op QOL rather than recurrence

31. Abdominal Procedures
♦ Anterior rectopexy or Ripstein procedure
● Anterior wrapping of the rectum and fixation to sacrum
♦ Posterior rectopexy - Wells procedure
● Synthetic mesh
● Sutures alone
♦ Sigmoid colectomy with sutured rectopexy
● Low recurrence
● Low morbidity
● Improves constipation

32. Ripstein Procedure

33. Ripstein Procedure

34. Ivalon Sponge

35. 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

36. 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

37. Laparoscopic Rectopexy
♦ 152 pts over 16 yrs
♦ Conversion rate 0.7%
♦ Mean OR time – 204 mins
♦ Mean follow up – 47 months
♦ Improvement or no constipation – 81%
♦ Recurrence rate – 11%
Laubert et al, Surg Endoscopy 2010

38. Laparoscopic vs. Open Rectopexy
♦ 40 patients
♦ Randomized to laparoscopic or open group
♦ Significant differences in favor of laparoscopy in
narcotic requirement, pain and mobility scores
♦ Respiratory morbidity greater in open group
Solomon et al, BJS, 2002

39. Laparoscopic vs. Open Rectopexy
♦ 126 laparoscopic rectopexy vs 46 open rectopexy vs
21 resection rectopexy
♦ Median follow up – 5 yrs
♦ No significant difference in recurrence between
groups (4%)
Byrne et al, DCR, 2008

40. Laparoscopic vs. Open Rectopexy
♦ Meta analysis
♦ 12 studies of 688 pts
♦ Laparoscopy
● Longer operation
● Decrease LOS
♦ No difference in constipation, incontinence, M&M
♦ Recurrence not recorded
Sajid et al, DCR, 2010

41. Recurrence
♦ Can happen after either perineal or abdominal
procedure
● Overall 15% recurrence rate (range is 0-60%)
● Abdominal operations – up to 10%
● Perineal operations – up to 20%

42. Recurrence
♦ 2 types of recurrence
● Mucosal
● Full thickness
♦ Early recurrence
● Occurs within first year
● Likely the result of a specific technical failure
♦ Non-early recurrence
● Generally occurs 18-24 months postoperatively

43. Recurrence - Etiology
♦ Surgical factors
● Inadequate mobilization of rectum
● Inadequate fixation of the rectum to the sacrum
● Incomplete resection of a redundant rectosigmoid
♦ Nonsurgical factors:
● Vigorous physical activity or childbirth – disruption of pexy
● Continued constipation with persistent straining
♦ Pathophysiologic factors:
● Disordered defecation
● Intestinal dysmotility

44. Recurrence - Literature
♦ Meta-analysis
♦ 264 pts in 8 trials
♦ Included both abdominal and perineal operations
♦ Extent of rectal dissection is the single most important
factor in decreasing recurrence (divide the lateral
ligaments)
♦ No difference between mesh or suture alone
Bachoo, Cochrane Database Sys Rev 2000

45. 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