© Springer-Verlag 2001
Tech Coloproctol (2001) 5:33-35 O R I G I N A L A RT I C L E
R. Nelson • J. Spitz • R.K. Pearl • H. Abcarian
What role does full rectal mobilization alone play in the treatment of rectal prolapse?
Received: 22 December 2000 / Accepted in revised form: 13 February 2001
Abstract Rectal mobilization is a component of many operations for the treatment of rectal prolapse. How much of the successful treatment of this condition is due to this procedure alone has not been previously investigated. Full posterior rectal mobilization was done alone without sigmoid resection or rectopexy in thirteen patients. Of the thirteen patients with a mean follow-up of 33.4 months, there have been one early and one late recurrence. One further patient had a anterior mucosal prolapse at 1 year. Ten patients remain recurrence-free. In conclusion, rectal mobilization alone gives results close to more extensive operations and may be the major component of their success. In addition it may have less risk of sepsis. Key words Rectal prolapse • Surgery
Introduction The most commonly performed operation for rectal prolapse today in the United States is probably anterior resection with rectopexy. There are three components to this operation: resection of the sigmoid colon with anastomosis; full rectal mobilization; and suture of the rectum (beneath the anastomosis) to Waldeyer’s fascia of the sacrum. The rectopexy is usually accomplished with only one or two sutures from poorly defined areas of the rectum to poorly defined areas of the pelvis. The resected sigmoid is not directly involved in the prolapse, which originates well distally to the sigmoid, nor has sigmoid resection alone ever been demonstrated to correct the dyschezia that is suspected to be the cause of the prolapse. This leaves the rectal mobilization. In order to determine what role mobilization alone plays in the cure of procidentia, a group of patients in whom we were reluctant to open the bowel were subjected to rectal mobilization alone without rectopexy or sigmoid resection. As it became apparent that this simple procedure might be efficacious, it was also offered to some less complicated prolapse patients.
Patients and methods
R. Nelson () • J. Spitz • R.K. Pearl • H. Abcarian Department of Surgery, University of Illinois at Chicago, 1740 West Taylor, Room 2204 m/c 957, Chicago, IL 60612, USA
Only patients with full-thickness rectal prolapse are described herein. Obstructing lesions of the colorectum were ruled out and organic diseases of the colon, including infectious enteritis, were routinely investigated. Anorectal physiologic testing was performed only as indicated for defecation disorders, and usually in the postoperative period. Under general anesthesia in the supine position, the abdomen was opened through a lower midline incision. The peritoneum on either side of the rectum was incised from the pelvic brim to the peritoneal reflection. Using sharp dissection, the rectal mesentery, which is often quite thick and fibrotic, was separated from the presacral fascia from the pelvic brim to the pelvic diaphragm or levator musculature. No lateral stalks were divided and no dissection was done anteriorly to the rectum. Once the operative field was dry, an “0” silk ligature was tied to the areolar tissue overlying the pre-
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R. Nelson et al.: Full rectal mobilization for prolapse
sacral fascia, which was held in the heel of a right angle clamp, but not to the mesorectum. It was then cut long (2 cm). Four such ligatures were placed from the coccyx to just beneath the pelvic brim in the midline (Fig. 1). At this time, the procedure was completed and the surgical opening was closed. Postoperative care was routine.
Results We treated 13 patients with full rectal mobilization for rectal prolapse (Table 1). There has been one early recurrence at one week, in a disturbed HIV-positive woman who had suffered severe and repeated pelvic trauma. Her prolapse fell out when she was upright whereas the other patients seemed to drive their prolapse out during defecation. She was treated immediately with a perineal proctectomy and has not had further recurrences. Two patients suffered varying degrees of recurrence one year after surgery, one being full thickness and one being an anterior mucosal prolapse alone. Both have been reoperated without recurrence. There was also one
Fig. 1 Posterior mobilization only with no vascular division and simple ligatures to areolar tissue over Waldeyer’s fascia
Table 1 Full rectal mobilization for rectal prolapse: patients’ characteristics Age at Gender repair (years)
Other problems
18
Male
25
Recurrence
Morbidity
Incontinence Solitary Follow-up rectal ulcer (months)
Neuropsychiatric disorder No
No
No
No
No
15
Male
Amoebiases
No
No
No
No
No
40
28
Female
–
No
No
No
No
No
30
31
Female
Perineal descensus
Perineal proctectomy No
No
No
Yesb
33
31
Male
No bowel preparation
Delorme
No
No
No
No
57
32
Female
Crohn’s colitis
No
No
No
No
No
36
35
Female
HIV, psychosis, perineal No trauma
Rectal prolapse at 1 weeka
Otherwise
No
No
32
43
Female
Microscopic colitis
No
Anterior mucosal prolapse at 1 year
No
No
Yesb
33
49
Female
Paraplegia
No
No
No
No
No
34
58
Female
–
Anterior resection
No
No
No
No
46
59
Female
Scleroderma
Perineal proctectomy Rectal prolapse at 1 yeara
Otherwise
No
No
34
72
Female
–
No
No
No
Yes
No
12
83
Female
Dementia
No
No
Small bowel No obstruction
No
32
aRe-operated bHealed
with perineal proctectomy
Previous repair
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R. Nelson et al.: Full rectal mobilization for prolapse
patient who suffered postoperative bowel obstruction that was due to factors not directly related to the technique described above. Follow-up has varied from 12 to 57 months with a mean of 33.4 months.
Discussion Over 130 operations have been described for the treatment of rectal prolapse [1]. Some of these procedures were devised with the assumption that procidentia is a hernia and others for the treatment of intussusception. Whereas the question of etiology remains unresolved, the vast majority of previously described procedures have been abandoned because they were unsuccessful in preventing recurrent prolapse. More recently the Ripstein procedure has fallen from favor, not because of its ineffectiveness, but because it exacerbated the dyschezia that accompanies, if not causes, this disease. Procedures currently in common use for procidentia involve resection either from an abdominal, or perineal approach (anterior resection, perineal proctectomy or Delorme) [1]. The operation we describe was conceived at first because we were faced with several patients in whom it was undesirable for a variety of reasons to open the bowel either during an abdominal or perineal operation, including: failure of the patient to take the pre-operative bowel prep; Crohn’s disease of the colon; recent amoebic enteritis; or previous anastomotic leak after perineal proctectomy in a patient with scleroderma. The success in these individuals along with the minimal septic risk engendered by a procedure in which the bowel is not opened and less hemorrhagic risk when sutures are not place in Waldeyer’s fascia emboldened us to perform the operation in less complicated individuals. This operation has been done in four patients that had recurrent prolapse, following anterior resection (1 individual), perineal proctectomy (2 individuals) and Delorme (1 individual) procedures. In
addition two patients had solitary rectal ulcer syndrome related to their prolapse. In both cases the ulcer healed postoperatively. The silk ligatures to the face of the sacrum were placed at first because we felt that something was needed to create a foreign body reaction with adhesions of the mesorectum to Waldeyer’s fascia. The early success of this procedure and the apparent innocuousness of the ligatures has perpetuated this practice, though we have no specific data supporting the need to add them to the mobilization. Recurrence risk after surgical repair of rectal prolapse has varied in recent reports from nil to 15%, in general being less than 10% [2-4]. The failure rate of this new operation is 15% for full thickness prolapse in a medically complicated group of patients, though our longest follow-up is only five years. It seems that if this operation were to be more prone to failure than other commonly performed procedures, the failure should occur in the immediate post-operative period. This is indeed what we did see in one failure. This early failure has led us to consider doing other procedures, such as perineal proctectomy, for “droppers” (individuals whose rectum drops out with only gravity as a stimulus) as opposed to “drivers” (who drive their rectums out during straining at defecation).
References 1. Nelson RL, Pearl RK (1989) Rectal prolapse. In: Nyhus LM, Condon RE (eds) Hernia. Lippincott, Philadelphia 2. Madoff RD, Williams JG, Wong WD, Rothenberger DA, Goldberg SM (1992) Long-term functional results of colon resection and rectopexy for overt rectal prolapse. Am J Gastroenterol 87:101-104 3. Schlinkert RT, Beart RW, Wolff BG, Pemberton JH (1985) Anterior resection for complete rectal prolapse. Dis Colon Rectum 28:409-412 4. Bachoo P, Brazzelli M, Grant A (2000) Surgery for complete rectal prolapse in adults (Cochrane Review). In: The Cochrane Library, 1. Update Software, Oxford
