1. Surgery for rectal
prolapse
Karen Nugent, Southampton
Dukes’ Club 2013

2. What is rectal prolapse?
• Full-Thickness rectal prolapse describes the entire
rectum protruding through the anus
• Mucosal prolapse describes only the rectal mucosa
(not the entire wall) prolapsing
• Internal intussusception where the rectum collapses
but does not exit the anus.

3. Anatomical abnormality
• Abnormally deep pouch of
Douglas
• Lax/atonic muscles of pelvic
floor and anus
• Weakness of sphincters (often
with pudendal neuropathy)
• Lack of normal fixation of
rectum with mobile
mesorectum and lax lateral
ligaments

4. Cause of rectal prolapse
• Rectal prolapse may be associated with the following conditions:
– advanced age,
– long term constipation,
– long term straining during defecation,
– receiving anal sex,
– long term diarrhoea,
– pregnancy and stresses of childbirth,
– previous surgery,

5. Anatomy of the pelvic floor.

6. How common?
• Rectal prolapse is uncommon; however, the true
incidence is unknown because of underreporting,
especially in the elderly population.
• Age – under 3 years old and after the 5th decade
• 80-90% patients are women.
• Associated features: 50% incontinence, 15%-65%
constipation
• The condition is often concurrent with pelvic floor
descent and prolapse of other pelvic floor organs,
such as the uterus or the bladder.
• 35% of patients are nulliparous.

7. Fang et al DCR 2012:55:1167

8. Demographics of rectal prolapse surgery
patients

9. Demographics of rectal prolapse surgery
patients

10. Investigations
• Colonic imaging – to exclude neoplasm
• Sigmoidoscopy - ? SRUS
• Defecography
• Anal rectal manometry is sometimes used to evaluate
the anal sphincter muscles.
• Marker study

11. Aims of treatment
• Control prolapse and prevent recurrence
• Restore normal bowel function
– Restore continence
– Prevent constipation/ impaired evacuation
EITHER resection/plication of redundant bowel
OR fixation of the rectum to the sacrum

12. Incarceration
• An incarcerated rectal prolapse is rare.
– Sugar!!
– Emergency resection is required if the prolapse
cannot be reduced and the viability of the bowel is
in question.

13. Many ways to skin a cat!
• 1959 – Charles Wells
– ‘ I have traced in the literature between 30 and 50
operations for prolapse of the rectum and would
like to add still one more’
– Over 100 procedures now described!

14. Delormes’ Operation
• First described in 1900
• A circumferential incision is made through the mucosa of the
prolapsed rectum near the dentate line
• Using electrocautery, the mucosa is stripped from the rectum to
the apex of the prolapse and excised.
• The denuded prolapsed muscle is then plicated with a suture
and is reefed up like an accordion.
• The transected edges of the mucosa are then sutured together.
• Low morbidity- can be done under spinal

15. Delormes
• Mortality 0 - 4%
• Recurrence 0 - 38%
• Improvement in constipation – 13-100%, Incontinence – 32-67%

16. Altemeier
• First used by Miles in 1933, Altemeier in 1971
• Full-thickness circumferential incision is made in the prolapsed
rectum at about 1-2 cm from the dentate line
• The hernia sac is then entered, and the prolapse is delivered.
• The mesentery of the prolapsed bowel is serially ligated until no
further redundant bowel can be pulled down.
• The bowel is transected and hand sewn to the distal anal canal
or stapled using a circular stapler.
• Before anastomosis, some surgeons plicate the levator ani
muscles anteriorly, which may help improve continence

18. Altemeier
• Recurrence 0-16%

19. Perineal stapled prolapse (PSP) – stapled
altemeier
• Pulling out the prolapse completely
• At 3 and 9 o’clock, in lithotomy position — axially
cutting it open with a linear stapler

20. PSP
• Resection performed using a
curved Contour Transtar
stapler.
• 32 patients (30 female:2
male)
• Median age 80 years (range
26-93)
• Median operation time was
30 minutes (range 15-65)
• Median hospital stay was 5
days
• 6 cartridges (range 4-12)

21. Functional outcome after PSP for
external rectal prolapse
• The median follow-up was 6 months (4-22)
• Before surgery twelve (39%) patients complained of
constipation, 10 (31%) reported a continuation of their
symptoms after surgery.
BMC Surgery 2010, 10:9

22. Incontinence after PSP

23. Perineal approach
• Low morbidity
• Possibly high recurrence rates
• Avoids abdominal surgery and pelvic dissection
• ‘cutting off an upturned sock – not fixing it’

24. Abdominal procedures
• Suture rectopexy
• Mesh rectopexy
• Resection rectopexy
• Lap vs Open

25. Posterior suture rectopexy
First described by Cutait in 1959
Mobilisation an upward fixation by fibrosis and suturing
Recurrence 0-9%

26. Mobilisation alone may cause
adequate fibrosis to treat prolapse
• Suggested by John Goligher
• 643 patients (1979-2001)
– 46 mobilisation only
– 130 resection -pexy
– 467 pexy only
• No significant difference in recurrence rates
• 1,5 and 10 year recurrence rates were 1.06%, 6.61%,
and 28.9 %
Raftopoulos et al, DCR 2005 ;48:1200-6

27. Randomised controlled trial of
rectopexy vs no rectopexy
• 252 patients in 41 centres randomised
• Sigmoid resection was allowed in presence of
constipation (more frequently in no rectopexy group)
• No significant difference in complication rates
• 5 year recurrence 8.6% vs 1.5% (p=0.003)
Karas et al., DCR 2011:54:29

28. Posterior mesh rectopexy
To create more fibrosis – Sponge used by Wells in 1959
Also a variety of absorbable and non absorbable meshes

29. Posterior mesh rectopexy
• Low recurrence and low mortality
• Pelvic sepsis – 2-16%
• Haematoma should be avoided by draining pelvis (esp
if considerable ooze)
• Incontinence improved but constipation made worse

30. Resection rectopexy
• Resection of redundant rectosigmoid
• Straight course of left colon – more fixation
• Relief of constipation

31. Out with the old and in with the new

32. Lap vs Open
• Simple procedure
• Reduced pain
• Reduced hospital stay
• Studies show lap as effective as open
– No difference in incontinence, constipation or
recurrence
Sajid et al, Colorectal Dis 2010:12:515-25

33. Lap vs Open - Operative time

34. Lap vs Open – Hospital stay

35. Long term results
• 10 year period – 1994-2004
– 321 patients treated by 4 colorectal surgeons
– 128 perineal procedures
• 99 Delormes’
• 29 Altemeier
– 193 abdominal procedures
• 126 laparoscopic rectopexies
• 46 open rectopexies
• 21 resection rectopexies
Byrne et al DCR 2008: 51:1597

36. Lap rectopexy method
• Full circumferential mobilisation to pelvic floor
• ‘lateral ligaments’ divided
• Polypropylene mesh secured to sacrum and lateral
rectum (with protacker)
• Audit
• Low numbers interviewed re functional results
• Poor definition of recurrence

37. Long term results (lap rectopexy)
• 17 patients thought they had a recurrence at median of 5 years
of follow up
• 5 confirmed full thickness recurrence (126) – 4%
• 7 had banding for mucosal prolapse
• Others had no evidence of FTRP
• Incontinence scores improved - 6.6 to 3.4
• Constipation scores no change – 4.2 to 4.3

38. –

39. Summary of results
Recurrence
•Delormes 0-38%
•Altemeier 0-16%
•Posterior suture rectopexy 0-9%
•Mesh posterior rectopexy 0-6%
•Resection rectopexy 0-5%
•Post operative constipation in up to 50% of rectopexy
patients

40. Why constipation associated with
rectopexy?
Full mobilisation of rectum
Autonomic nerve injury
Dysmotility and impaired evacuation

41. Lap ventral mesh rectopexy
• Purpose of surgery for rectal prolapse to correct
prolapse, protect or restore continence and avoid
constipation
• Correct middle compartment prolapse too
• D’Hoore and Penninckx 2004
• 42 patients with total rectal prolapse
D’Hoore et al: BJS 2004:91:1500

42. Dissection from sacral promontory
avoiding nerves

43. Deep part of fold of Douglas retracted
and incised

44. Polypropylene mesh sutured
to anterior aspect of rectum and fixed
to sacral promontory (Loosely)

45. Posterior vaginal suture

46. Further rectal sutures

47. Closure of peritoneum

48. By 2006
• 109 patients (From 1995 – 2004)
• Mean age 49.3 years
• Hospital stay 5 days
• Minor morbidity – 7%
• 3 recurrences – detachment at sacral promontory
• No mesh erosions
D’Hoore and Penninckx Surg Endosc 2006:20:1919

49. Lap ventral mesh rectopexy
• Systematic review in
2010 of 12 non
randomised studies -728
patients
• Recurrence of 3.4%
• Improvement in
incontinence of 45%
• Improvement in
constipation of 24%

50. Complications
• Complications of 1.4 – 47%
– 1 death from septicaemia from mesh infection
– 1 mesh erosion of posterior vaginal wall
– 2 mesh detachments
– 3 deaths – MI, PE and CVA
– 6 post – operative bleeds
• Less constipation
• Short follow up in some patients
• Mixed reasons for VMR
Samaranavake CB et al. Colorectal Dis 2009

51. Lap Ventral Mesh Rectopexy
-Oxford results
• 65 patients with external prolapse
• 93% female
• Median age 72 years (range 16-93)
• Median follow up 19 months
Boons et al Colorectal Dis 2010: 12:526-32

52. Lap VMR results
• Median operating time 140 mins
• Length of stay 2 days
• 1 recurrence – delormes and 2 mucosal prolapse –
banding
• No mortality
• 5 surgical re-interventions – 1 portsite haematoma
and 4 port site hernias

53. Functional outcome

54. Lap VMR -? Treats prolapse with low recurrence
and improves constipation without resection

55. Warning
• In 2008, the FDA released a warning to healthcare
professionals outlining complications linked to the
use of surgical mesh in treating pelvic organ prolapse
(and stress urinary incontinence).
• To date, FDA has received almost 4000 reports of
adverse events linked to the surgical mesh.
• The agency issued a second warning July 13, 2011, as
a result of a spike in reports of serious adverse events
associated with mesh.

56. US Litigation
• On July 13, 2011, the FDA announced that patients
undergoing pelvic organ prolapse repair with a
surgical mesh may be at a greater risk for mesh
complications than women pursuing other surgical
treatments.
• Because the manufacturers of trans vaginal meshes
failed to warn patients and doctors about this
increased risk, women suffering mesh complications
may be able to file a claim seeking compensation for
medical bills, pain and suffering and other damages.

58. Incidence of complications with mesh
for vaginal prolapse repair – systematic review
1950-2010
110 studies overall synthetic biological
• Mesh erosion 10.3% 10.3% 10.1%
• Wound granulation 7.8% 6.8% 9.1%
• Dyspareunia 9.1% 8.9% 9.6%
• Treatment – removal required in >50%
Abed et al Int Urogynecol J 2011:22:789

59. Vaginal mesh contraction with
polypropylene meshes
• Shown by ultrasound- progressive and linear
relationship
– 30% contraction at 3 years
– 65% contraction at 6 years
– 85% contraction at 8 years
• Presents with
– Pain
– Dyspareunia
– Erosion
– Discharge Feiner and Maher: Obs and Gyne 2010:115:325

60. Transabdominal not transvaginal
• Abdominal sacrocolpopexy
• 322 patients
• 6% mesh erosion
• Risk factors
– Expanded PTFE mesh (OR 4.2)
– Concurrent hysterectomy (OR 4.9)
– Smoking (OR 5.2)
Cundiff et al. AJOG:2008

61. Erosion rates for gynaecologists
273 patients
Erosion rates
• Abdominal sacrocolpopexy 3.2%
• Abdominal sacro colpo perineopexy 4.5%
• Transvaginal 16%
• Time to mesh erosion 6 weeks to 6 years – mean of
21 months
Visco et al: Am J Ob Gyn 2001:184:297

62. Lap VMR – is it a time bomb?
• Contraction
• Erosion

63. Lap VMR – cure?
• An excellent cure rate and improvement in
incontinence and constipation for full thickness rectal
prolapse
• Good long term results and no reports of mesh
erosion in colorectal literature

64. Lap VMR – or not?
• Mesh may continue to shrink with time
• Worrying and increasing numbers of vaginal erosions
in gynaecological procedures
• Erosion – difficult to treat

65. What procedure?
• Role for perineal procedure in elderly unfit patients
– Low morbidity and high recurrence
• Role for rectopexy – preferably laparoscopic in
patients fit for anaesthetic
– Posterior suture rectopexy as good as posterior
mesh (avoid taking the lateral ligaments)
– Ventral mesh rectopexy adds a mesh but is
superior if perineal descent and other organ
prolapse, avoids new constipation – MESH!

66. Is perineal approach really safer?
• 1469 patients identified from American College of
Surgeons National Surgical Quality improvement data
(2008-9)
• Age
• ASA class
• Approach
Fang et al DCR 2012:55:1167

67. Comparing mortality – 7 deaths
Abdominal (1) Perineal (6)
Overall mortality 0.13% 0.9% P=0.033
ASA 3 and 4 0.35% 1.3% P=0.19
mortality
(1) (5)

68. Conclusion
• Tailor the procedure to the patients fitness and
anaesthetic risks
• Tell the patient the risks vs the recurrence rates
• VMR in women with any evidence of middle
compartment prolapse
– Mesh
– Longer op time
– Potential mesh compications
– Remember 10% are men