Rectal Prolapse

Operation to choose:
Old, small prolapse: Delormes
Old, bigger prolapse: Altemeier
Young, no constipation: Abdominal rectopexy
Young, constipation: Resection rectopexy

Suture/mesh rectopexy
1.Position patient in lithotomy, Trendelenberg with yellowfin boots.
2.Low midline incision, can also use a Pfannensteil.
3.Place a Balfour self-retaining retractor and conduct a laparotomy and confirm absence of co-incident disease.
4.With the small bowel packed away in the upper abdomen, incise the pelvic peritoneum on either side of the mesorectum extending down to the deepest part of the cul de sac.
5.Retract the redundant rectum upwards which should by now have an anterior surface denuded of peritoneum.
6.Dissect the mesorectum staying in the plane outside the mesorectal envelope.
7.Once the mesorectum is free, place a 10X5cm vicryl mesh posterior to the rectum. The upper level of this mesh should be 5cm below the sacral promontory. Secure the mesh to the sacrum using sutures or staples (usually just the one or two large prolene sutures to the sacrum).
8.Wrap the mesh around to the antero-lateral surface of the rectum and secure with sutures (three on each side) leaving a gap anteriorly to allow distension of the rectum. In the Ripstein operation, similar to above but mesh is placed on the anterior surface of rectum and sutured posteriorly 2cm from the midline of the sacrum.
9.Close the pelvic peritoneum.
10.Mass abdominal closure and staples/monocryl.

Delormes
1.Position patient in lithotomy, Trendelenberg with yellowfin boots
2.With a lone star retractor in place, begin by infiltrating a small amount of LA with adrenalin to define the correct plane.
3.Make an incision 2-3cm above the dentate line on the prolapse and begin to mobilize a flap of mucosa circumferentially in a submucosal plane, retracting the edges with artery forceps. Avoid full thickness defects in the muscle wall and if occurs, repair immediately but should not be a cause for concern as it will be taken up in the plication.
4.Extend the flap tube to the distal extent of the prolapse.
5.Excise redundant mucosa at this stage. Place plicating sutures of 3/0 vicryl in the muscular tube starting near the dentate line and ending at the apex of the prolapse including mucosa at the ends and place these in the lone star retractor for control. Place sutures as such along the entire circumference.
6.With all sutures now in place, tie them sequentially bunching the muscle deep to mucosa. The prolapse will automatically reduce.
7.Inspect the wound to confirm satisfactory repair, placing additional sutures if required.

Perineal rectosigmoidectomy (Altemeier)
1.Position patient in lithotomy, Trendelenberg with yellowfin boots
2.The prolapse will usually be evident as the main indication for this procedure is a strangulated prolapse.
3.Make a full thickness incision 2-3cm above the dentate line circumferentially and evert the outer tube for ease of dissection.
4.Retract any redundant sigmoid downwards and include it with the excision specimen. Divide any blood vessels close to the bowel wall.
5.Incise the inner tube starting anteriorly.
6.Place circumferential 3/0 vicryl sero-muscular sutures in sequence with further division of the inner tube and hold within a Lone Star retractor.
7.Tie the sutures once all in place and inspect the repair for satisfactory apposition, placing additional sutures as necessary.