Aims of Rectal Prolapse Surgery
The purpose of rectal prolapse surgery is to relieve the patient from chronic symptoms that occur with a rectal prolapse and to return the rectum to its normal anatomical position. When the patient is unable to push the rectum back into place, rectal prolapse surgery is warranted. Chronic symptoms include stool leakage, or the patient may be unable to control bowel movements.
Details of Surgical Procedures
The surgeon will decide the appropriate surgical procedure depending on the degree of prolapse, the age of the patient and their general health. There is no one surgical procedure that is perfect for each patient. Most rectal prolapse surgeries do relieve the symptoms, and they improve fecal incontinence.
Abdominal Surgical Approaches – There are several types of abdominal surgical approaches to this surgery. General anesthesia is used for these procedures. Abdominal surgeries are most commonly used on healthy adults.
- Marlex rectopexy – This abdominal procedure uses a monofilament knitted polypropylene mesh that is sutured to the sacrum and lateral ligaments.
- Suture rectopexy – The suture rectopexy is the simplest surgical procedure. The rectum is lifted, pulled straight and sutured to the inner surface of the sacrum (the lower backbone). A soft piece of mesh is often used to help keep the rectum in place
- Ripstein anterior sling rectopexy uses a sling material made of Teflon, marlex or goretex. The rectum is pulled, then a 4-5 centimeter mesh is sutured to the sacral bone and the anterior wall.
- Resection and fixation – The anterior resection (sigmoid colectomy) is a surgical procedure that removes the S-shaped sigmoid colon. The surgeon then sutures the two ends of the colon together. The purpose of this procedure is to straighten the colon so stool can pass through the colon more easily. There may be a lower chance of prolapse recurrence when this procedure and the rectopexy are performed in the same surgery. They reduce the possibility of complications.
- Posterior prosthetic rectopexy – This procedure uses a prosthesis, which is inserted into the space between the sacrum and the posterior rectum. It is also sutured to the rectum and sacrum.
Laparoscopy – Laparoscopy is also known as the keyhole or telescopic surgery. This surgery is done by making several small abdominal incisions and inserting slender tools through the incisions to complete the prolapse repair. It can also be performed robotically. This procedure causes less postoperative pain, a shorter hospital stay and the recovery time is also shorter.
Perineal Approach – This repair of a rectal prolapse involves the anus and perineum. The two most common procedures are the Altemeier procedure and the Delorme procedure.
The Atlemeier procedure is a major procedure. The rectal prolapsed portion of the rectum and the sigmoid colon are removed; then, the ends are sutured together and placed in an appropriate anatomical position. An anterior levatoplasty is usually performed as well, which lowers the rate of complications to less than 10 percent.
The Delorme procedure only resects the mucosa, which is the inner lining of the prolapsed rectum. The muscular layer is folded and stitched, with the cut edges being sutured together. This surgery can be done with a regional anesthetic, which means the patient will stay awake. This is ideal for older patients, and it reduces the risk of complications.
Potential Complication of These Surgeries
The laparoscopy is the least invasive procedure, therefore, the recovery is faster, and the risk of complications are fewer.
The risks for these surgeries include:
- Breathing problems
- Post-operative pneumonia
- Allergic reactions to medications
- Intra-abdominal or rectal bleeding
- Urinary retention
It is possible that the two bowel ends that are sutured together will not heal properly.
Abdominal operations have a higher complication rate than perineal repairs. Patients that undergo the Delorme procedure will require surgery to treat complications from this procedure approximately 25 percent of the time
The Atlemeier procedure is preferred in the United States and in England.
Instructions for Patient Following the Surgery
The common hospital stay is five to eight days for the abdominal procedures. The laparoscopic surgery or perineal surgeries require about a two to three day hospital stay.
It takes about three months for a complete recovery. Patients are given written instructions when they are discharged.
- Get as much rest as much as possible.
- Take pain medication as prescribed.
- Constipation and straining should be avoided.
- Use fluids, fiber, stool softeners and mild laxatives as necessary.
- There should be no heavy lifting or any straining that increases abdominal pressure for six months following surgery.
- Eat high fiber foods and drink plenty of water to avoid constipation.
- Contact you doctor for any signs of infection, such as a fever over 101°, difficulty with urination, heavy bleeding or any sign of infection at the wound site.
- Most patients return to normal activities four to six weeks following surgery.
Surgical Success Rates
Most rectal prolapse surgeries effectively relieve the symptoms, and they usually eliminate fecal incontinence. However, fecal incontinence is slightly more common in patients who have the perineal procedure as compared to the abdominal surgery. Clinical data has shown the abdominal approach in not as prohibitive as once thought for higher risk patients.
Following the suture rectopexy surgery continence is improved by 50-70 percent. Constipation is not often improved as most patients have had a life-long history of this problem.
Mortality following any rectal prolapse surgery is very uncommon.
Number of Retrospective Procedures
Recurrence rates for patient following the suture rectopexy is 2-10 percent and for the Ripstein mesh procedure the recurrence rate is 0-13 percent. The recurrence rate for resection and fixation is very low, at 0-5 percent. The Posterior prosthesis rectopexy has a three percent recurrence rate.
The recurrence rate for the Delorme procedure is from 4-38 percent as the rectum in not sutured to the sacrum.
The Altemeier procedure surgery has a recurrence rate of three percent. If the prolapse should reoccur, it is typically corrected by using this same surgical method, although some physicians will opt for the abdominal approach due to the risk of distal rectum ischemia.
The laparoscopic procedure has a low recurrence rate of 0-4 percent.
The diverse number of surgical procedures for rectal prolapse indicate there is not one preferred procedure that is perfect for each person.