Surgical treatment of severe rectal prolapse with pelvic floor hernia in 7 cases

The specific cause of rectal prolapse, also known as prolapse, is unknown, and the possible pathogenesis is thought to be the “sliding hernia” theory and the “intussusception” theory, with most scholars currently agreeing with the intussusception theory [1]. However, in the observed cases, the peritoneal reflexion of the anterior rectal recess was found to be too low intraoperatively as a result of pressure on the anterior rectal wall and gradual inversion of the rectum into the intestinal cavity. Therefore, Ahermeier believes that both may lead to rectal prolapse and chronic “intussusception” as a result of a “sliding” hernia [2]. With the emergence of new techniques of pelvic floor imaging, such as pelvic imaging combined with fecal imaging, multiple combined pelvic organography and pelvic floor dynamic MRI [3], it is found that severe rectal prolapse rarely occurs alone, but is often accompanied by prolapse of other pelvic organs or pelvic floor lesions, and rectal prolapse combined with pelvic floor hernia is the most common. Pelvic floor hernia, also known as pelvic peritoneal bulge, rectal genital sink hernia or Douglas sink hernia, refers to herniation of the pelvic peritoneal sac down into the rectovaginal compartment or the peritoneum-lined hernial sac into the Douglas sink below the level of the upper third of the vagina or the superior border of the prostate. Broadly, this should include pelvic peritoneal reflexes and pathologic herniation of intrapelvic organs. In a narrower sense, only pathological protrusion occurring in the genital rectal sink. If only rectal prolapse is corrected and the presence of pelvic floor hernia is ignored, it may lead to recurrence of the lesion and insignificant relief of clinical symptoms. In our hospital, according to the theory of “acidic fixation”, we use perirectal injection and submucosal spot injection of anti-hemorrhoid injection [4] to produce sterile inflammation and fibrosis in local tissues, and the efficacy is satisfactory. However, for some of the recurring cases, the possible reason was considered that the treatment with anti-hemorrhoid injection could not solve the problem of pelvic floor hernia. Although adhesions between the rectum and the pelvic wall were not formed or the scope of adhesions was small, in 5 cases, although adhesions between the posterior rectal wall and the pelvic wall were formed, the peritoneum of the pelvic floor was lax and the anterior rectal recess was low, which caused recurrence of rectal prolapse over time. For clinical treatment of rectal prolapse and pelvic floor hernia, there are various surgical approaches such as transabdominal, transperineal, transabdominal perineal and trans-sacral [5]. Each has advantages and shortcomings. How to improve the efficacy, reduce postoperative complications, and decrease the recurrence rate, especially for recurrent cases after clinical treatment, is a key and difficult clinical concern. It has been suggested that rectal prolapse with the presence of pelvic floor hernia is an important clinical indication for transabdominal surgery for rectal prolapse [6]. Open surgery can visually observe and determine the possible causes of rectal prolapse recurrence, eliminate the recurrence factors through targeted surgery, correct the abnormal anatomical site, close the pelvic floor peritoneal defect, and appropriately elevate the deepened Douglas depression to restore it to its normal position [7]. In the previous traditional rectal suspension fixation, there are Repstems surgery, Wells surgery, Nigro surgery, etc., all of them use synthetic material strips to partially wrap the rectum, suture and fix it with the anterior rectal wall, which on the one hand can cause narrowing of the intestinal lumen and cause the occurrence of constipation; on the other hand, it increases the risk of bleeding because it is fixed to the posterior rectal wall and the presacral fascia. The advantages of this procedure: ( 1) The rectum is fixed according to the doctrine of intussusception, and the anatomical weakness of rectal prolapse is corrected. ( 2) The lateral and posterior rectal walls are suspended to support and fix the loosened rectal tissues, so that the rectum will not prolapse. ( 3) Repairing the pelvic floor and restoring the deep rectal bladder sink (or rectal uterine sink), which can strengthen the pelvic floor fascia in female patients with pelvic organ prolapse. (4) The use of patches reduces surgical trauma by eliminating the need for autologous extraction of material [8]. Also, polypropylene patches (size 250px×250px, Bard), [9] have a significant effect on stimulating fibrous tissue proliferation. Its mesh structure is easily crossed by fibrous growth and can be fixed in the tissue at an early stage. It maintains a high tensile strength after implantation. No chemical reaction with the body. Good histocompatibility, does not cause cellular mutations or aberrations in the body. Soft, elastic, good toughness and mechanical tension, with the effect of inducing fibroblast growth, promoting the growth of connective tissue into the pores of the network, in order to enhance the local tissue stress. It is easy to prepare and can be cut according to the size of the defect. It also has some anti-infective properties [10]. In order to ensure the success rate of the operation and reduce complications, attention should be paid during the operation: ( 1) Because the patient’s intestinal wall has been repeatedly detached for a long time, the intestinal wall is tough and hypertrophic, and the tissue gap is dense, bleeding should be avoided during sharp separation. ( 2) When fixing the patch with rectal suture, the suture needle should only pass through the pulpy muscle layer, not penetrate the intestinal wall. ( 3) The rectum should be completely free to the bottom of the pelvis to restore the normal pelvic structure, and then fix it. ( 4) The polypropylene mesh must be kept in contact with the abdominal organs on the anti-adhesive side. In recent years, with the invention and application of various new biological patch materials, biological (absorbable) patch repair of pelvic floor hernias is gradually attracting the attention of scholars. However, there are no reports of its application to this disease.