The treatment of complete rectal prolapse in adults is mainly surgical, with four surgical routes: transabdominal, transperineal, transabdominal perineal and sacral. There is no single surgical method that can be used for all patients, and sometimes several surgical methods are needed for the same patient. In the past, the surgery only paid attention to repairing the pelvic floor defect, and the recurrence rate is high. In recent years, the doctrine of rectal prolapse has been studied, and the surgery pays attention to treating the rectum itself, and now the following surgeries are mostly used.
1, rectal suspension and fixation
(1) Ripstein surgery: Transabdominal incision of the peritoneum on both sides of the rectum, freeing the posterior wall of the rectum to the tip of the tailbone and raising the rectum. A 5 cm wide Teflon mesh suspension band was used to surround the upper rectum and fixed to the presacral fascia and periosteum under the sacral bulge, and the edge of the suspension band was sewn to the anterior rectal wall and its lateral wall without repairing the pelvic floor. Finally, the peritoneal incision on both sides of the rectum and the layers of the abdominal wall are sutured. The main point of this operation is to raise the pelvic trap, the operation is simple and does not require resection of the intestinal canal, the recurrence rate and mortality rate are low, and this operation is mostly used in the United States and Australia. However, there are still certain complications, such as fecal impaction obstruction, presacral bleeding, stricture, adhesive small bowel obstruction, infection and slippage of the suspensory band, etc. Gorden synthesized the results of 1111 cases of rectal prolapse with Ripstein’s surgery in the literature, with a recurrence rate of 2.3% and complications of 16.6%. tjandra (1993) treated 169 cases of rectal prolapse in 27 years, and performed a total of The results of the Ripstein procedure were unsatisfactory in 35% of the patients, because the symptoms of bowel dysfunction (constipation, diarrhea or alternating constipation and diarrhea) still persisted. Therefore, he stated that bowel resection with or without fixation is preferable to the Ripstein procedure in patients with rectal prolapse with constipation.
(2) Ivalon sponge implantation: This procedure was pioneered by Well, so it is also known as Well procedure and posterior rectal suspension fixation. At present, this method is mostly used in the UK to treat adult human complete rectal prolapse. Method: Transabdominal free rectum to the posterior wall of the anorectal ring, sometimes cut the upper half of the lateral rectal ligament, suture the semicircular Ivalon sponge sheet in the sacral recess with nonabsorbable sutures, pull the rectum upward and place it in front of the Ivalon sheet, or wrap it around with the free rectum suture only, not with the sacrum, to avoid presacral bleeding. The Ivalon sponge was sutured to the lateral wall of the rectum, and the anterior rectal wall was kept open with a gap of about 2 to 3 cm wide to avoid intestinal stenosis. Finally, the pelvic peritoneum is used to cover the sponge piece and rectum. The advantages of this method are the fixation of the rectum and sacrum, hardening of the rectum, prevention of intussusception formation, and low mortality and recurrence rate. In case of infection, the spongy piece becomes a foreign body and a fistula will form. The most important complication of this procedure is pelvic septicemia caused by implantation of the sponge sheet.
Prevention requirements.
① Adequate colonic preparation should be made before surgery;
(ii) placement of antibiotic powder in the implanted lamella;
③Intraoperative use of high-dose broad-spectrum antibiotics;
④Stop bleeding thoroughly;
⑤If the conjunctiva is inadvertently broken during surgery, the implantation should not be done.
In case of pelvic infection, the dangling lamellae should be removed. There are reports of no recurrence of rectal prolapse after removal. marti (1990) collected literature and reported 688 cases of well surgery, with an infection rate of 2.3%, operative mortality rate of 1.2% and recurrence rate of 3.3%.
(3) Suspension of the rectum over the sacrum: Early Orr fixed the rectum to the sacrum generally twice as prolapsed with two layers of the broad fascia of the thigh (generally folded in no more than 5 layers). The depression of the bowel wall folding must be downward and the stitches must not be upward, each about 2 cm wide and 10 cm long. after the rectum is properly free, one end of the broad fascia band is sewn to the anterolateral wall of the rectum after elevation, and the other end is sewn to fix the sacral promontory for suspension purposes. In recent years, it is advocated to replace the broad fascia with nylon or silk tape or two fasciae taken from the anterior sheath of the rectus abdominis, with good results. There have been two reports of Orr surgery in China, with 31 cases and a recurrence rate of 19.3%.
(4) Anterior rectal wall folding: In 1953, Shen Kefei proposed anterior rectal wall folding according to the pathogenesis of complete rectal prolapse in adults.
Method: Transabdominal free raising of the rectum. The lower part of the sigmoid colon is lifted upward, and several layers of transverse folding sutures are made at the upper end of the rectum and the anterior wall of the lower end of the sigmoid colon from top to bottom or from bottom to top, and each layer is interrupted with 5 to 6 stitches of silk thread. Each folded layer can shorten the anterior rectal wall by 2 to 3 cm, and each two layers are folded 2 cm apart, and the length of the folded intestinal wall can only pass through the plasma muscle layer. As a result of folding the anterior rectal wall, the rectum is shortened, stiffened, and fixed with the sacrum (sometimes the lateral wall of the rectum is sutured and fixed to the anterior sacral fascia), which not only solves the lesion of the rectum itself, but also reinforces the fixation point at the junction of the sigmoid and rectum, in line with the view of treating intussusception.
(5) Nigro surgery: Nigro believed that because the puborectalis muscle lost its contraction and could not pull the rectum forward, the pelvic floor defect was enlarged, the “anorectal angle” disappeared, the rectum was in a vertical position, and the rectum prolapsed, so he advocated the reconstruction of the rectal sling. Nigro used Teflon band to fix the lower rectum posteriorly and laterally, and pulled the rectum anteriorly, and finally sutured the Teflon band to the pubic bone to establish the “rectal angle”. The sling can be palpated by rectal palpation after surgery, but it has no contractile effect. Nigro reported more than 60 cases, with no recurrence after more than 10 years of follow-up. This procedure is more difficult and the main complications are bleeding and infection, which need to be performed by more experienced surgeons.
2.Prolapsed intestinal canal resection
(1) Altemeir procedure: trans-perineal resection of the rectosigmoid colon; Altemeir advocates trans-perineal resection of the prolapsed intestine in one stage. This procedure is especially suitable for elderly people who are not suitable for transabdominal surgery, those who have prolapsed for a long time and cannot be repositioned or whose intestinal canal is necrotic.
The advantages are.
① Access from the perineum allows visualization of the anatomical variation and facilitates repair.
②Anesthesia need not be too deep, and the elderly can easily tolerate deeper.
(3) Simultaneous repair of sliding hernia and removal of the long intestinal canal.
④No need to transplant artificial fabric and reduce the chance of infection.
⑤The mortality rate and recurrence rate are low.
However, this method still has certain complications, such as perineal and pelvic abscess, rectal stricture, etc. Altemeir (1977) had reported 159 cases with 8 recurrences (5.03%). There was one case of death. Early complications were 47 cases, such as perineal abscess (6 cases), cystitis (14 cases), pyelonephritis (7 cases), pulmonary atelectasis (7 cases), cardiac insufficiency (6 cases), hepatitis (4 cases), and ascites (3 cases). Late complications were observed in 6 cases: pelvic abscess (4 cases), rectal stenosis (2 cases).
(2) Goldberg surgery: transabdominal resection of sigmoid colon + fixation: because of the complications of removing the prolapsed intestine through the perineum, Goldberg advocated raising the rectum after freeing it through the abdomen, fixing the lateral wall of the rectum with the sacral periosteum and removing the lengthy sigmoid colon at the same time, with good results. 1980 he summarized 103 cases over 20 years (1952-1977), and only one case died. Nine cases had mucosal prolapse in the follow-up, and the recurrent cases were treated with injection of vegetable oil of petrolatum or rubber ring ligature with good results. Complications were 12 cases (12%): 3 cases each of colonic obstruction and small bowel obstruction, 1 case each of anastomotic fistula, wound dehiscence, severe presacral hemorrhage, fecal fistula, acute pancreatitis and acute clamping of esophageal hiatal hernia.
3. Anal reduction.
A 1.5-cm-wide fascial nylon mesh band or silicone rubber mesh band is placed around the anal canal to reduce the size of the anus and stop rectal prolapse. It is only suitable for the elderly and the physically weak. Method: A small incision is made at the front and back of the anus, and the two incisions are separated subconsciously through the anus with a curved vascular clamp at the subcutaneous margin. From the incision, a nylon mesh band is wrapped around the upper part of the anal canal and knotted into a loop so that one index finger can pass through the anus. Postoperative infection and fecal impaction are likely to occur, and the recurrence rate is high.