The main manifestation of rectal prolapse is partial or total prolapse of the rectal wall with pelvic floor dysfunction, which often causes anal mucus leakage, bleeding, incontinence and constipation, thus affecting the patient’s quality of life. The pathological and anatomical changes of rectal prolapse include deep peritoneal reflexion, redundant sigmoid colon, relaxed anal sphincter and sacro-rectal separation. Surgery is the main means of treatment for this disease.
I. Surgical approach
Clinically, there are transabdominal surgery and transperineal surgery according to the surgical access.
(a) Transabdominal surgery: transabdominal surgery for rectal prolapse mainly includes transabdominal rectal fixation with or without sigmoid resection, which can be accomplished by conventional open surgery or minimally invasive laparoscopic (or even robotic) surgery. For male (especially young and middle-aged) patients, there is a risk of nerve damage leading to sexual dysfunction, so this surgical approach should be carefully chosen.
1, transabdominal anterior rectal suspension patch fixation (Ripstein procedure): free the rectum to the tip of the tailbone, maintaining the integrity of the fascia of the posterior rectal wall. The rectum is pulled upward, and a mesh patch is wrapped around the anterior rectal wall and fixed to the sacral promontory or anterior sacral fascia. Care should be taken to avoid too tight a wrapping that could lead to intestinal obstruction. The procedure does not require resection of the intestinal canal and has a low rate of postoperative recurrence and complications. The incidence of postoperative complications reported in the literature is 13%-33%, and the recurrence rate is 2%-8%.
Ivalon patch implantation hardens the rectum and induces aseptic inflammatory fibrosis, effectively preventing the occurrence of rectal stenosis and rectal prolapse, with a low recurrence rate and operative mortality. The incidence of postoperative constipation and defecation difficulties is reported to be 13%-19%.
The recurrence rate reported by Loygue is 5 or 6%, and 84% of patients have improved anal incontinence.
4. Rectal suture fixation: The rectum is freed from the pelvis to the level of the tip of the coccyx, preserving the lateral rectal ligament. The anterior sacral fascia and rectal mesentery were closed with non-absorbable sutures below the sacral promontory. Fixation is achieved by reactive scarification and fibrosis of the rectum. The recurrence rate is 3-9%, and approximately 15% of patients develop postoperative constipation. Since rectal fixation alone without resection of the sigmoid colon can aggravate the existing constipation, this procedure is mainly used for the treatment of rectal prolapse without constipation.
5, transabdominal rectal fixation, sigmoid resection: patients with preoperative constipation and prolapsed rectum with long sigmoid colon should be considered for rectal fixation combined with sigmoid resection. For patients with preoperative constipation, surgical treatment can significantly improve the symptoms. The postoperative recurrence rate is 2-5%, but there is a risk of postoperative complications (intestinal obstruction, anastomotic fistula, etc.).
One of the debates on transabdominal rectal prolapse surgery is whether to perform a sigmoidectomy. Most authors believe that patients with rectal prolapse combined with constipation or sigmoid redundancy should undergo sigmoidectomy + rectal suspension and fixation. We believe that an in-depth evaluation of the cause of constipation, gastrointestinal transmission test, and fecal imaging should be performed before surgery. If the test results suggest slow sigmoid transmission or a long sigmoid colon that falls into the pelvis and forms a pelvic floor hernia, we recommend partial sigmoid resection, rectal suspension, and additional pelvic floor elevation reconstruction. Patients with total pelvic organ loosening or prolapse are often encountered clinically, when it is more important to consider the treatment strategy of rectal prolapse as a part of total pelvic organ prolapse as a whole.
The current evidence-based medical evidence makes it difficult to conclude which rectal fixation is the optimal procedure. In combination with the author’s work experience, special attention should be paid to the free rectum procedure to avoid or reduce the impairment of sexual and urinary function due to paraneoplastic nerve injury.
(b) Trans-perineal surgery: Trans-perineal surgery is often used for elderly and frail patients. Other indications for transconjunctival surgery are: 1, combined with other diseases unsuitable for transabdominal surgery; 2, recurrence after transabdominal rectal prolapse repair; 3, history of previous pelvic surgery; 4, after pelvic radiotherapy; 5, young male patients to avoid the risk of sexual dysfunction.
1, trans-perineal rectosigmoidectomy (Altemeier procedure): surgical indications: 1, full rectal prolapse greater than 125px; 2, the elderly and frail; 3 rectal prolapse with impaction. The main surgical principles include: excision of the overgrown rectosigmoid colon, elevation and reconstruction of the descending pelvic floor peritoneum and folding and repair of the anal levator muscle. Surgical approach: A circumferential full rectal incision is made 1-50px from the dentate line to open the descending pelvic floor peritoneum anteriorly. The outer intestinal canal is dissected and turned over to reveal the prolapsed inner rectum and part of the sigmoid colon. The excess pelvic floor peritoneum is removed, and the pelvic floor is elevated and reconstructed; the posterior rectum is repaired by anal levator, and the proximal inner bowel is pre-excised about 2-75 px outside the anus, and the proximal bowel is separated along the pre-excision line and the colon and anal canal are sutured layer by layer. Since this procedure is a low-level coloanal anastomosis, the risk of anastomotic dehiscence and pelvic infection may occur after surgery. The advantages of this procedure are less trauma, fewer complications, no effect on sexual function, and the possibility of additional anal levatorplasty to reduce the postoperative recurrence rate, but the procedure results in varying degrees of defecation impairment due to the removal of part of the rectum or rectosigmoid colon. Postoperative complication rates of 5%-24% and recurrence rates of 0%-50% have been reported in the literature. It has been suggested that anorectoplasty can reduce the recurrence rate. In the past 5 years, we have treated 42 cases of rectal prolapse with this procedure, and the postoperative complications include: 1 case of anastomotic bleeding, 1 case of anastomotic stenosis, and 1 case of localized anastomotic dehiscence, and only 1 case of recurrence in the follow-up period of 1-55 months.
2, trans-perineal cutting suture rectal resection: In recent years, the initial experience of trans-perineal cutting suture for rectal prolapse has been reported at home and abroad, and the procedure is actually a modified version of Altemeier’s procedure. The brief operation steps are as follows: first, a linear cutting suture is used to cut the intestinal wall longitudinally to about 37,5px on the dentate line, and then the prolapsed intestine is circumferentially cut several times counterclockwise with an arc-shaped cutting suture. This procedure is suitable for patients with rectal prolapse greater than 125px, and has the advantages of short operation time and simple operation. The author believes that the following two points should be noted: (1) for patients with severe dilatation, edema and hypertrophy of the prolapsed intestine, the use of cutting sutures may result in incomplete cutting and suturing; (2) the operation is likely to damage the pelvic floor peritoneal hernia intestinal canal, so it is recommended that the operator operate under laparoscopic monitoring of the pelvic organs. In the author’s opinion, the operation only resects the prolapsed intestinal canal and does not deal with the descending pelvic floor peritoneum and repair the anal levator muscle, and its long-term efficacy needs further observation.
3, rectal mucosal resection and muscle folding (Delorme operation): commonly used in elderly patients with prolapsed intestinal segment less than 125px and coexisting medical diseases. First, the rectal mucosa is removed in a circular sleeve, and then the muscle layer is folded and sutured longitudinally. The complication rate is 4-12%, mainly including infection, bleeding, defecation obstruction, etc., and the recurrence rate after surgery is more than 30%.
4.External pelvic rectal suspension (Express surgery): additional rectal fixation on the basis of Delorme’s surgery. The collagen strip is inserted into the end of the prolapsed rectum, and then the collagen strip is implanted upward between the prolapsed bowel wall, and the collagen strip is pulled up and sutured to the periosteum of the superior pubic symphysis to restore the anatomical position of the rectum. The results of a small foreign sample study showed that the Express procedure reduced the postoperative recurrence rate. A postoperative recurrence rate of 15% has been reported in the literature.
5.Anastomotic transanal proctocolectomy (STARR or TST STARR+): STARR or TST STARR+ is mainly used for the treatment of outlet obstruction type constipation (ODS), and some scholars at home and abroad have tried to use this procedure to treat complete rectal prolapse of less than 125px and achieved good recent results. We also achieved the same results in 5 cases of rectal prolapse treated with this procedure. This procedure has the advantages of less trauma, faster recovery, fewer complications, and shorter hospital stay. However, the long-term efficacy needs further observation.
Defecation function
Most patients with constipation and anal incontinence can be relieved after surgery. Anal incontinence is the main symptom of patients with total rectal prolapse. About 50%-80% of patients have anal incontinence before surgery, and 30% of patients still have anal incontinence after surgery, which is related to anal sphincter injury or pubic neuropathy caused by repeated pulling. The rate of improvement of postoperative fecal incontinence symptoms was similar between transabdominal and transperineal surgery.
The literature reports improvement in constipation after transabdominal surgery in 14-83% of patients, but 14-50% of patients have worsened constipation or new defecation difficulties. Possible causes include nerve injury to the free collateral ligament, altered compliance after rectal fixation and suspension, and increased outlet resistance due to redundant sigmoid colon folding in the superior rectum.
The literature reports postoperative relief of constipation in 13%-100% of patients undergoing transperineal surgery, with 1-15% of patients experiencing new defecation difficulties. The reasons for this are postoperative reduction in rectal volume, intestinal mucosal overturning and functional obstruction relieved after rectal resection.
III. Summary
The etiology of rectal prolapse is complex, and there are many surgical methods. The choice of surgical method should take into full consideration the patient’s gender, age, general physical condition, severity of prolapse, whether the intestinal tube is embedded and the patient’s expectation of postoperative quality of life (sexual function, defecation function, etc.), and combine with the surgeon’s experience to develop an individualized surgical treatment plan.