Rectal Prolapse Repair

Operative options for Rectal Prolapse (Procidentia) — several of these procedures (ventral mesh rectopexy, STARR) are also used for internal rectal prolapse/intussusception and rectocele, as part of the broader Obstructed Defecation Syndrome (ODS) treatment algorithm; that cross-over is noted inline below. Content below is from textbook reference chapters (Sabiston Ch52 - Pelvic Floor Disorders & Constipation, ASCRS Ch59 - Treatment of Difficult-Obstructive Defecation, and ASCRS Ch60 - Rectal Prolapse), not primary literature except where a specific study is named.

Overview

Over 100 surgical techniques have been described to repair rectal prolapse, and no single technique has been declared a gold standard — every option carries some risk of recurrence. The approach falls into two broad categories: abdominal and perineal. Choice of procedure depends on the patient's general health/comorbidities, prolapse-associated symptoms, concomitant pelvic organ prolapse (POP), prior surgical history, and surgical urgency.

Incarcerated rectal prolapse requires a perineal approach. Attempt manual reduction first if the prolapsed rectum appears pink and well perfused (topical granulated sugar can reduce edema to facilitate reduction); if irreducible or gangrenous, an emergent Altemeier procedure is performed to excise the incarcerated segment.
Otherwise, perineal repair generally carries a higher recurrence risk and is reserved for patients who are poor abdominal-surgery candidates — though growing evidence supports minimally invasive abdominal approaches even in elderly/frail patients (see "Choosing an approach" below).
A multidisciplinary evaluation is increasingly recommended when concomitant POP is present, since correcting only one pelvic compartment can worsen symptoms in the others; the choice of operation should ideally address all affected compartments together.

Abdominal procedures

Rationale: fix the rectum with adequate upward tension to prevent recurrence, while still allowing appropriate evacuatory movements during defecation. Open or minimally invasive (laparoscopic/ robotic) approaches can be used; minimally invasive approaches show lower recurrence rates, better functional results, and lower morbidity than perineal operations, and — while historically advanced age was considered a reason to exclude abdominal surgery — NSQIP and Danish national registry data both suggest minimally invasive abdominal repair is in fact safer than perineal repair in high-risk/elderly patients (see "Choosing an approach" below).

Suture rectopexy: first described by Cutait in 1959. The rectum is mobilized anteriorly and posteriorly to the levators, with identification and preservation of the hypogastric nerves; it is pulled cephalad and the mesorectum is sutured (or tacked) to the anterior longitudinal ligament at the sacral promontory with nonabsorbable material — no mesh is used. Recurrence rates up to 20%. Continence improves in 34–42% of patients, though new-onset incontinence occurs in about 7%; new constipation occurs in up to 50% of cases, thought to result from denervation of the rectum via division of the lateral ligaments — preserving one lateral stalk and fastening the mesentery unilaterally has been proposed to mitigate this. A double-blind randomized trial (Hidaka et al., 6-year follow-up) found suture rectopexy recurrence (23.3%) significantly higher than ventral mesh rectopexy (8.2%), with functional outcomes (including obstructive defecation symptoms, incontinence, constipation, and quality of life) also favoring ventral mesh rectopexy.
Suture rectopexy with sigmoid resection (Frykman-Goldberg procedure): described by Frykman and Goldberg in 1969. Adds a sigmoid colectomy to the suture rectopexy, which decreases postoperative constipation — especially in patients who present with constipation preoperatively — without the feared added morbidity of anastomotic leak (reported leak rates only 0–2.3% across several studies). One series found improved incontinence in 64% and improved constipation in 77% of patients; another found similar constipation/obstructive-defecation improvement compared with laparoscopic ventral mesh rectopexy. Recurrence (10–13%) is lower than rectopexy alone.
Posterior rectopexy with mesh (Wells procedure): first described by Charles Wells in 1959, originally using a polyvinyl alcohol sponge (Ivalon) placed in the presacral space; pelvic sepsis in up to 16% of patients drove a shift toward mesh instead of sponge. The rectum is mobilized posteriorly and laterally to the level of the levators, and an anterior sling of fascia lata or mesh is fixed to the anterior rectum and to the anterior longitudinal ligament on both sides. Recurrence up to 13% — reported three times higher in males (24%) than females per Roberts et al. Improves continence but not constipation; de novo constipation occurs in 14% and fecal impaction requiring hospital admission in 5%. Ripstein's own later modification of the sling (leaving a gap anteriorly rather than encircling the rectum completely) aimed to reduce this obstructive complication. High morbidity (a 52% complication rate reported by Roberts et al.) has led to this procedure being performed much less frequently today.
Ripstein procedure (anterior sling rectopexy): first described by Ripstein in 1952 — a distinct historical technique from the Wells posterior mesh rectopexy above, though the two are sometimes conflated as "mesh rectopexy" generically. After complete rectal mobilization, an anterior mesh sling is fixed to the anterior longitudinal ligament and wrapped around the mobilized rectum, leaving the anterior rectal wall open, then attached to the lateral stalks. Constipation is significantly worse postoperatively. Recurrence 6% for complete prolapse and 12% for mucosal prolapse, increasing with longer follow-up; morbidity from pelvic sepsis remains high even with mesh rather than sponge.
Ventral mesh rectopexy (VMR): first described by D'Hoore, and now considered the gold standard treatment for rectal prolapse in Europe given its low recurrence and symptomatic improvement. The dissection is purely anterior (avoiding the autonomic-nerve-injury risk of posterior rectal mobilization and lateral-stalk division): the sacral promontory is exposed, the rectum is mobilized anteriorly, and the rectovaginal septum is opened down to the pelvic floor. Biologic or synthetic mesh is cut to size, sutured to the distal/mid-anterior rectum (typically 8–12 stitches), then to the anterior longitudinal ligament at the sacral promontory — correcting rectocele, rectal prolapse, and intussusception by elevating the pelvic floor. In patients with severe pelvic floor laxity, additional stitches may anchor the mesh to the levator ani/ pubococcygeus. The peritoneum is reapproximated over the mesh at completion. A posterior colpopexy (suturing the mesh to the posterior vaginal wall) or, if a concomitant supracervical hysterectomy is performed, a full sacrocolpopexy (mesh to the vagina both anteriorly and posteriorly) can be added to address a concurrent enterocele/sigmoidocele or middle-compartment prolapse — see Obstructed Defecation Syndrome (ODS) for the enterocele/sigmoidocele-specific indication, and Pelvic Organ Prolapse (Anterior & Middle Compartment) for the full urogynecologic-side technique, candidacy, mesh-safety, and operative-sequencing detail behind combined sacrocolpopexy+rectopexy surgery.
Outcomes: fecal incontinence improves in 60–80.2% of patients, constipation in 58–85%, and obstructive defecation syndrome symptoms specifically in 78.6%. Recurrence of rectal prolapse after VMR ranges 0–15%, and recurrence of pelvic organ prolapse is about 8.5%. When combined with sacrocolpopexy, whole-pelvic-floor function improves (measured via three axial perineal evaluation, TAPE, scores): stress urinary incontinence improves in 53%, gynecological prolapse symptoms in up to 93.75%, and sexual function improves significantly. New/worsening fecal incontinence after VMR occurs in 1–3.9%; new/worsening constipation in 1.4–12.9%.
Mesh and suture choice: a multicenter series of 2,203 patients (Evans et al.) found mesh erosion in only 2% overall — 2.4% with synthetic mesh vs. 0.7% with biologic mesh (and even some of the "biologic mesh erosion" cases were actually non-absorbable suture sinuses rather than true mesh erosion). Within synthetic mesh, polyester carried much higher erosion risk (6.5%) than polypropylene (1.6%). Suture choice also matters: a 495-patient comparison (Tejedor et al.) found 4% erosion with non-absorbable suture (Ethibond) vs. 0% with absorbable suture (PDS) securing polypropylene mesh.
Discitis has been described as a complication of any sacral-fixation procedure, reported in 0.1–2% of VMR cases specifically — suspect it in a patient with back pain radiating to the lower extremities and evaluate/treat aggressively.
Technique and approach: laparoscopic VMR is technically demanding, requiring complete ventral dissection of the rectovaginal (or rectovesical, in men) septum and suturing in a confined space; the proficiency-gain learning curve for optimal functional/quality-of-life outcomes is 82–105 cases (operative-time proficiency is reached sooner, at 54 cases). A systematic review/ meta-analysis of robotic vs. laparoscopic VMR found similar recurrence, conversion, and reoperation rates, but robotic VMR had significantly longer operative time, significantly lower blood loss, fewer postoperative complications, and a shorter hospital stay.
VMR is also the newer preferred technique for internal rectal prolapse/intussusception and can be effective for Solitary Rectal Ulcer Syndrome (SRUS) specifically when associated with rectal prolapse — see Obstructed Defecation Syndrome (ODS) for the internal-prolapse indication, where absorbable/biodegradable mesh appears to give outcomes similar to nonabsorbable mesh. A comparative study (Altomare et al.) found VMR and STARR both improve pelvic floor function for obstructed defecation, without establishing clear superiority of one over the other.

Perineal procedures

Allow resection of the prolapse without concomitant fixation, generally under lighter anesthesia (avoiding paralysis, sometimes spinal or local only) and without an abdominal incision — facilitating early ambulation and reducing postoperative discomfort. Traditionally considered lower-morbidity but higher-recurrence than abdominal approaches, though recent reviews/trials have found no significant differences in recurrence/reoperation rates between the two — so perineal procedures remain a reasonable option to consider broadly, not only in poor surgical candidates.

Anal encirclement (Thiersch procedure): reduction of the prolapse followed by placement of a permanent encircling material (thick suture, biologic mesh, permanent mesh, or wire) in the subcutaneous space around the anus, narrowing the canal to prevent recurrence. Has largely fallen out of practice due to high failure and complication rates (encircling-device erosion, severe outlet dysfunction, and recurrence 33–44%); now reserved for patients with the most extreme comorbidities, or those with a permanent colostomy who cannot tolerate other options.
Delorme procedure: first described by Delorme in 1900. Appropriate for a short (<5 cm) rectal prolapse, typically in patients who are poor abdominal-surgery candidates. A circumferential incision within the submucosal plane is made ~2 cm proximal to the dentate line; the mucosal sleeve over the prolapsed segment is stripped and resected, the underlying muscularis is plicated (creating an "accordion" effect that shortens/supports the rectal wall), and the mucosal edges are reapproximated as a neo-anastomosis. Morbidity/mortality are very low, but recurrence is reported 16–30% across several series.
Altemeier procedure (perineal rectosigmoidectomy): first described in the 1960s. The rectum is prolapsed out through the anus and a full-thickness circumferential incision made ~2–5 cm above the dentate line; the mesorectum is divided, the redundant rectosigmoid is delivered and resected, and a hand-sewn or stapled coloanal anastomosis is created (tension-free, with confirmed adequate blood supply). A levatorplasty (anterior approximation of the levator ani) can be added to support the pelvic floor and may improve postoperative continence. Reported recurrence ranges up to 20% in most series, but was as high as 50% in one Danish national registry review specifically for the Altemeier operation — recurrence for perineal procedures generally exceeded that of abdominal procedures in that same registry. A prior sigmoid resection is a contraindication to a subsequent Altemeier (risk of leaving a devascularized bowel segment between two anastomoses); a tension-free coloanal anastomosis can instead be performed if the proximal bowel is healthy with good blood supply.
Mortality by approach in high-risk patients: an ACS NSQIP analysis (Fang et al., 2008 data) found perineal procedures carried 4× the relative mortality risk of abdominal procedures in ASA 3–4 patients, with 0% mortality in the laparoscopic-abdominal group. A Danish national registry review (Bjerke and Mynster, 2004–2014, 41% octogenarians) found an overall 30-day mortality of only 2.1%, but mortality was significantly higher after perineal procedures than abdominal ones (open rectopexy 3.3%, laparoscopic rectopexy 1.4%, Altemeier 4.4%, Delorme 2.3%). Both studies carry inherent selection bias (sicker patients more often get perineal repair), but both support growing evidence that minimally invasive abdominal repair can be performed safely even in elderly/frail patients.
STARR (stapled transanal rectal resection) / Transtar: proposed for symptomatic intrarectal prolapse specifically, and also extensively studied for rectocele (see Rectocele). A full-thickness rectal resection including the internal prolapse, done with a circular stapler (STARR) or a curved stapler (Transtar). Initially showed good results for obstructed constipation, but chronic proctalgia and stool urgency with postoperative incontinence have often been reported subsequently. Other complications: staple-line bleeding (common), and rarely staple-line disruption and rectovaginal fistula (overall morbidity rate 7–21%) — corroborated as a recognized STARR-specific cause on Rectovaginal Fistula (ASCRS Ch15). Because of the high rate of serious complications and poor functional outcome, this is not recommended by the ASCRS Clinical Practice Guidelines. STARR (and the TST STARR plus variant) is also used for internal rectal prolapse/intussusception and rectocele (see Obstructed Defecation Syndrome (ODS)) — it has lost favor in the US for those indications too, though it remains more widely used in some other countries; a comparative study found VMR and STARR give similar pelvic-floor functional improvement for obstructed defecation without a clear winner.

Choosing an approach, and recurrent rectal prolapse

The single most ideal surgical repair has not been determined — over 100 techniques exist, none declared a gold standard. In patients without prohibitive comorbidities, an abdominal repair generally has the best anatomical/functional results with the lowest mortality; minimally invasive abdominal approaches (particularly VMR) carry lower morbidity/mortality than open abdominal surgery. In male patients, and in females without multicompartment POP, current evidence does not provide a single clear recommendation, though better functional outcomes and lower recurrence are generally seen with resection rectopexy (Frykman-Goldberg) or ventral mesh rectopexy than with suture rectopexy alone or perineal approaches.

Managing a recurrence is difficult, and current evidence is insufficient to build a formal algorithm:

Recurrence after a prior perineal repair carries a much higher risk of a second recurrence (up to 50% per one systematic review, Hotouras et al.) — given the lower re-recurrence rates seen with abdominal procedures, a recurrence should generally be managed abdominally.
Gurland et al. found recurrence after VMR was much higher and occurred sooner in patients who had a prior prolapse surgery (25% at 5-year follow-up) than in patients receiving VMR as their primary repair (9.7% at 5-year follow-up) — and the risk was even higher if the prior operation had been a Delorme procedure.
A prior Altemeier procedure is a specific hazard for a subsequent resection rectopexy: leaving a devascularized bowel segment between the two anastomoses has been reported to cause mucosal sloughing or stricture — a second anastomosis should be avoided unless the prior anastomosis can be included in the resected specimen.
If a recurrence occurs early after VMR specifically, mesh detachment from the sacral promontory should be suspected, with reattachment (occasionally via a more extensive dissection including a posterior approach) considered.
Female patients with multicompartment POP at the time of a rectal prolapse recurrence should get a multidisciplinary re-evaluation, since correcting only one pelvic compartment in isolation often worsens symptoms in the others — see Pelvic Organ Prolapse (Anterior & Middle Compartment) for the full urogynecologic rationale and evaluation/staging detail behind this recommendation.
Patients undergoing any repair for recurrent prolapse should be counseled about a substantially higher risk of re-recurrence regardless of which operation is chosen.

Open items / gaps

No primary trial data comparing suture rectopexy, resection rectopexy, posterior mesh rectopexy, Ripstein, and VMR head-to-head as a full field — individual comparisons exist (Hidaka et al. for suture vs. VMR; Altomare et al. for VMR vs. STARR) but a comprehensive comparative trial across all abdominal techniques has not been identified.
No standardized algorithm exists for choosing an approach in male patients or in females without multicompartment POP — the chapter itself flags this as an unresolved evidence gap, not just a wiki gap.
Several load-bearing studies are flagged in Research Priorities.md given how much of this page's outcome data now rests on them (Hidaka et al., Evans et al., Fang et al., Gurland et al., Altomare et al.).