Rectal Prolapse Repair

Operative options for Rectal Prolapse (Procidentia). Content below is from a textbook reference chapter (Sabiston Ch52 - Pelvic Floor Disorders & Constipation), not primary literature.

Overview

Goals of surgery: eliminate the prolapse and correct the anatomic/functional abnormalities. The approach can be transabdominal or transperineal. Neither has shown a clear superiority in terms of recurrence rates, which vary 13–31%. Choice of procedure is based on the patient’s comorbidities, age, bowel function, and surgeon preference.

Abdominal procedures

Rationale: fix the rectum with adequate upward tension to prevent recurrence, while still allowing appropriate evacuatory movements during defecation. Can be done open or with minimally invasive approaches (laparoscopic or robotic); both have equivalent clinical/functional results, but laparoscopy offers benefits in pain control, hospital stay, and recovery time (recurrence rates 4–8%, morbidity 10–33%). Robotic repair offers ease of suturing/tying and improved visualization of the deep pelvis.

• Posterior mesh rectopexy (modified Ripstein operation): the rectum is dissected, retracted intraabdominally, and fixed to the presacral fascia with sutures (posterior rectopexy). A mesh can be used to increase scarring and improve fixation of the rectum, posteriorly or anteriorly. With the posterior mesh rectopexy, the rectum is mobilized posteriorly and laterally down to the levator ani muscles, and a mesh is fixed to the presacral fascia below the sacral promontory and to the rectum laterally. A simultaneous resection of a redundant sigmoid colon can be added in selected patients with coexisting constipation.
• Ventral mesh rectopexy: a technique involving limited anterior rectal mobilization and a mesh suspension to the sacral promontory; the mesh is fixed to the anterior wall of the rectum and suspended to the sacral promontory. Advantages: improvement in postoperative incontinence and constipation, with few cases of de novo postoperative constipation, and low complication/ recurrence rates (3–5%).
• Mesh-related complications (either technique): erosion, usually into the vagina; infection and pelvic sepsis; bowel obstruction; mesh detachment/migration. In theory, biologic mesh carries lower infection/erosion risk but higher recurrence risk than nonabsorbable mesh — though recent literature shows no statistically significant difference in recurrence/complication rates between biologic and nonabsorbable mesh; follow-up for biologic mesh studies has, however, been short.

Perineal procedures

Allow resection of the prolapse without concomitant fixation. Recommended for elderly or medically unfit patients, thought to carry lower operative morbidity/mortality but higher recurrence rates — though recent reviews/trials have found no significant differences in recurrence/reoperation rates between perineal and abdominal approaches. Therefore, perineal procedures may be a reasonable option to consider for all rectal prolapse patients.

• Altemeier procedure (perineal proctectomy / perineal rectosigmoidectomy): the prolapse is exteriorized, grasped with Allis clamps, and a full-thickness circumferential incision is made through the rectum 1 cm above the dentate line. The peritoneal cavity is entered anteriorly, and the redundant sigmoid colon is extracted transanally; the levator muscles are visualized and can be plicated posteriorly to reinforce the pelvic floor and restore the anorectal angle (levatorplasty or Parks postanal repair). A hand-sewn or stapled coloanal anastomosis is performed. Can be done under epidural anesthesia with minimal postoperative pain. Allows resection of redundant bowel, has low complication rates, and — especially with levator plication — is associated with low recurrence rates (10%).
• Delorme procedure: appropriate for a short (<5 cm) rectal prolapse. A circumferential incision within the submucosal plane is made 1 cm proximal to the dentate line, and the mucosa is stripped away from the muscularis propria of the rectum up to the most proximal portion of the prolapse. The stripped mucosa is excised, a longitudinal suture plication of the exposed muscularis propria is performed, and finally an anastomosis is made between the proximal and distal mucosal edges. Very safe, short hospital stay, lower complication rates than the abdominal approach. Incontinence and constipation both improve. Overall recurrence rates 7–27%, comparable to Altemeier or abdominal procedures.
• STARR (stapled transanal rectal resection) / Transtar: proposed for symptomatic intrarectal prolapse specifically. A full-thickness rectal resection including the internal prolapse, done with a circular stapler (STARR) or a specific curved-shape 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%). Because of the high rate of serious complications and poor functional outcome, this is not recommended by the ASCRS Clinical Practice Guidelines.

Open items / gaps

• No primary trial data comparing these techniques head-to-head beyond the ranges cited above — the chapter presents them as roughly comparable in recurrence but doesn’t cite a specific comparative RCT.
• No detail on how to select between abdominal and perineal approaches beyond general “comorbidity/ age/surgeon preference” guidance.