The abdominal procedures for patients with severe intussusception or rectal prolapse with normal sphincter function are sigmoid resection with or without rectopexy and rectopexy alone. Both operations—rectopexy or resection—require complete mobilization of the rectum to the pelvic floor in order to avoid distal intussusception.
Rectopexy aims to secure the rectum to the sacral hollow. It may be performed with sutures or prosthetic materials such as polypropylene mesh (Marlex), Gore-Tex, or polyglycolic acid or polyglactin mesh (Dexon or Vicryl). Many studies have suggested a higher complication rate with the prosthetics, a lower continence rate, and no difference in recurrence, suggesting that suture rectopexy is preferable. Suture rectopexy is performed with heavy nonabsorbable sutures, attaching the rectum to the sacral hollow.
Laparoscopic methods for repair of rectal prolapse involve fixation, with or without resection. Patients may experience less pain and have a shorter duration of hospitalization than with the open abdominal approach.
Perineal operations for rectal prolapse consist of anal encirclement, the transanal Delorme procedure, and the Altemeier procedure. Anal encirclement has limited application and should only be performed selectively in patients with a very high operative risk or a limited life expectancy. The original Thiersch procedure involved placing a silver wire around the external sphincter within the ischiorectal fat. Now synthetic mesh or silicone tubes are used instead of wire. The foreign body creates an outlet obstruction, and laxatives or enemas are required for rectal evacuation. Erosion of the foreign material into the rectum and infection are significant complications that limit the utility of this technique.
The Delorme procedure is essentially a mucosal proctectomy with plication of the prolapsing rectal wall. The dissection is started 1–2 cm above the dentate line and carried to the apex of the prolapsing segment, where the mucosa is amputated. The muscle is reefed in with four to eight heavy absorbable sutures.
The Altemeier procedure is a complete proctectomy and often a partial sigmoidectomy. The apex of the prolapsing segment is delivered and placed on traction, and a full-thickness incision is made approximately 1 cm above the dentate line. The rectum is everted. The dissection is carried into the deep cul-de-sac anteriorly. Laterally and posteriorly, the vascular supply to the rectum is taken with electrocautery or clamps when necessary. The dissection is carried up onto the midline mesorectum and sigmoid mesentery until the redundant segment of bowel has been completely mobilized. If a levatoroplasty is planned, it is most easily carried out at this time with heavy absorbable suture. A levatoroplasty plicates the pelvic floor musculature and adds to improved continence by increasing the anorectal angle. The bowel is transected proximally, excising the redundant portion, and a hand-sewn (heavy absorbable suture) or stapled anastomosis is performed.
Sphincter function returns and incontinence resolves in 65% of patients who were incontinent preoperatively. Those who do not have return of sphincter function will not tolerate a sigmoid resection. Therefore, perineal proctectomy and posterior sphincter enhancement are recommended in these patients. The posterior reconstruction may alter the angle of the rectum or obstruct the outlet sufficiently to bring about continence. Individuals with severe intussusception and those who have rectal prolapse without sphincter dysfunction should do well with either the abdominal or the perineal approach.
The prognosis for patients with moderate intussusception who are treated with bulking agents is excellent. Individuals with severe intussusception and those who have rectal prolapse without sphincter dysfunction should do well. Those with sphincter dysfunction have a 60–70% chance of regaining function. The abdominal approach is associated with approximately a 10% recurrence rate. The perineal approach is associated with a 30% recurrence rate. Reoperation for recurrence is possible after either approach but may be technically easier from the perineum if an abdominal resection has not been previously performed.