Classification of rectal prolapse: Partial: prolapse of rectal mucosa only Partial: prolapse of...

Classification of rectal prolapseClassification of rectal prolapse::

Partial: prolapse of rectal mucosa onlyPartial: prolapse of rectal mucosa only


Complete: prolapse with all layersComplete: prolapse with all layersGrade 1: occult prolapseGrade 1: occult prolapse


Complete: prolapse with all layersComplete: prolapse with all layersGrade 2: prolapse to but not through anusGrade 2: prolapse to but not through anus


Complete: prolapse with all layersComplete: prolapse with all layersGrade 3: any protrusion through anusGrade 3: any protrusion through anus

Complications of prolapse includeComplications of prolapse include::

UlcerationUlceration


StrangulationStrangulation


Urinary and fecal incontinenceUrinary and fecal incontinenceSpontaneous rupture with eviscerationSpontaneous rupture with evisceration

Partial Rectal ProlapsePartial Rectal Prolapse

1-4 cms PROTRUSION of rectal 1-4 cms PROTRUSION of rectal mucous membrane and submucosa mucous membrane and submucosa outside the anus.outside the anus.

Common in Extremes of lifeCommon in Extremes of lifeChildrenChildrenElderlyElderly

Partial Rectal ProlapsePartial Rectal ProlapsePredisposing Factor- InfantsPredisposing Factor- Infants

Underdeveloped Sacral CurveUnderdeveloped Sacral Curve low Anal Sorelow Anal Sore

Predisposing Factor- ChildrenPredisposing Factor- Children DiarrhoeaDiarrhoea Whooping CoughWhooping Cough Loss of WeightLoss of Weight

Predisposing Factor- AdultsPredisposing Factor- Adults HaemorrhoidsHaemorrhoids Prolonged strainingProlonged straining Perineal Tears Perineal Tears Females Females Secondary to Surgery Secondary to Surgery

Damage to SphincterDamage to Sphincter

Investigation in Elective CaseInvestigation in Elective Case

Finding ppt. factorFinding ppt. factorAt least a flexible sigmoidoscopyAt least a flexible sigmoidoscopy

Assessment of surgical risk (no Assessment of surgical risk (no effective nonoperative treatment)effective nonoperative treatment)

Anorectal manometry, pudendal nerve Anorectal manometry, pudendal nerve testtestPredicts functional outcome after surgeryPredicts functional outcome after surgery

TreatmentTreatmentIn children (partial or complete)In children (partial or complete)

Alleviate straining due to constipation or diarrhea Alleviate straining due to constipation or diarrhea (tenesmus)(tenesmus)

Construct regular bowel habits Construct regular bowel habits Strap the buttocks together after defecation after Strap the buttocks together after defecation after

spontaneous or manual reductionspontaneous or manual reduction Build up the body of the child and fat reservoirsBuild up the body of the child and fat reservoirs Use sclerosant injection (phenol in almond oil for Use sclerosant injection (phenol in almond oil for

submucous injection in partial prolapse and alcohol for submucous injection in partial prolapse and alcohol for retrorectal injection in complete prolapse)retrorectal injection in complete prolapse)

In case of failure one of the operations described is In case of failure one of the operations described is resorted to resorted to

TreatmentTreatment

In partial prolapseIn partial prolapse mucosal hemorroidectomy mucosal hemorroidectomy

will often suffice to deal will often suffice to deal with the condition, with the condition,

recently Longo’s procedure recently Longo’s procedure (PPH stapler is used to (PPH stapler is used to induce anal lift and induce anal lift and refixation of the prolpased refixation of the prolpased mucosa back to the rectum mucosa back to the rectum and anal canal)and anal canal)

Operations of prolpaseOperations of prolpase The choice of the operation depends on The choice of the operation depends on

Degree of prolapse present Degree of prolapse present Associated disorders (cystocele, rectocele, Associated disorders (cystocele, rectocele,

incontinence or constipation)incontinence or constipation) Co-morbid conditions (spinal cord lesion, mental or Co-morbid conditions (spinal cord lesion, mental or

psychic problems or vital system problems)psychic problems or vital system problems) The main symptoms of presentationThe main symptoms of presentation

Goals are Goals are Resection of redundant colon Resection of redundant colon Fixation of the rectum to the sacrumFixation of the rectum to the sacrum Improving symptoms of fecal incontinence and Improving symptoms of fecal incontinence and

constipationconstipation

Aim of treatmentAim of treatment

Primary objectivePrimary objectiveEradicate the prolapse Eradicate the prolapse improve the quality of lifeimprove the quality of life

Secondary gainSecondary gain Improvement in continence and bowel Improvement in continence and bowel

functionfunction

Elective Presentation :Elective Presentation :Operative TreatmentOperative Treatment

Perineal ProceduresPerineal Procedures

Thiersch ProcedureThiersch ProcedureConsidered obsolete nowadays!Considered obsolete nowadays!

Delorme ProcedureDelorme ProcedureThe minimum you should do!The minimum you should do!

Altemeier OperationAltemeier Operation (Perineal Proctosigmoidectomy)(Perineal Proctosigmoidectomy)

Perineal Procedures :Perineal Procedures :Delorme ProcedureDelorme Procedure

Mortality 0-4%Mortality 0-4%Recurrence 4-38% (St Marks 12.5%)Recurrence 4-38% (St Marks 12.5%)

Good for short prolapseGood for short prolapseCan be repeated if necessaryCan be repeated if necessary

Perineal Procedures :Perineal Procedures :Delorme ProcedureDelorme Procedure

Perineal Procedures :Perineal Procedures :Perineal ProctosigmoidectomyPerineal Proctosigmoidectomy

(Altemeier Procedure)(Altemeier Procedure)

Perineal Procedures :Perineal Procedures :Perineal ProctosigmoidectomyPerineal Proctosigmoidectomy

(Altemeier Procedure)(Altemeier Procedure) Mortality 0-5%; Mortality 0-5%; complication: pelvic sepsis, leakage Recurrence 0-complication: pelvic sepsis, leakage Recurrence 0-

16%16%

Best if Best if combined with posterior levatorplastycombined with posterior levatorplasty Ideal for Ideal for incarcerated and strangulated onesincarcerated and strangulated ones Difficult to perform for small prolapseDifficult to perform for small prolapse

Deen KL Br J Surg 1994:81: 302-304 Deen KL Br J Surg 1994:81: 302-304 Wexner, Cleveland Clinic Florida; Archieves of Surgery; Jan 2005; Wexner, Cleveland Clinic Florida; Archieves of Surgery; Jan 2005;

140,1140,1

Abdominal ProcedureAbdominal Procedure

RectopexyRectopexySutured RectopexySutured RectopexyProsthesis or Mesh RectopexyProsthesis or Mesh Rectopexy

Anterior ventral rectopexyAnterior ventral rectopexyPosterior rectopexy Wells operationPosterior rectopexy Wells operation

Resection rectopexy (Frykman-Goldbery Resection rectopexy (Frykman-Goldbery procedure)procedure)

Laparoscopic Vs OpenLaparoscopic Vs Open

Sutured RectopexySutured Rectopexy

Abdominal Procedure :Abdominal Procedure :Sutured RectopexySutured Rectopexy

No reported mortalityNo reported mortalityRecurrence (majority 0-8%; ranges 0-Recurrence (majority 0-8%; ranges 0-

27%)27%)Variable response to constipationVariable response to constipation

Posterior mobilization to tip of coccyxPosterior mobilization to tip of coccyxDivision of lateral ligaments on either Division of lateral ligaments on either

sidessides

Anterior ventral rectopexyAnterior ventral rectopexy

Posterior Rectopexy Wells Posterior Rectopexy Wells operationoperation

Abdominal Procedure :Abdominal Procedure :Prosthesis or Mesh RectopexyProsthesis or Mesh Rectopexy

Makes use foreign material to evoke Makes use foreign material to evoke more fibrous tissue reaction, examplesmore fibrous tissue reaction, examplesAnterior Sling RectopexyAnterior Sling RectopexyRipstein ProcedureRipstein ProcedurePosterior Mesh repair e.g. Wells OperationPosterior Mesh repair e.g. Wells Operation

Problems: Increased pelvic sepsis and Problems: Increased pelvic sepsis and rectal strictrectal strict

Resection rectopexy (Frykman-Resection rectopexy (Frykman-Goldbery procedure)Goldbery procedure)

Abdominal Procedure :Abdominal Procedure :Resection RectopexyResection Rectopexy

Add 1% to mortalityAdd 1% to mortalityRecurrence 0-5%Recurrence 0-5%Majority has Majority has improved constipationimproved constipation

Abdominal Procedure :Abdominal Procedure :A ComparisonA Comparison

ProcedureProcedure SuturedSutured

RectopexyRectopexy

MeshMesh

RectopexyRectopexy

ResectionResection

RectopexyRectopexy

RecurrenceRecurrence 0-8%0-8% 0-13%0-13% 0-5%0-5%

MortalityMortality 0%0% 0-2.8%0-2.8% 1-4%1-4%

ComplicationComplication rarerare 8-52%8-52% Up to 30%Up to 30%

ContinenceContinence improveimprove improveimprove improveimprove

ConstipationConstipation variablevariable Up to 42%Up to 42% improveimprove

Laparoscopic ApproachLaparoscopic Approach Rectopexy (sutured, stapled, posterior mesh, Rectopexy (sutured, stapled, posterior mesh,

resection)resection) Recurrence 0-10%Recurrence 0-10% As effective as open ( no long term difference)As effective as open ( no long term difference) BenefitBenefit

Shorter post-op hospitalizationShorter post-op hospitalization Overall reduction in costOverall reduction in cost Earlier recoveryEarlier recovery Less morbidityLess morbidity Earlier return to workEarlier return to work

Laparoscopic approach is desirable because ofLaparoscopic approach is desirable because of Benign nature of the conditionBenign nature of the condition Patients are often at high surgical risk for laparotomyPatients are often at high surgical risk for laparotomy

Choice of Operation :Choice of Operation :IndividualizedIndividualized

Abdominal procedures are ideal for young fit patient Abdominal procedures are ideal for young fit patient and provide best chance of cureand provide best chance of cure

Sutured rectopexy gives good resultSutured rectopexy gives good result Combination of a resection reduce constipationCombination of a resection reduce constipation Laparoscopic approach provides similar results with Laparoscopic approach provides similar results with

less morbidityless morbidity Perineal procedure for frail patients with extensive Perineal procedure for frail patients with extensive

co-morbidity, not fit for major abdominal surgeryco-morbidity, not fit for major abdominal surgery Perineal rectosigmoidectomy, combined with Perineal rectosigmoidectomy, combined with

levatorplasty gives better result than Delorme’s levatorplasty gives better result than Delorme’s operationoperation

Classification of rectal prolapse: Partial: prolapse of rectal mucosa only Partial: prolapse of...

Documents

Transcript of Classification of rectal prolapse: Partial: prolapse of rectal mucosa only Partial: prolapse of...