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Altemeier Using the Circular StaplerLisa S. Poritz, MD

There are three different clinical entities that are oftenlumped together and called rectal prolapse: full thick-ness rectal prolapse, mucosal prolapse, and internal prolapseor internal intussusception. Full thickness rectal prolapse isthe most commonly recognized and is dened as the protru-sion of the full thickness of the rectal wall through the anus.This article will deal only with this entity. The true incidenceof rectal prolapse is unknown because it is often underre-ported especially in the elderly population. There are peaksin occurrence in the 4th and 7th decade with the majority of patients, 80% to 90%, being women.

Indications forSurgery and EvaluationThere is no medical therapy for rectal prolapse and thereforethe presence of rectal prolapse is the indication for surgery.Contraindications to surgical correction of rectal prolapse arebased on the patient’s comorbidities and their ability to tol-erate surgery. Rectal prolapse is a clinical diagnosis thatshould be able to be made in the ofce. The patient is askedto sit on a toilet and strain and the rectum should then pro-lapse. If it does not prolapse with just straining, the admin-istration of a phosphate enema usually produces the pro-lapse. The protruding mass should show concentric rings of mucosa that are classic for rectal prolapse.

Operative TechniquePreparationPatients should undergo a full mechanical and antibioticbowel preparation before surgery. Perioperative intrave-nous antibiotics should also be used. General, epidural, orspinal anesthesia can be used, however, patients underregional anesthesia may experience nausea and vomitingwhen the colonic mesentery is pulled on. Patients may beplaced in “candycane” lithotomy or the prone jackknifeposition depending on the surgeon’s preference. The Alte-meier (perineal rectosigmoidectomy) is a full thicknessresection of the prolapsed rectum. As part of the proce-

dure, the surgeon can reapproximate the levator ani mus-cles if desired.

DissectionThe rectum is prolapsed with Allis clamps as far as possible. A full thickness circumferential incision is made in the pro-lapsed rectum about 2 cm proximal to the dentate line. Theperitoneal reectionis thenidentied anteriorly, incised, andthe peritoneal cavity is entered. The prolapse is then un-

folded. Allisclamps can be placedon the distal cut edge oftherectum in four quadrants as retractors. The clamps may beclipped to the drapes to help with retraction. The mesenteryof the prolapsed bowel, usually found laterally, is seriallyligated until no further redundantbowel canbe pulleddown.Care must be taken that the divided mesentery is securelyligated as it may retract into the pelvis after division. Once noadditional bowel can be prolapsed, the anterior wall of theprolapsed bowel is opened and a 2-0 PDS full thicknessstay suture is placed so the proximal bowel does not re-tract. The incision in the bowel is then extended laterallyand further 2-0 PDS stay sutures are placed. The redun-dant bowel is then completely transected and a posteriorstay suture is placed.

AnastomosisThe anastomosis is created by placing pursestring sutures inboth the proximal bowel and the distal rectum ( Fig 1). Thesize of the circular stapler is determined by the diameter of the proximal bowel. One should use as large a stapler as theproximal bowel will hold, atleast a 28 mm. Sizerscan be usedto determine the appropriate stapler if needed and to dilatethe bowel to accommodate a larger instrument. The anvil of the circular stapler is then inserted into the proximalbowel and the pursestring suture is tied ( Fig 2). The cir-cular stapler and the anvil are then engaged, the distalpursestring suture is tied around the shaft of the stapler,

and the instrument is closed and red, completing theanastomosis (Fig 3).

Postoperative careThese patients do well postoperatively with minimal painand a short hospital stay. Initially patients are kept NPOfor about 12 to 24 hours after which liquids are institutedand rapidly advanced to a regular diet. Bowel functionreturns quickly because there is no abdominal incision andpatients can often be discharged between 24 to 72 hours.

Department of Surgery, Division of Colon and Rectal Surgery, Penn StateCollege of Medicine, Milton S. Hershey Medical Center, Hershey, PA.

Address reprint requests to Lisa S. Poritz, MD, Associate Professor of Sur-gery, Division of Colon and Rectal Surgery, Penn State College of Med-icine, Milton S. Hershey Medical Center, 500 University Drive, H137,Hershey, PA 17033. E-mail: lporitz@psu.edu

194 1524-153X/08/$-see front matter © 2008 Published by Elsevier Inc.

doi:10.1053/j.optechgensurg.2008.10.006

mailto:lporitz@psu.edumailto:lporitz@psu.edu

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Figure 1 A 2-0 prolene pursestring suture is then placed in the proximal rectum (sigmoid colon). The stay sutures areremoved as the pursestring is placed. A second pursestring suture in then placed in the distal rectum with 0 prolene.Stronger suture is used for this second pursestring because the tissue is often thicker and of larger diameter.

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Figure 2 The anvil of the circular stapler is then placed into the proximal bowel and the suture tied. The tails of theprolene should be left long to help prevent the proximal bowel from retracting.

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ResultsThe Altemeier has a recurrence rate that varies from 5% to50% depending on the series. Because of this and the lowermorbidity than abdominal procedures, it is thought to bebetter suited for more elderly patients.

The two major complications seen after an Altemeier pro-cedure are anastomotic breakdown and bleeding. These can

occur whether the anastomosis is hand sewn or stapled. De-spite the low anastomosis, true disruption of theanastomosisis rare and the need for exploration and fecal diversion isinfrequent. A perianastomotic abscess canbe drained locally. When bleeding occurs, it is most likely from one of the points

of mesenteric ligation that has retracted. Laparotomy may berequired for adequate control.

Suggested Reading Johansen OB, Wexner SD, Daniel N: Perineal rectosigmoidectomy in the

elderly. Dis Colon Rectum 36:767-772, 1993PoritzLP: Perineal procedures forprolapse. Oper Tech GenSurg 7:121-125, 2005 Watts JD, Rothenberger DA, Buls JG: The management of procidentia. 30

years’ experience. Dis Colon Rectum 28:96-102, 1985

Williams JG, Rothenberger DA, Madoff RD: Treatment of rectal prolapse in theelderly by perineal rectosigmoidectomy. Dis Colon Rectum 35:830-834,1992.

Zbar AP, Takashima S, Hasegawa T, et al: Perineal rectosigmoidectomy(Altemeier’s procedure): A review of physiology, technique and out-come. Tech Coloproctol 6:109-116, 2002

Figure 3 The anvil is then inserted into the body of the circular stapler and the instrument advanced through the anus.The distal purstring is then tied around the shaft of the instrument. The instrument is then further advanced into therectum until the tissue is taught. The instrument is then closed, red and removed.

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