Rectal Prolapse: Perineal Rectosigmoidectomy

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Rectal ProlapsePerineal Rectosigmoidectomy

• Juan J. Nogueras, MD, FACS, FASCRS
• Chairman, Division of Surgery
• Cleveland Clinic Florida
• Weston, FL

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Rectal prolapse Surgical repair

• Abdominal procedures
• Perineal procedures

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Perineal Procedures

• Early part of this century
• Preferred approach
• Relative technical simplicity
• Safety

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Perineal procedures

• Mid century
• Laparotomy becomes safer
• Reports of high recurrence rates (50-60 ) after
  perineal rectosigmoidectomy
• Loss of popularity in perineal procedures

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Perineal procedures

• 1971
• W.A. Altmeier publishes report
• Am Surgeon 1971173993-1001
• Claimed only 3 recurrences in 106 patients
• Rekindled interest in perineal procedures

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What procedure to perform

• Many factors involved in decision
• Condition of patient
• Experience of surgeon
• Size of the prolapse
• No lack of opinion
• Lack of science

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University of Minnesota

• 19 year period (1976 - 1994)
• 372 patients
• Perineal rectosigmoidectomy 183 (49)
• Rectopexy with resection 161 (43)

Kim, et al. Dis Colon Rectum 199942460-469
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Procedures from 1976 - 1994
Kim, et al. Dis Colon Rectum 199942460-469
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Recurrence rates
Kim, et al. Dis Colon Rectum 199942460-469
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Recurrence rates
Kim, et al. Dis Colon Rectum 199942460-469
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Abdominal vs Perineal

• ABDOMINAL
• Lower recurrence
• Better functional results
• Abdominal surgery
• Laparotomy
• Laparoscopy

• PERINEAL
• Higher recurrence
• Levatorplasty
• No abdominal surgery
• No pelvic dissection

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Perineal procedures

• Anal encirclement
• Delorme procedure
• Perineal rectosigmoidectomy
• Levatorplasty

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Thiersch procedure
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Delorme procedure
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Delormeprocedure
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Delormeprocedure
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Delorme procedure
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Perineal rectosigmoidectomy
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Perineal rectosigmoidectomyIdentifying the
hernia sac
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Entering the peritoneal hernia sac
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When do you stop

• Enter the peritoneal sac
• Palpate the colon along the sacral curve
• Is it straight?
• Estimate redundancy
• Avoid tension

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Length of excised segment can be large73 cm in
this case
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Posterior Levatorplasty
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Anterior Levatorplasty
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Recurrence Rates
3/8

4/32
1/21
ns
ns
p lt 0.05

Agachan F, et al. South Med J 1997
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Recurrence Free Period
Mean Recurrence Period (months)


p lt 0.05

Agachan F, et al. South Med J 1997
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Preoperative vs Postoperative Results of
Incontinence Scores for Each Procedure
Mean Incontinence Score


p lt 0.05

Agachan F, et al. South Med J 1997
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Conclusion - IPerineal rectosigmoidectomy with
levatorplasty

• Morbidity rate
• Recurrence rate
• Recurrence free period
• Continence level

Agachan F, et al. South Med J 1997
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Perineal rectosigmoidectomy with levatorplasty

• 44 patients (41F 3M)
• Mean age 76 (57-96) years
• Average size of resected specimen 21.2 cm
• Complication rate 9.1
• Mortality 0
• Follow up mean 49 (24-120) months
• Recurrence rate 7.1
• Improved continence 86 patients

Habr-Gama A, et al. Hepatogastroenterology 2006
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Perineal rectosigmoidectomyModifications

• Stapled anastomosis
• Colonic J pouch reservoir

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Stapled perineal rectosigmoidectomy
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Handsewn anastomosis
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Stapled vs handsewn anastomosisRandomized,
controlled trial

• Monopolar electrocautery, handsewn anastomosis vs
  Harmonic scalpel, circular stapled anastomosis
• 40 patients randomized between two groups
• Clinical and functional long term results no
  different between two groups

Boccasanta P, et al. Dis Colon Rectum 2006
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Perineal rectosigmoidectomyColonic J reservoir
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Colonic J reservoir
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Pouch perineal rectosigmoiredectomy

• Provides better functional results than
  conventional rectosigmoidectomy
• Yoshioka K, Ogunbiyi OA, Keighley MR. Br J Surg
  1998
• Useful technique for patients with unusually
  large lengths of colon excised
• Baig MK, et al. Surg Innov 2005

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Summary

• Perineal rectosigmoidectomy is an acceptable
  option in the treatment of rectal prolapse
• Levatorplasty improves recurrence rates and
  functional results
• Modifications
• Stapled anastomosis
• Colonic reservoir