Transperineal Repair of Rectal Prolapse
Rectal prolapse is characterized by a circumferential full-thickness protrusion of the rectum from the anus. It is believed to represent the culmination of a series of events leading to a sliding hernia through the levator hiatus (Fig. 101–1). This includes loss of sacral fixation, redundancy of the sigmoid colon and its mesentery, a deep anterior cul-de-sac, and a patulous anus. Treatments for rectal prolapse attempt to correct these problems and either restore the rectum to the pelvis or remove the hernia and redundant rectum. Although a number of options are available for the surgical correction of rectal prolapse, they can be broadly classified as transabdominal or transperineal.
Transabdominal repairs (laparoscopic or open) are better suited for most patients as they provide a more durable repair with a lower incidence of recurrence and improved functional outcomes when continence and overall bowel function are assessed.
This chapter addresses transperineal repairs, which are performed more often in elderly patients, who are poor candidates for general anesthesia or an abdominal incision. These patients tend to be older, to reside more frequently in nursing homes or assisted living, and to have a significantly greater number of comorbidities. In all transperineal approaches, the redundant rectum and any redundant sigmoid colon are resected, the cul-de-sac is obliterated, and the levators can be plicated posteriorly. The decision to perform a full-thickness resection (perineal proctectomy or the Altemeier procedure) or a partial-thickness resection (Delorme procedure) is based mainly on the surgeon’s preference, as these procedures seem to result in similar functional outcomes and recurrence rates.
Perineal Proctectomy (Altemeier Repair)
1. Spinal anesthesia is adequate for this procedure, but general anesthesia is acceptable if deemed safe. Most colorectal surgeons prefer to position the patient in a prone jackknife position under a spinal anesthesia with the buttocks taped apart. However, if the patient requires a vaginal procedure concomitantly, then a lithotomy position (Fig. 101–2) is preferred, so there is no need to reposition the patient. It is important to point out that in any type of combined procedure, the rectal prolapse should be addressed first, as it will be difficult to prolapse the rectum once the posterior colporrhaphy is performed.
2. Once positioned, the rectum is prolapsed and a retractor is used to evert the anal canal (Fig. 101–3A, B), exposing the dentate line and the anal transition zone (zone between the rectal mucosa and the squamous mucosa of the anus). It is important to retain the transition zone, as it is important in discriminating gas from liquid and solid stool.
3. Electrocautery is then used to divide the rectal wall circumferentially (Fig. 101–4). With a finger in the rectum, folding of the rectal wall creates several layers, and the incision should be deep enough to expose the mesorectal fat on the inner tube of the rectum (Fig. 101–5).
4. Between the anterior rectal wall and the vagina (Fig. 101–6A), the hernia sac or enterocele sac can be found and should be opened to facilitate lateral and posterior dissection (Fig. 101–6B).
5. The author’s preference is to divide the mesorectum with a bipolar energy device (Fig. 101–7A), but it can be clamped and ligated just as effectively with heavy Vicryl ties (Fig. 101–7B
