Rectal ProlapseDr.Sudhir K. Jain

Professor Surgery

MAMC

Rectal Prolapse:

Presented By:

Dr. Sudhir. K. Jain, M.S, MBA(HCA), FRCS, FICS, FIAS.

Professor of Surgery,

Maulana Azad Medical College and Associated Lok Nayak Hospital,

New Delhi.

With Credits to:

Dr. Vishnuraja, PG2, Dept of Surgery, MAMC.

Dr. Ronal Kori, PG2, Dept of Surgery, MAMC.

1/7/2015 Dr SK Jain Prof Surgery MAMC

Rectum-Anatomy• 18-20 cm long

• Begins –from rectosigmoid junction

• Ends- At anorectal junction

• Follows curve of sacrum.

Three lateral curvatures:

1. Upper/Lower- Convex to right

2. Middle-Convex to left

On mucosal side- they correspond to semicircular folds (Houston’s valve)

• Part of rectum between middle and lower valve is widest-ampulla of rectum.

Anatomy-Contd

• Upper 1/3rd: Peritoneal covering all around

• Middle 1/3rd: Peritoneal covering anteriorly and laterally

• Lower 1/3rd: No peritoneal covering

• Lower rectum separated from other organs by fascial condensation

• Anterior-Fascia of DenonVilliers

• Posterior- Fascia of Waldeyers

Mesorectum• Present in post/lateral aspect of extraperitoneal portion of rectum .

• Derived from hindgut.

• Contents:1. Sup rectal artery/branches2. Sup rectal vein/tributaries3. Lymphatics/L.nodes4. Autonomic nerves5. Loose areolar tissue

• Surrounded by fascia propria, which is an extension of pelvic fascia.

• Mesorectum excised along with rectum in carcinoma.

• Total mesorectal excision

Arterial supply

• Superior rectal artery-branch of inferior mesenteric artery

• Middle rectal artery-branch of anterior division of internal iliac

• Inferior rectal artery-terminal branch of internal pudendal artery

Veins- Corresponds arteries.

Lymphatics

• Mainly upward (Upper 2/3rd) to inferior mesenteric nodes-Paraaortic nodes

• Laterally to internal iliac nodes-from Lower 1/3rd .

Rectal prolapse

• Falling down of hind gut.

• First described by Papyrus in 1500 BC

• Types:

• 1. Complete-full thickness

• 2. Partial- Only mucosa (Circumferential, only portion of mucosa)

Factors preventing prolapse:

• Curvature of sacrum (under developed sacral curve)

• Tilt of pelvis

• Serpentine course of rectum

• Levator ani muscles- fixes rectum

• Puborectalis sling-Tilt and elevate lower end of rectum

Etiology

• Congenital

• Acquired

• Poor bowel habits

• Neurological diseases-• Cauda equine lesion• Spinal cord injury• Congenital anamoly ie spina bifida

• Female gender

• Nulliparity

• Redundant rectosigmoid

• Deep pouch of douglas

• Patulous anus

• Defect in pelvic floor

• After operation- Piles surgery, fistulotomy

• Free mesentry to entire rectum

• Lack of fixation of sactum to rectum

• Torn perineum- Straining at micturition

Clinical features

• Something coming out of anal canal during straining, coughing, lifting weights

• Constipation (58%)

• Fecal incontinence• More common in long standing complete prolapse

• Due to stretching of pudental and perineal nerves

• Dilatation of anal canal and relaxation of anal sphincters.

• Mucus discharge

• Bleeding (rare)- of massive or irreducible

Differential Diagnosis

1. Prolapsed haemorrhoid

2. Large polypoidal lesion protruding through anus

Investigations

• Barium enema

• Colonoscopy

• Anorectal physiology1. Low resting anal pressure

2. Low squeeze pressure

3. Poor anorectal sensations to electric stimulation

Treatment:

• Surgical correction is treatment of choice

Non operative treatment: When surgery is contraindicated or Patient refuses surgery

Non-Operative methods:

• Adhesive strapping of buttocks

• Manual anal support during defecation

• Correction of constipation

• Perineal exercises

• Electrical stimulation

• Submucosal injection of phenol in almond oil

• Infrared coagulation

Surgical Management:

• Partial prolapse• Simple excision of prolapsed part

• Complete mucosal prolapse• Circumferential excision

• Use of circular stapler (Used for stapled haemorrhoidopexy)

Management of acute irreducible rectal prolapse:• Reduction under anaesthesia to relax sphincter

• Tapping the buttocks together

• Trendelenberg position

• Placement of sugar/salt topically to reduce edema

• Injection of hyaluronidase

• If prolapsed rectum is not viable-resection of part

Complete rectal Prolapse:

• Surgical treatment

• Perineal approach

• Abdominal operation1. Open

2. Laparoscopic

Perineal operations:

• High recurrence rates than abdominal operations

• Indications:1. Pediatric age group

2. Frail/very elderly patients

3. Injury or disease of spinal cord

4. Young men

Thiersch repair:

• Anal canal is tightened by passing a silver/nylon/silicone rubber in perineal space.

Delrome procedure:

• Prolapse part of rectum is fully denuded of its mucosa

• Underlying rectal musculature plicated

• Defect of mucosa repaired

Altmeir procedure:

• Rectosigmoidectomy through perineal route.

Abdominal Operations:

• Suspension or fixation of the rectum1. To sacrum

2. To pubis

• Rectum is fully mobilized

• Lateral peritoneal reflections are incised

• Dissection done till levators.

• Lateral rectal ligaments divided.

• Rectum is fixed to sacrum by 1. Simple sutures

2. Teflon mesh (Ripstein Procedure)

3. Ivalon sponge (Polyvinyl alcohol) Well’s 1959

• Resection rectopexy (Fuykwan)Anterior resection with fixation of rectum to presacral fascia

• Resection procedures• Redundant sigmoid/rectum resected

• Descending colon fully mobilized till splenic flexure

• Anastomosis is constructed 12 cm above anal verge

Thank you