Chapter 25. Operative Management of Rectal Prolapse

• Symptomatic rectal prolapse with or without fecal incontinence.

Resection Rectopexy

• Elderly patients with limited life expectancy.
• Patients with severe comorbidities or those unable to tolerate general anesthesia or major abdominal surgery.

Perineal Rectosigmoidectomy (Altemeier Procedure)

• None.

Resection Rectopexy

• The patient should be supine on the operating table.
• A Foley catheter is placed to decompress the bladder.
• Either a nasogastric or an orogastric tube is placed to decompress the stomach.

Perineal Rectosigmoidectomy (Altemeier Procedure)

• The patient may be positioned either in the lithotomy position or in the prone jackknife position.
• A Foley catheter is inserted to decompress the bladder.
• A Lone Star retractor is used for exposure.

Resection Rectopexy

• The patient should be managed in the hospital postoperatively, with attention paid to fluid balance and gastrointestinal function.
• Standard postcolectomy perioperative care principles apply.
• Patients are usually maintained on intravenous fluids only with nothing by mouth for the initial 24–48 hours or until there is return of bowel function.
• Epidural or patient-controlled analgesia is appropriate.

Perineal Rectosigmoidectomy (Altemeier Procedure)

• Patients should have minimal pain.
• The patient should be monitored in the hospital postoperatively with attention paid to bowel function.
• Nothing should be inserted per rectum.
• The diet is advanced as tolerated.
• The patient may use sitz baths three times daily and after all bowel movements.
• Stools softeners should be used to keep stools from becoming hard and disrupting the anastomotic suture line.
• Digital rectal examination should be deferred and no rectal suppositories should be given in the first 2–4 weeks postoperatively.

Resection Rectopexy

• Mortality rate of 0% in all but one published study (which had one death in 15 patients for a 6.7% mortality rate).
• Recurrence rates range from 0–5%.
• Postoperative constipation rates range from 18–80% in reported surgical series.
• Incontinence may not improve with the procedure.

Perineal Rectosigmoidectomy (Altemeier Procedure)

• Mortality rate of 0% in all studies except one (which had one death in 20 patients for a 5% mortality rate).
• Rectal prolapse recurrence rate is higher with the Altemeier procedure than with resection rectopexy, ranging from 0–16%.
• Bowel injury can occur upon entering the hernia sac in the anterior plane of dissection, particularly when the patient is in the lithotomy position.