Rectal Prolapse Surgery
There are two general approaches to surgery for rectal prolapse – abdominal operations (through the belly) and perineal operations (through “the bottom”). Both approaches aim to stop the prolapse from occurring again and usually result in a significant improvement in quality of life.
The choice of surgery type depends on both patient factors and procedural factors. Patient factors include the patient’s age, sex, bowel function, continence, prior operations, and severity of associated medical problems. Procedural factors include extent of prolapse, what effect the procedure might have on bowel function and incontinence, complication rates of the procedure, recurrence rates of the procedure and the individual surgeon’s experience. No procedure is considered the best overall. Discuss your options with your surgeon.
There are two types of rectal prolapse surgery:
1. Rectopexy and anterior resection are the two most common abdominal surgeries used to treat rectal prolapse. The patient is usually placed under general anesthesia for the duration of surgery.
During rectopexy, an incision into the abdomen is made, the rectum isolated from surrounding tissues, and the sides of the rectum lifted and fixed to the sacrum (lower backbone) with stitches or with a non-absorbable mesh. Anterior resection removes the S-shaped sigmoid colon (the portion of the large intestine just before the rectum); the two cut ends are then reattached. This straightens the lower portion of the colon and makes it easier for stool to pass. Rectopexy and anterior resection may also be performed in combination and may lead to a lower rate of prolapse recurrence.
As an alternative to the traditional laparotomy (large incision into the abdomen), laparoscopic surgery may be performed. Laparoscopy is a surgical procedure in which a laparoscope (a thin, lighted tube) and various instruments are inserted into the abdomen through small incisions. Rectopexy and anterior resection have been performed laparoscopically with good results. A patient’s recovery time following laparoscopic surgery is shorter and less painful than following traditional abdominal surgery.
2. Perineal repair of rectal prolapse involves a surgical approach around the anus and perineum. The patient may be placed under general or regional anesthesia for the duration of surgery.
The most common perineal repair procedures are the Altemeier and Delorme procedures. During the Altemeier procedure (also called a proctosigmoidectomy), the prolapsed portion of the rectum is resected (removed) and the cut ends reattached. The weakened structures supporting the rectum may be stitched into their anatomical position. The Delorme procedure involves the resection of only the mucosa (inner lining) of the prolapsed rectum. The exposed muscular layer is then folded and stitched up and the cut edges of mucosa stitched together.
A rarely used procedure is anal encirclement. Also called the Thiersch procedure, anal encirclement involves the insertion of a thin circular band of non-absorbable material under the skin of the anus. This narrows the anal opening and prevents the protrusion of the rectum through the opening. This procedure, however, does not address the underlying condition and therefore is generally reserved for patients who are not good candidates for more invasive
If you have rectal prolapse and certain other conditions, such as vaginal prolapse or pelvic organ prolapse, you might have both repairs done in one surgery.
Post –Op Recovery
Some patients may spend a brief time in the hospital recovering and regaining their bowel function. A Foley catheter may remain for one to two days after surgery. The patient will be given a liquid diet until normal bowel function returns.
The recovery time following perineal repair is faster than recovery after abdominal surgery and usually involves a shorter hospital stay (one to three days following perineal surgery, three to seven days following abdominal surgery). The patient will be instructed to avoid activities for several weeks that will cause strain on the surgical site; these include lifting, coughing, long periods of standing, sneezing, straining with bowel movements,and sexual intercourse. High-fiber foods should be gradually added to the diet to avoid constipation and straining that could lead to prolapse recurrence.
Most patients return to normal activities within four to six weeks after surgery. Some people require physical therapy to relearn how to use the pelvic floor muscles.
National Institute of Diabetes and Digestive and Kidney Diseases https://www.niddk.nih.gov/health-information/digestive-diseases/hemorrhoids/symptoms-causes
Mills, S. Chapter 33, “Rectal Prolapse”. Chapter in Beck, D. E., Roberts, P. L., Saclarides, T. J., Senagore, A. J., Stamos, M. J., Wexner, S. D., Eds. ASCRS Textbook of Colon and Rectal Surgery, 2nd edition. Springer, New York, NY; 2011.
ASCRS website, 2008 Core Subjects; Varma, M. G. “Prolapse, Intussusception, and SRUS”
Varma, M., Rafferty, J., Buie, W. D.; Standards Practice Task Force, American Society of Colon and Rectal Surgeons. Practice Parameters for the Management of Rectal Prolapse. Dis Colon Rectum. 2011;54(11):1339-1346.
American Society of Colon and Rectal Surgeons https://www.fascrs.org/patients/disease-condition/rectal-prolapse-expanded-version