Question

A 60-year-old lady presents with complete rectal prolapse.
Brief notes on evaluation and surgical options for this patient.

Hint:

The choice of surgical procedure depends on the patient’s age, general health, and the degree of prolapse. Minimally invasive approaches like laparoscopic rectopexy offer shorter recovery times and lower recurrence rates.

Answer 1

Rectal prolapse is a condition in which the rectum protrudes through the anus. It can be complete, where the entire rectum is everted, or incomplete, with only part of the rectum prolapsing. This condition is more common in older women and can cause significant morbidity.
Step 1: Clinical Evaluation:
1. History: A detailed history is crucial, including the onset of symptoms, frequency of prolapse, and associated symptoms such as fecal incontinence, constipation, or straining during bowel movements. Risk factors include age, multiparity, chronic constipation, and a history of pelvic surgery.
2. Physical Examination: A careful perineal examination is needed to assess the degree of prolapse. Digital rectal examination can help identify any associated abnormalities such as rectocele or sphincter weakness.
3. Endoscopy and Imaging: Flexible sigmoidoscopy or colonoscopy may be used to rule out other pathologies such as rectal cancer. Defecography (a radiological study) can assess rectal function and the extent of the prolapse, and anorectal manometry can evaluate sphincter function.
Step 2: Surgical Options:
1. Abdominal Approaches:
- Abdominal Rectopexy: This is the gold standard for the treatment of complete rectal prolapse. The rectum is fixed to the sacrum using sutures or mesh. Abdominal approaches have a lower recurrence rate compared to perineal procedures.
- Laparoscopic Rectopexy: Minimally invasive techniques are increasingly being used. Laparoscopic rectopexy involves the same principles as open abdominal rectopexy but with smaller incisions and shorter recovery time. 2. Perineal Approaches:
- Perineal Rectosigmoidectomy: This approach involves removal of the prolapsed rectum via the perineum and is suitable for frail or elderly patients who may not tolerate abdominal surgery. However, the recurrence rate is higher with this procedure. - Altemeier's Procedure (Perineal Rectopexy): In this procedure, the rectum is mobilized, reduced, and fixed to the sacrum using sutures. It is typically used for incomplete prolapse and is associated with a relatively quick recovery. 3. Transanal Approaches:
- Transanal Rectal Resection: A newer technique involves the resection of the redundant rectal tissue via the anus, followed by rectopexy. This is minimally invasive but has limited indications for complete prolapse.
Step 3: Postoperative Care:
Postoperative care includes ensuring adequate pain control, monitoring for complications such as infection, and advising on stool softeners to avoid straining. Long-term follow-up is necessary to monitor for recurrence and manage bowel function.