MANEJO OPERATIVO DEL PROLAPSO RECTAL

Indications Symptomatic rectal prolapse with or without fecal incontinence. Contraindications 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. Informed Consent Resection Rectopexy Expected Benefits Resection rectopexy is more durable than perineal rectosigmoidectomy and can often be performed via a laparoscopic approach. Potential Risks Bleeding or hematoma development requiring reoperation. Wound infection. Injury to one or both ureters requiring repair. Sexual dysfunction, including impotence or retrograde ejaculation in men. Incisional hernia. Possible temporary or permanent colostomy. Perineal Rectosigmoidectomy (Altemeier Procedure) Expected Benefits Preferred over an abdominal approach in high-risk patients. Potential Risks Infection, most notably perirectal abscess. Bleeding, primarily from the sacral venous plexus but also potentially from the mesenteric vascular supply divided as part of the procedure. Anastomotic dehiscence. Recurrence of rectal prolapse. Loss of or failure to regain fecal continence. Equipment Resection Rectopexy Standard general surgery set used in gastrointestinal surgery. Perineal Rectosigmoidectomy (Altemeier Procedure) Lone Star retractor. Patient Preparation Complete colonoscopy (preferable) or barium enema and sigmoidoscopy to rule out malignancy or other colonic disease. Bowel preparation according to surgeon preference. Patient Positioning 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. Procedure Resection Rectopexy Figure 25–1: As the normal rectal attachments become lax, the rectum intussuscepts through the pelvic floor, telescoping through the anus. Figure 25–2: The redundant sigmoid colon is resected in the usual manner, down to the peritoneal reflection. The peritoneum is incised posteriorly and laterally to mobilize the rectosigmoid out of the pelvis, but the lateral attachments of the rectum are left intact. Redundant rectosigmoid is resected. The proximal colon is then anastomosed to the rectum to provide intestinal continuity and the rectum is sutured to the presacral fascia to fix it in place. Figure 25–3: The completed procedure is shown, with the anastomotic line at or below the peritoneal reflection and tacking sutures between the rectum and the presacral fascia fixing the colon in place. Figure 25–1 Figure 25–2 Figure 25–3 Perineal Rectosigmoidectomy (Altemeier Procedure) Figure 25–4: After the patient is positioned on the table and prepped in the usual fashion, the prolapsed bowel is grasped with a Babcock clamp and tension is applied in an outward direction. Four absorbable 3–0 stay sutures are placed in the midline anterior and posterior to the rectum and laterally on either side. The outermost layer of the rectum is then incised circumferentially approximately 5–10 mm distal to the everted dentate line. The incision is carried through the mucosa and muscular layer, with care taken not to enter the muscular layer of the underlying intussuscepted rectum (see Figure 25–1 for further illustration of this relationship). Figure 25–5: Once the entire outer layer of intussuscepted rectum has been incised, it is folded outward and the mesenteric attachments to the intussusception are divided as they are encountered. As mesenteric attachments are divided, more rectosigmoid colon can be pulled out. The location for transection of the redundant rectosigmoid colon is identified when no more sigmoid can be pulled through and the anastomosis can be made with minimal tension. Figure 25–6: The redundant rectosigmoid colon is divided axially along the anterior and left lateral surfaces and stay sutures are placed through at the base of these cuts, through the mucosa and muscular wall, attaching them to the cut edge of the distal mucosa. The redundant tissue between these stay sutures is resected and the first quadrant, from 12 o'clock to 3 o'clock, is closed with interrupted fine, absorbable sutures. Another axial cut is made along the posterior surface of the redundant mucosa, a stay suture is placed at 6 o'clock and the second quadrant is closed with interrupted fine, absorbable sutures. This procedure continues by quadrants until the entire anastomosis is complete and the redundant sigmoid colon is removed. Figure 25–7: Once the anastomosis is complete, the four stay sutures along the anastomosis are cut and the anastomosis is allowed to retract through the anal canal. Figure 25–8: Sagittal section of the completed reconstruction. Note that the anastomotic line is significantly lower for this procedure than for the resection rectopexy. Figure 25–4 Figure 25–5 Figure 25–6 Figure 25–7 Figure 25–8 Postoperative Care 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. Potential Complications 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. Pearls and Tips Resection Rectopexy The recognition of full-thickness rectal prolapse as distinguished from redundant or prolapsed mucosa, severe hemorrhoidal disease, or skin tags is classically based on detecting circular mucosal layers rather than radially oriented folds on external examination. Examination of the patient after sitting and straining on a commode can facilitate visualization of the extent of prolapse. Defecography can be helpful if there is any question about the diagnosis. Perineal Rectosigmoidectomy (Altemeier Procedure) Care must be taken when incising the anterior surface of the intussuscepted rectosigmoid, as intra-abdominal contents such as small intestine may be present in the pouch of Douglas. References Altemeier WA, Culbertson WR, Schowengerdt C, Hunt J. Nineteen years' experience with the one-stage perineal repair of rectal prolapse. Ann Surg. 1971;173:993–1006.[PubMed: 5578808] [Full Text] Madiba TE, Baig MK, Wexner SD. Surgical management of rectal prolapse. Arch Surg. 2005;140:63–73.[PubMed: 15655208] [Full Text]

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