Rectal Prolapse Surgery

What is Rectal Prolapse Surgery?

Rectal prolapse surgery is performed to treat rectal prolapse. It can be performed either through an abdominal approach or through the rectum, also called the perineal approach.

The abdominal approach is most commonly employed in medically fit and healthy individuals, while the perineal approach is employed in elderly patients or those with significant medical problems. The perineum is the region between the scrotum and the anus in the male and between the vulva and the anus in the female.

The goal of rectal prolapse surgery is to prevent prolapse recurrence and enable a better quality of life.

What is Rectal Prolapse?

Rectal prolapse is a condition in which the lowest part of the large intestine, known as the rectum, becomes displaced from its natural position within the pelvic region and starts to drop down towards and through the anus.

There are three types of rectal prolapse:

Internal prolapse

In this type of rectal prolapse, the rectum has only dropped slightly so that it hasn’t reached the anus.

Partial prolapse

In this type of rectal prolapse, the rectum has partially protruded through the anus.

Complete or full-thickness prolapse

This type is where the rectum completely protrudes through the anus.

What are the Indications for Rectal Prolapse Surgery?

Rectal prolapse surgery is recommended for people who have moderate to severe rectal prolapse and have symptoms such as:

Long-term history of straining during bowel movements
A sensation of a bulge outside your anus
Presence of a red mass outside the anal opening
Pain in the rectum or anus
Rectal bleeding
Leakage of stool, blood, or mucus from the anus

Usually, a mild rectal prolapse can be treated non-surgically where your doctor may recommend stool softeners so you can have bowel movements without straining and the prolapsed tissue is manually pushed back in place with a gloved finger.

Pre-Surgical Preparation for Rectal Prolapse Surgery

Pre-procedure preparation for rectal prolapse surgery involves the following steps:

A thorough examination by your doctor to check for any medical issues that need to be addressed prior to surgery.
You may undergo tests such as blood work and imaging to help detect any abnormalities that could threaten the safety of the procedure.
Inform your surgeon if you have any allergies and also about your current medications, including any vitamins, or supplements.
Your surgeon will give you specific instructions regarding your diet, medications, and other lifestyle changes that need to be followed before and after your surgery.
Avoid consumption of any solids or liquids at least 8 hours prior to surgery.
You may be prescribed laxatives to empty your bowel.
Arrange for someone to drive you home as you will not be able to drive yourself after surgery.
A written consent will be obtained from you after the surgical procedure has been explained in detail.

Rectal Prolapse Surgery Procedure

Rectal prolapse surgery can be performed in two ways, either using the abdominal approach or through the rectal/perineal approach. The common steps for both approaches are listed below:

You are placed on the operating table. The use of stirrups is optional.
You may be placed in Trendelenburg position also called Lloyd Davis position, with legs apart or in a head-down Lithotomy. It is a modification of the supine position with the hips flexed at a 15° basic angle and a 30° head-down tilt.
General anaesthesia is administered.
Intravenous antibiotics may be administered at the same time to prevent infection during and after the surgery.
Blood thinners or anticoagulants such as heparin may also be administered to prevent blood clots.

The differences in each of these procedures are outlined below:

Abdominal Approach

The abdominal approach can be performed either through open surgery or laparoscopically. The choice depends on your surgeon’s discretion based on your age, severity of rectal prolapse, and overall health condition.

Open surgery:

While you are under anaesthesia, your surgeon makes an incision in the abdomen and pulls the rectum back up in place, and uses a mesh sling or sutures to fix the rectum to the back wall of your pelvis (sacrum) so that it does not prolapse again. This procedure is known as rectopexy. In some individuals with a long-term history of constipation, your surgeon may remove a section of the colon. The wounds are then closed with sutures or staples.

Laparoscopic (keyhole) surgery or Rectopexy:

This procedure is performed with the help of a laparoscope by performing small keyhole incisions. In this procedure, a thin flexible fibreoptic tube attached with a camera and lens at the end (laparoscope) is inserted into the abdominal cavity through one of the keyhole incisions, and small miniature instruments are inserted through other keyhole incisions to repair the rectal prolapse with the help of magnified images of the abdominal cavity displayed on a large monitor.

Perineal Approach

The two most common perineal approaches are the Delorme and Altemeier procedures.

Delorme procedure:

This procedure is typically done for short prolapses and involves removing the lining of the rectum and folding the muscular layer to shorten the rectum.

Altemeier procedure or perineal proctosigmoidectomy:

This is the most commonly performed perineal surgery. While under anaesthesia, your surgeon pulls the rectum via the anus, cuts off a section of the rectum and sigmoid, and connects the remaining rectum to the large intestine. This procedure is usually reserved for individuals who are not good candidates for laparoscopic or open repair.

Post-surgical Care for Rectal Prolapse Surgery

After your surgery, you will be transferred to the recovery area.

You will be monitored by a nurse or a doctor who will check for any adverse reactions to the medications and anaesthesia used. Your nurse will also monitor your blood oxygen level and other vital signs as you recover.
You may experience pain, inflammation, and discomfort in the operated area. Pain and anti-inflammatory medications are provided as needed.
Medications may also be prescribed as needed for symptoms associated with anaesthesia, such as vomiting and nausea.
Walking and moving around in bed is strongly encouraged as it lowers the risk of blood clots and pneumonia. It also helps to stimulate your bowels and assist with passing gas.
Antibiotics are prescribed to address the risk of surgery-related infection.
Your diet is slowly advanced post-surgery. You will start with nutrition through IV drips, then to clear liquids, and finally progress to having normal solid foods, as tolerated.
It is important to keep the surgical site clean and dry. Instructions on surgical site care and bathing will be provided.
Refrain from smoking for a specific period of time as it can negatively affect the healing process.
Refrain from strenuous activities and lifting anything heavier than 10 pounds for the first couple of months. A gradual increase in activities over a period of time is recommended.
Eating a healthy low fat, high fibre diet is strongly recommended to promote healing and a faster recovery as well as drinking 8 to 10 glasses of water daily to prevent constipation. Laxatives or stool softeners may also be recommended as needed.
Most patients are discharged after 2 to 4 days of hospital stay depending on the type of surgery. You will need to take off work at least a week or two to rest and promote healing. It may take a couple of months until you begin to feel back to normal.
Walking is a good exercise and is strongly recommended to improve your endurance. Some may require physical therapy to strengthen pelvic floor muscles.
Refrain from driving until you are fully fit and receive your doctor’s consent. Most patients can resume driving around a couple of weeks following surgery.
You will be able to resume your normal activities within a couple of weeks but may have certain activity restrictions.

A periodic follow-up appointment will be scheduled to monitor your progress.

What are the Risks and Complications of Rectal Prolapse Surgery?

As with any surgical procedure, rectal prolapse surgery may also have certain risks and complications. These may include:

Infection
Bowel obstruction
Intra-abdominal or rectal bleeding
Urinary retention or inability to pass urine
Fistula (an abnormal connection between 2 body parts, such as the vagina and rectum)
Stricture or narrowing of the anal opening