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A new concept for the management of rectal prolapse
A New Concept for the Management of Rectal Prolapse
J. Wedell,
MD, Herford, West Germany
P. Meier zu E&en, FL Fiedler,
MD, Herford, West Germany
MD, Herford, West Germany
The numerous surgical procedures that exist for the treatment of rectal prolapse indicate that a dilemma still exists. Graham [I] was the first to mobilize the rectum down t.o the levator muscles. This approach is still considered the most. important step, indicating the importance of mobilizing the rectum to the pelvic floor. The currently preferred operative technique represents a modification in which fixation procedures of the entire mobilized rectum are used. In Orr’s operation [S] introduced in 1947, t,he extensively mobilized rectum is fixed by two st.rips of fascia lat,a. The first is sutured above the promontory of the sacrum and the other below to the sides and in front of the rect,um. The modification by Loygue et al [s] uses, instead of fascia ista, strips of nylon mesh which are sutured to the sides and in front of the ret:t,um distally as far as possible. Ripstein [4] uses a Teflon@ sling for fixation of the mobilized rectum to the sacral hollow. A sling of Teflon mesh is passed around t,he rectum and the ends are sutured to the fascia and peritoneum in l’rclnt of t>he sacrum about :! cm below the promontory. Wells [.5] developed a technique employing perirectal implantation of a polyvinyl-alcohol sponge. A thin sheet, of this plastic sponge is wrapped around the extensively mobilized rect,um to initiate subsequent fixation of the bowel to the surrounding parts. Pathophysiologic
Aspects
Hroden and Snellman a special cineradiographic
[6] and Devadhar [7] using technique, found that the
From the Department of Surgery. Academic Teaching Hospital, Herford, West Germany. Reprint requests should be addressed to J. Wedell, MD. Department of Surgery. Academic Teaching Hospital, Postfach 523, 49 Herford, West Germany.
Volume
139, May 1990
initial step in the development of prolapse is intussusception of the rectum starting ahout 6 to 8 cm from the anal verge. The bowel is affected not only anteriorly but also, and mostly, circumferentially. The apex passes down into the lower part of the rectum and through the anus t,o the exterior. Devadhar [7] objects to the concept of complete rect,al prolapse as a sliding hernia of the pouch of Douglas on the grounds that the anterior wall in complet,e prolapse is not longer than t,he posterior one and the lumen of the bowel is situated not, posteriorly but centrally. However, no one has offered a definite explanation for the initiation of intrlssusception. New Surgical Technique
The various modified fixation procedures take into account the pathophysiological concept of complete prolapse of the rectum as a form of sliding hernia. From this point of view, that is, complete rectal prolapse as a sliding hernia of the pouch of Douglas, arises a new technique to prevent, the initiation of this mechanism. FixaGon of t,he rectum to the OS sacrum or promontory is a limiting factor to the success of all surgical procedures used until now. On the basis of the pathophysiologic changes, we believe it meaningful and effective to prevent the possibility of intussusception by reinforcing the wall of the extensively mobilized rectum. We therefore mobilize the rectum all around down to the pelvic floor and wrap an Ivalonm sponge around the bowel fixed hy a row of VicryP sutures (Figures 1 to 3). The edges are not fully approximated anteriorly t,o avoid stenosis. We have used this technique in another form of prolapse, t,hat of the terminal colostomy, and it, proved successful. The mobilized descending and sigmoid colon was wrapped in an Ivalon sleeve for SO
723
Wedell et al
Figure 1. The rectum is mobilized and wrapped with an lvalon sponge. Figure 3. lntraoperatively, the mobilized rectum is wrapped in the sleeve and fixed with a row of sutures.
Comments
Figure 2, The tvalon sheet is fixed on every side with single sutures without additional fixation to the OSsacrum.
cm beginning at its passage through the abdominal wall. The fixation approached the mesocolon, and the proximal and distal ends were circularly fixed to the intestinal wall. Intussusception of the colonic wall and therefore the development of prolapse was thus permanently prevented. Two other successfully treated cases of terminal colostomy prolapse convinced us of the usefulness of this simple technique.
724
From 1974 to 1978, twenty-six patients were operated on for complete prolapse of the rectum. Initially we used the procedure developed by Wells [5]. However, we treated our last five cases of rectal prolapse without fixation of the Ivalon sleeve. We simply wrapped the mobilized rectum in the sleeve and fixed them together. The results did not differ from those when the prosthesis was additionally fixed. This procedure is simpler and avoids damage to the presacral venous plexus during suture to the presacral fascia, which could lead to serious bleeding that is difficult to stop. Other investigators [8,9] have also avoided the additional fixation of the Ivalon sponge during the Wells operation, and they have had the same good results as before. Summary The various modified fixation procedures used for rectal prolapse take into account the pathophysiologic concept of complete prolapse of the rectum as a sliding hernia of the pouch of Douglas. The possibility of intussusception by reinforcement of the wall of the extensively mobilized rectum was successfully
The American
Journal
of Surgery
Rectal Prolapse
prevented by a new technique. The use of this simple technique in another form of prolapse, namely, prolapse of the terminal colostomy, convinced us of its usefulness. References 1. Graham RR. The operative repair of massive rectal prolapse. Ann Surg 1942;115:1007. 2 C)rr TE. A suspension operation for prolapse of the rectum. Ann Surg 1947; 126:833. 3. Loygue J. Huguier M, Mlafosse M, Biotois H. Complete prolapse of rectum: a report on 140 cases treated by rectopexy. Br J Surg 1971;58:847.
Volume
139,
May 1980
4. Ripstein CB. Surgical care of massive rectal prolapse. Dis Colon Rectum 1965;8:34. 5. Wells CA. Polyvinyl-alcohol sponge. An inert plastic for use as a prosthesis in the repair of large hernias. Br J Surg 1955; 42:618. 6. Broden B, Snellman B. Procidentia of the rectum studied with cineradiography: a contribution to the discussion of causative mechanism. Dis Colon Rectum 1968;1:33. 7. Devadhar DSC. A new concept of mechanism and treatment of rectal procidentia. Dis Colon Rectum 1965;8:75. 8. Arnold K. Personal communication with the Section of Proctology of the Royal Society of Medicine, Cologne, May 1978. Meeting of the German Society of Phlebology and Proctology. 9. Todd JP. Round table discussion: rectal prolapse. First World Congress of Colo-proctology, Madrid, July 1978.
725
J. Wedell,
MD, Herford, West Germany
P. Meier zu E&en, FL Fiedler,
MD, Herford, West Germany
MD, Herford, West Germany
The numerous surgical procedures that exist for the treatment of rectal prolapse indicate that a dilemma still exists. Graham [I] was the first to mobilize the rectum down t.o the levator muscles. This approach is still considered the most. important step, indicating the importance of mobilizing the rectum to the pelvic floor. The currently preferred operative technique represents a modification in which fixation procedures of the entire mobilized rectum are used. In Orr’s operation [S] introduced in 1947, t,he extensively mobilized rectum is fixed by two st.rips of fascia lat,a. The first is sutured above the promontory of the sacrum and the other below to the sides and in front of the rect,um. The modification by Loygue et al [s] uses, instead of fascia ista, strips of nylon mesh which are sutured to the sides and in front of the ret:t,um distally as far as possible. Ripstein [4] uses a Teflon@ sling for fixation of the mobilized rectum to the sacral hollow. A sling of Teflon mesh is passed around t,he rectum and the ends are sutured to the fascia and peritoneum in l’rclnt of t>he sacrum about :! cm below the promontory. Wells [.5] developed a technique employing perirectal implantation of a polyvinyl-alcohol sponge. A thin sheet, of this plastic sponge is wrapped around the extensively mobilized rect,um to initiate subsequent fixation of the bowel to the surrounding parts. Pathophysiologic
Aspects
Hroden and Snellman a special cineradiographic
[6] and Devadhar [7] using technique, found that the
From the Department of Surgery. Academic Teaching Hospital, Herford, West Germany. Reprint requests should be addressed to J. Wedell, MD. Department of Surgery. Academic Teaching Hospital, Postfach 523, 49 Herford, West Germany.
Volume
139, May 1990
initial step in the development of prolapse is intussusception of the rectum starting ahout 6 to 8 cm from the anal verge. The bowel is affected not only anteriorly but also, and mostly, circumferentially. The apex passes down into the lower part of the rectum and through the anus t,o the exterior. Devadhar [7] objects to the concept of complete rect,al prolapse as a sliding hernia of the pouch of Douglas on the grounds that the anterior wall in complet,e prolapse is not longer than t,he posterior one and the lumen of the bowel is situated not, posteriorly but centrally. However, no one has offered a definite explanation for the initiation of intrlssusception. New Surgical Technique
The various modified fixation procedures take into account the pathophysiological concept of complete prolapse of the rectum as a form of sliding hernia. From this point of view, that is, complete rectal prolapse as a sliding hernia of the pouch of Douglas, arises a new technique to prevent, the initiation of this mechanism. FixaGon of t,he rectum to the OS sacrum or promontory is a limiting factor to the success of all surgical procedures used until now. On the basis of the pathophysiologic changes, we believe it meaningful and effective to prevent the possibility of intussusception by reinforcing the wall of the extensively mobilized rectum. We therefore mobilize the rectum all around down to the pelvic floor and wrap an Ivalonm sponge around the bowel fixed hy a row of VicryP sutures (Figures 1 to 3). The edges are not fully approximated anteriorly t,o avoid stenosis. We have used this technique in another form of prolapse, t,hat of the terminal colostomy, and it, proved successful. The mobilized descending and sigmoid colon was wrapped in an Ivalon sleeve for SO
723
Wedell et al
Figure 1. The rectum is mobilized and wrapped with an lvalon sponge. Figure 3. lntraoperatively, the mobilized rectum is wrapped in the sleeve and fixed with a row of sutures.
Comments
Figure 2, The tvalon sheet is fixed on every side with single sutures without additional fixation to the OSsacrum.
cm beginning at its passage through the abdominal wall. The fixation approached the mesocolon, and the proximal and distal ends were circularly fixed to the intestinal wall. Intussusception of the colonic wall and therefore the development of prolapse was thus permanently prevented. Two other successfully treated cases of terminal colostomy prolapse convinced us of the usefulness of this simple technique.
724
From 1974 to 1978, twenty-six patients were operated on for complete prolapse of the rectum. Initially we used the procedure developed by Wells [5]. However, we treated our last five cases of rectal prolapse without fixation of the Ivalon sleeve. We simply wrapped the mobilized rectum in the sleeve and fixed them together. The results did not differ from those when the prosthesis was additionally fixed. This procedure is simpler and avoids damage to the presacral venous plexus during suture to the presacral fascia, which could lead to serious bleeding that is difficult to stop. Other investigators [8,9] have also avoided the additional fixation of the Ivalon sponge during the Wells operation, and they have had the same good results as before. Summary The various modified fixation procedures used for rectal prolapse take into account the pathophysiologic concept of complete prolapse of the rectum as a sliding hernia of the pouch of Douglas. The possibility of intussusception by reinforcement of the wall of the extensively mobilized rectum was successfully
The American
Journal
of Surgery
Rectal Prolapse
prevented by a new technique. The use of this simple technique in another form of prolapse, namely, prolapse of the terminal colostomy, convinced us of its usefulness. References 1. Graham RR. The operative repair of massive rectal prolapse. Ann Surg 1942;115:1007. 2 C)rr TE. A suspension operation for prolapse of the rectum. Ann Surg 1947; 126:833. 3. Loygue J. Huguier M, Mlafosse M, Biotois H. Complete prolapse of rectum: a report on 140 cases treated by rectopexy. Br J Surg 1971;58:847.
Volume
139,
May 1980
4. Ripstein CB. Surgical care of massive rectal prolapse. Dis Colon Rectum 1965;8:34. 5. Wells CA. Polyvinyl-alcohol sponge. An inert plastic for use as a prosthesis in the repair of large hernias. Br J Surg 1955; 42:618. 6. Broden B, Snellman B. Procidentia of the rectum studied with cineradiography: a contribution to the discussion of causative mechanism. Dis Colon Rectum 1968;1:33. 7. Devadhar DSC. A new concept of mechanism and treatment of rectal procidentia. Dis Colon Rectum 1965;8:75. 8. Arnold K. Personal communication with the Section of Proctology of the Royal Society of Medicine, Cologne, May 1978. Meeting of the German Society of Phlebology and Proctology. 9. Todd JP. Round table discussion: rectal prolapse. First World Congress of Colo-proctology, Madrid, July 1978.
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