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Posterior sagittal anorectoplasty for pediatric recurrent rectal prolapse
Posterior Sagittai Anorectoplasty for Pediatric Recurrent Rectal Prolapse By Richard H. Pearl, Sigmund H. Ein, and Bernard Churchill Toronto, Ontario 9 The recent use of the posterior sagittal anorectoplasty for repair of high imperforate anus has demonstrated several advantages: elimination of laparotomy, more direct approach, easier division of rectourethral fistula, more exact identification of the muscles of fecal continence, proper relocation of anorectum within these muscles and sphincters, and virtual elimination of postoperative anal prolapse. It is this latter advantage that attracted us to use this procedure for the repair of a recurrent rectal prolapse in a 1-year-old girl who also had a recurrent bladder exstrophy. The latter probably contributed to her constantly pushing out her rectum, which easily admitted t w o fingers. T w o attempts w e r e made to repair the rectal prolapse using the subcutaneous Thiersch's perianal technique; however, each was successful for only 6 weeks. When her recurrent bladder exstrophy was repaired, w e also repaired her recurrent rectal prolapse using the posterior sagittal anorectoplasty. The midline sacrococcygeal incision w a s carried down to but not through the external sphincter, and the patulous rectum was plicated back to a normal size. Reapproximation of the levator sling and lower muscle complex then incorporated the plicated rectum. Both repairs remain intact after 1 year. 9 19B9 by W.B. Saunders Company. INDEX WORDS: Rectal prolapse; posterior sagittal anorectoplasty.
E ARE TWO types of approach to the repair T HofE Rrectal prolapse in the pediatric patient: perianal '-6 (common, simple) and retrorectal 7-9 (rare, complex). Our patient failed the former twice, and we preferred to try the Lockhart-Mummery ~'7'8procedure, which has several drawbacks. Therefore, we successfully modified its principle by applying the posterior sagittal anorectoplasty as popularized by Pefia and DeVries ~~for the repair of high imperforate anus. CASE REPORT
R.G. was born October 1986 with a bladder exstrophy that was repaired shortly afterwards. The repair broke down, and at 8 months of age (June 1987) she developed a rectal prolapse that was symptomatic and present all the time but reducible; rectal exam admitted two adult fingers (Fig 1). It was felt that the recurrent From the Divisions of General Surgery and Urology, Hospital for Sick Children, Toronto, Ontario, Canada. Presented at the 20th Meeting of the Canadian Association of Paediatric Surgeons, Ottawa, Ontario, Canada, September 21-24, 1988. Address reprint requests to Dr Sigmund H. Ein, Hospital for Sick Children, Toronto, Ontario, Canada M5G IXS. 9 1989 by W.B. Saunders Company. 0022-3468/89/2410-0039503.00/(9
1100
exstrophied bladder was contributing to her constant grunting and persistent rectal prolapse. In September 1987, the rectal prolapse was repaired with a Thiersch's technique 4'6 using heavy Dexon suture and silastic tubing; she was also treated for her constipation. The prolapse recurred in October 1987, at first intermittently and then constantly as before. A second Thiersch's repair using heavy Dexon suture that was performed in October 1987 lasted 2 months. She was readmitted to the hospital in December 1987 at age 14 months to have her recurrent bladder exstrophy and rectal prolapse repaired. Since this dual repair, she has been followed for almost 2 years and her rectum looks, feels, and functions normally. OPERATIVE TECHNIQUE
T h e p a t i e n t was p l a c e d prone with a bolster u n d e r the pelvis to a c c e n t u a t e the j a c k k n i f e position. A m i d l i n e incision was m a d e using the e l e c t r o c a u t e r y from j u s t above the coccyx down to but not t h r o u g h the e x t e r n a l sphincter. T h e incision was c a r r i e d down to the d i l a t e d r e c t u m using the cautery; to easily identify the rectum, a large H e g a r d i l a t o r was placed in it. T h e sides o f the r e c t u m were freed from the s u r r o u n d i n g tissues. W i t h a finger in the B e t a d i n e ( P u r d u e F r e d e r ick Inc, Toronto, O n t a r i o ) - p r e p p e d r e c t u m , t h e d i l a t e d r e c t u m was plicated over a length of 3 to 4 c m to n o r m a l size with i n t e r r u p t e d 2-0 Dexon sutures. T h e closure of the levator ani a n d muscle complex as d e s c r i b e d by Pefia a n d DeVries 1~was c o m p l e t e d using i n t e r r u p t e d 3-0 Vicryl sutures i n c o r p o r a t i n g the posterior ( p l i c a t e d ) r e c t u m between the 2-0 Dexon sutures, T h e operative p r o c e d u r e took 30 minutes. T h e postoperative c a r e required nothing special except the usual wound and bowel function attention. O n c e stooling r e s u m e d in a d a y or so the patient was d i s c h a r g e d home. DISCUSSION
Most rectal prolapses are self-limiting. 1'4'5'7'" However, if this situation does not occur and operative correction is required, every pediatric institution and most pediatric surgeons have their own favorite procedure to cure this problem. In our patient when the most common, easiest, and usually most successful repair (Thiersch's perianal suture) 3-6 failed twice after being successful each time for a month or so, the second most common, albeit rare, procedure at the Hospital for Sick Children, Toronto, was proposed (ie, Lockhart-Mummery retrorectal pack). ~'5'7'8The fact that this choice was not altogether appealing to some and required a hospital stay of up to 2 weeks prompted the suggestion that the same end Journal of Pediatric Surgery, Vo124, No 10 (October), 1989: pp 1100-1102
POSTERIOR SAGITTAL ANORECTOPLASTY
1101
Fig 1. R.G., age 8 months, with recurrent bladder exstrophy and rectal prolapse. The former was felt to be a contributor to her constant grunting and persistant prolapse.
result could be accomplished in a nicer, easier, neater, faster, and more anatomic way with minimal postoperative hospital stay or specific treatment by using the reconstruction (closing) aspect of the posterior sagittal anorectoplasty proposed by Pefia and Devries ~~ for repair of the high imperforate anus. It has long been recognized that infants with bladder exstrophy ~'2'12 will have a 15% to 20% incidence of a coexisting rectal prolapse on the suggested basis of a pelvic floor weakness. Some surgeons claim that the rectal prolapse spontaneously disappears after the bladder exstrophy is successfully reconstructed) 2This conclusion raises the question as to whether the rectal
prolapse is due to the straining and irritability from the -exposed bladder or to the straight pelvis before the repair, or both. After considering the perianal operations (sclerosing injections, t'~ Thiersch's sutures, ~'6 mucosal cauterization ~'5or stripping]3), the remainder of the operative repairs (perineal, 5 transsacral, 11'14'15or abdominal ~'5'9) all seem to focus on the retrorectal area and attempts to get the rectum to stick up to the sacrococcygeal bony curve or hollow. Most investigators generally agree that if there is an anatomic cause for pediatric (and, indeed, adult) rectal prolapse, it is the shallow or straight sacral curve and the loss of retrorectal fat or attachments, z'5'15This condition is also proposed as the reason for the high incidence of rectal prolapse in the more active l- to 2-year-old child. Of course, toilet training, constipation, and straining at a stool, especially by the child seated on the adult type of toilet seat, may also contribute to these anatomic defectsY Most pediatric surgeons believe that major rectal suspensions and pelvic reconstructions have no place in any operative repair of the child's rectal prolapseY '13 Ripstein, 9 however, stated quite definitely that adequate posterior fixation of the rectum provides a cure. Our procedure focuses the attention of the repair on two anatomic and functional areas. First, the retrorectal area is fixed posteriorly to the levator ani and muscle complex, as directed by Pefia and DeVries, ~~ who stated that "these sutures also serve the purpose of preventing prolapse of the mucosa." The second area of attention is the plication of the commonly dilated rectum; this often occurs in continued prolapse and leads not only to a lax rectum but to stretched perirectal supporting tissues. H'~3 Others ~3 have also recognized the value of some form of plication or tapering of the dilated rectum from within by mucosal stripping and muscle pleating, claiming that not only is the prolapse eliminated, but the sphincters and pelvic supporting structures also are allowed to regain their tone.
ADDENDUM
The authors have since (until August 1989) performed this procedure on seven other children, with no recurrences up to almost 2 years.
REFERENCES 1. Leape LL: Other disorders of the rectum and anus, in Welch K J, et al (eds): Pediatric Surgery. Chicago, Year Book Medical, 1986, pp 1038-1046 2. Kay NRM, Zachary RB: The treatment of rectal prolapse in children with injections of 30 percent saline solutions. J Pediatr Surg 5:334-337, 1970
3. Krasna IH: A simple purse string suture technique for treatment of colostomy prolapse and intussusception. J Pediatr Surg 14:801-802, 1979 4. Stern RC, Izant RJ Jr, Boat TF, et al: Treatment and prognosis of rectal prolapse in cystic fibrosis. Gastroenterology 82:707-710, 1982
1102
5. Wassef R, Rothenberger DA, Goldberg SM: Recta| prolapse. Curr Probl Surg 23:398-451, 1986 6. Singhal GD: Singhal's modification of Thiersch's operation for prolapse of the rectum in children. Pediatr Surg lnt 2:359-361, 1987 7. Qvist N, Rasmussen L, Klaaborg KE, et al: Rectal prolapse in infancy: Conservative versus operative treatment. J Pediatr Surg 21:887-888, 1986 8. Loekhart-Mummery JP: Rectal prolapse. Br Med J 18:345347, 1939 9. Ripstein CB: Massive rectal prolapse, in Cooper P (ed): The Craft of Surgery. Boston, Little, 1964, pp 1140-1145 10. Pefia A, DeVries PA: Posterior sagittal anorectoplasty: Important technical considerations and new applications. J Pediatr Surg 17:796-811, 1982
PEARL, EIN, AND CHURCHILL
11. Holder TM, Ashcraft KW: Acquired anorectal lesions, in Holder TM, Ashcraft KW (eds): Pediatric Surgery. Philadelphia, Saunders, 1980, pp 429-432 12. Chisholm TC: Exstrophy of the urinary bladder, in Holder TM, Ashcraft KW (eds): Pediatric Surgery. Philadelphia, Saunders, 1980, pp 738-751 13. Momoh JT: Quadrant mucosal stripping and muscle pleating in the management of childhood rectal prolapse. J Pediatr Surg 21:36-38, 1986 14. Ashcraft KW, Amoury RA, Holder TM: Levator repair and posterior suspension for rectal prolapse. J Pediatr Surg 12:241-245, 1977 15. Chino ES, Thomas CG Jr: Transsacral approach to repair of rectal prolapse in children. Ann Surg 50:70-75, 1984
E ARE TWO types of approach to the repair T HofE Rrectal prolapse in the pediatric patient: perianal '-6 (common, simple) and retrorectal 7-9 (rare, complex). Our patient failed the former twice, and we preferred to try the Lockhart-Mummery ~'7'8procedure, which has several drawbacks. Therefore, we successfully modified its principle by applying the posterior sagittal anorectoplasty as popularized by Pefia and DeVries ~~for the repair of high imperforate anus. CASE REPORT
R.G. was born October 1986 with a bladder exstrophy that was repaired shortly afterwards. The repair broke down, and at 8 months of age (June 1987) she developed a rectal prolapse that was symptomatic and present all the time but reducible; rectal exam admitted two adult fingers (Fig 1). It was felt that the recurrent From the Divisions of General Surgery and Urology, Hospital for Sick Children, Toronto, Ontario, Canada. Presented at the 20th Meeting of the Canadian Association of Paediatric Surgeons, Ottawa, Ontario, Canada, September 21-24, 1988. Address reprint requests to Dr Sigmund H. Ein, Hospital for Sick Children, Toronto, Ontario, Canada M5G IXS. 9 1989 by W.B. Saunders Company. 0022-3468/89/2410-0039503.00/(9
1100
exstrophied bladder was contributing to her constant grunting and persistent rectal prolapse. In September 1987, the rectal prolapse was repaired with a Thiersch's technique 4'6 using heavy Dexon suture and silastic tubing; she was also treated for her constipation. The prolapse recurred in October 1987, at first intermittently and then constantly as before. A second Thiersch's repair using heavy Dexon suture that was performed in October 1987 lasted 2 months. She was readmitted to the hospital in December 1987 at age 14 months to have her recurrent bladder exstrophy and rectal prolapse repaired. Since this dual repair, she has been followed for almost 2 years and her rectum looks, feels, and functions normally. OPERATIVE TECHNIQUE
T h e p a t i e n t was p l a c e d prone with a bolster u n d e r the pelvis to a c c e n t u a t e the j a c k k n i f e position. A m i d l i n e incision was m a d e using the e l e c t r o c a u t e r y from j u s t above the coccyx down to but not t h r o u g h the e x t e r n a l sphincter. T h e incision was c a r r i e d down to the d i l a t e d r e c t u m using the cautery; to easily identify the rectum, a large H e g a r d i l a t o r was placed in it. T h e sides o f the r e c t u m were freed from the s u r r o u n d i n g tissues. W i t h a finger in the B e t a d i n e ( P u r d u e F r e d e r ick Inc, Toronto, O n t a r i o ) - p r e p p e d r e c t u m , t h e d i l a t e d r e c t u m was plicated over a length of 3 to 4 c m to n o r m a l size with i n t e r r u p t e d 2-0 Dexon sutures. T h e closure of the levator ani a n d muscle complex as d e s c r i b e d by Pefia a n d DeVries 1~was c o m p l e t e d using i n t e r r u p t e d 3-0 Vicryl sutures i n c o r p o r a t i n g the posterior ( p l i c a t e d ) r e c t u m between the 2-0 Dexon sutures, T h e operative p r o c e d u r e took 30 minutes. T h e postoperative c a r e required nothing special except the usual wound and bowel function attention. O n c e stooling r e s u m e d in a d a y or so the patient was d i s c h a r g e d home. DISCUSSION
Most rectal prolapses are self-limiting. 1'4'5'7'" However, if this situation does not occur and operative correction is required, every pediatric institution and most pediatric surgeons have their own favorite procedure to cure this problem. In our patient when the most common, easiest, and usually most successful repair (Thiersch's perianal suture) 3-6 failed twice after being successful each time for a month or so, the second most common, albeit rare, procedure at the Hospital for Sick Children, Toronto, was proposed (ie, Lockhart-Mummery retrorectal pack). ~'5'7'8The fact that this choice was not altogether appealing to some and required a hospital stay of up to 2 weeks prompted the suggestion that the same end Journal of Pediatric Surgery, Vo124, No 10 (October), 1989: pp 1100-1102
POSTERIOR SAGITTAL ANORECTOPLASTY
1101
Fig 1. R.G., age 8 months, with recurrent bladder exstrophy and rectal prolapse. The former was felt to be a contributor to her constant grunting and persistant prolapse.
result could be accomplished in a nicer, easier, neater, faster, and more anatomic way with minimal postoperative hospital stay or specific treatment by using the reconstruction (closing) aspect of the posterior sagittal anorectoplasty proposed by Pefia and Devries ~~ for repair of the high imperforate anus. It has long been recognized that infants with bladder exstrophy ~'2'12 will have a 15% to 20% incidence of a coexisting rectal prolapse on the suggested basis of a pelvic floor weakness. Some surgeons claim that the rectal prolapse spontaneously disappears after the bladder exstrophy is successfully reconstructed) 2This conclusion raises the question as to whether the rectal
prolapse is due to the straining and irritability from the -exposed bladder or to the straight pelvis before the repair, or both. After considering the perianal operations (sclerosing injections, t'~ Thiersch's sutures, ~'6 mucosal cauterization ~'5or stripping]3), the remainder of the operative repairs (perineal, 5 transsacral, 11'14'15or abdominal ~'5'9) all seem to focus on the retrorectal area and attempts to get the rectum to stick up to the sacrococcygeal bony curve or hollow. Most investigators generally agree that if there is an anatomic cause for pediatric (and, indeed, adult) rectal prolapse, it is the shallow or straight sacral curve and the loss of retrorectal fat or attachments, z'5'15This condition is also proposed as the reason for the high incidence of rectal prolapse in the more active l- to 2-year-old child. Of course, toilet training, constipation, and straining at a stool, especially by the child seated on the adult type of toilet seat, may also contribute to these anatomic defectsY Most pediatric surgeons believe that major rectal suspensions and pelvic reconstructions have no place in any operative repair of the child's rectal prolapseY '13 Ripstein, 9 however, stated quite definitely that adequate posterior fixation of the rectum provides a cure. Our procedure focuses the attention of the repair on two anatomic and functional areas. First, the retrorectal area is fixed posteriorly to the levator ani and muscle complex, as directed by Pefia and DeVries, ~~ who stated that "these sutures also serve the purpose of preventing prolapse of the mucosa." The second area of attention is the plication of the commonly dilated rectum; this often occurs in continued prolapse and leads not only to a lax rectum but to stretched perirectal supporting tissues. H'~3 Others ~3 have also recognized the value of some form of plication or tapering of the dilated rectum from within by mucosal stripping and muscle pleating, claiming that not only is the prolapse eliminated, but the sphincters and pelvic supporting structures also are allowed to regain their tone.
ADDENDUM
The authors have since (until August 1989) performed this procedure on seven other children, with no recurrences up to almost 2 years.
REFERENCES 1. Leape LL: Other disorders of the rectum and anus, in Welch K J, et al (eds): Pediatric Surgery. Chicago, Year Book Medical, 1986, pp 1038-1046 2. Kay NRM, Zachary RB: The treatment of rectal prolapse in children with injections of 30 percent saline solutions. J Pediatr Surg 5:334-337, 1970
3. Krasna IH: A simple purse string suture technique for treatment of colostomy prolapse and intussusception. J Pediatr Surg 14:801-802, 1979 4. Stern RC, Izant RJ Jr, Boat TF, et al: Treatment and prognosis of rectal prolapse in cystic fibrosis. Gastroenterology 82:707-710, 1982
1102
5. Wassef R, Rothenberger DA, Goldberg SM: Recta| prolapse. Curr Probl Surg 23:398-451, 1986 6. Singhal GD: Singhal's modification of Thiersch's operation for prolapse of the rectum in children. Pediatr Surg lnt 2:359-361, 1987 7. Qvist N, Rasmussen L, Klaaborg KE, et al: Rectal prolapse in infancy: Conservative versus operative treatment. J Pediatr Surg 21:887-888, 1986 8. Loekhart-Mummery JP: Rectal prolapse. Br Med J 18:345347, 1939 9. Ripstein CB: Massive rectal prolapse, in Cooper P (ed): The Craft of Surgery. Boston, Little, 1964, pp 1140-1145 10. Pefia A, DeVries PA: Posterior sagittal anorectoplasty: Important technical considerations and new applications. J Pediatr Surg 17:796-811, 1982
PEARL, EIN, AND CHURCHILL
11. Holder TM, Ashcraft KW: Acquired anorectal lesions, in Holder TM, Ashcraft KW (eds): Pediatric Surgery. Philadelphia, Saunders, 1980, pp 429-432 12. Chisholm TC: Exstrophy of the urinary bladder, in Holder TM, Ashcraft KW (eds): Pediatric Surgery. Philadelphia, Saunders, 1980, pp 738-751 13. Momoh JT: Quadrant mucosal stripping and muscle pleating in the management of childhood rectal prolapse. J Pediatr Surg 21:36-38, 1986 14. Ashcraft KW, Amoury RA, Holder TM: Levator repair and posterior suspension for rectal prolapse. J Pediatr Surg 12:241-245, 1977 15. Chino ES, Thomas CG Jr: Transsacral approach to repair of rectal prolapse in children. Ann Surg 50:70-75, 1984