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The Choice of an Operation for Massive Rectal Prolapse
The Choice of an Operation for Massive Rectal Prolapse GEORGE L. WALKER, M.D., F.A.C.S. * NORMAN D. NIGRO, M.D., F.A.C.S. **
The occurrence of a protrusion at the rectal opening is common and yet the making of a correct diagnosis justifies comment. The most likely protrusion is that due to internal hemorrhoids in which the overlying mucosa is in radial folds. If such hemorrhoids become strangulated, the mucosa becomes edematous and the increased size of the mass may give rise to the erroneous impression that the entire rectal wall is protruding. The continued occurrence of radially placed folds in the edematous mass establishes the correct diagnosis as being hemorrhoidal. Next most probable is a protrusion of the mucosa alone which accompanies straining. The amount of protrusion is small, of the order of 0.5 to 1 cm., and it is evident that all layers of the rectum are not being everted but only the mucosa. This is termed simple mucosal prolapse or incomplete rectal prolapse. Less common in occurrence is massive or complete rectal prolapse in which all layers of the rectum are everted and protrude. The patient may be required to strain in a squatting position in order for the protrusion to be visible. It is differentiated from simple mucosal prolapse by its greater size of the order of 5 to 10 cm. and from strangulated hemorrhoids by the circular arrangement of the mucosal folds that overlay the everted muscular wall. These folds are oftentimes more prominent anteriorly, so that the bowel opening appears to be directed posteriorly. The replacement of such a protrusion may be difficult and is greatly assisted by inserting a finger in the anal canal and pulling towards the coccyx, thereby relaxing the contracted levator muscle. Replacement is no problem when the levator muscle has been stretched and weakened as in elderly patients, or in those individuals who have had the protrusion for long periods of time.
* Clinical Associate Professor of Surgery, Wayne State School of Medicine; Surgeon, Harper and Jennings Memorial Hospitals, Detroit, Michigan
** Clinical Associate Professor of Surgery, Wayne State School of Medicine; Chief of Proctology, Harper Hospital, Proctologist,. Jennings Memorial Hospital, Detroit, Michigan
1293
1294
GEORGE
L.
WALKER, NORMAN
D.
NIGRO
CLASSIFICATION OF METHODS OF TREATMENT
Many operations are available today for the management of complete rectal prolapse. All are deficient in some degree and it appears that the long-range cure rate is still not satisfactory. As in other physiological disturbances associated with anatomical defects, there is a need for knowledge of the pathogenesis of this condition in order to treat the patient successfully. This knowledge is improving but it is incomplete. Still lacking is an understanding of a particular quality of the rectum and its normal relationship to the levator ani muscle. In the meantime, acceptable surgical results are obtainable if one selects an operation to match the needs of the patient. The majority of patients with this affliction are elderly and any surgical procedure must be weighed against what the patient can stand. In children, the problem will usually be outgrown. The commonly used methods of treatment are listed in the order of their surgical magnitude: 1. Conservative nonsurgical treatment including linear cautery of the mucosa. 2. Narrowing of the anal canal by the insertion of a Thiersch wire under local anesthesia. 3. A perineal operation incorporating circular excision of the prolapsed bowel with elevation of the cul-de-sac and suture of the levator muscles anterior to the rectum. 4. An abdominal operation emphasizing complete mobilization of the rectum, elevation of the rectum and its fixation in an elevated taut position. A segmental bowel resection may be a part of this operation insofar as it is a method of maintaining the rectum in an elevated position.
CHOICE OF MANAGEMENT
In infants, nonoperative measures are frequently sufficient. Most important are the avoidance of the causes of unusual straining and, when necessary, the use of sclerosing agents injected submucosally or the application of linear cautery to the mucosa. The latter maneuvers increase the fixation of the rectum sufficiently until such time as the growth of the child relieves the problem. Rarely are more aggressive measures needed, in which case a Thiersch wire is recommended. * The young to middle-aged adult presents massive rectal prolapse infrequently but here the expectations placed upon surgery are the most demanding. These individuals are in the most physically active period of life and inconveniences in constipation, soiling and incontinence are disconcerting if not disabling. Surgically, this group will readily withstand major abdominal operations and every worthwhile measure can be applied to them. The current approach is an abdominal operation which has three objectives: (1) complete mobilization of the rectum as low as possible,
* EDITOR'S NOTE: Linear cauterization has been abandoned by most surgeons. The Thiersch operation, as a tempory procedure, is useful.
THE CHOICE OF AN OPERATION FOR MASSIVE RECTAL PROLAPSE
1295
(2) elevation of the rectum in a straightened position and (3) some method of fixation which will maintain the rectum in this elevated position. Ideally, the primary objective should be to close and support the defect in the pelvic diaphragm. To date it has not been possible to accomplish this objective readily and as a substitute we recommend the insertion of a Thiersch wire. This is a simple perineal procedure and oftentimes a worthwhile supplement to an abdominal operation. The methods of fixation of the elevated rectum can be divided into two large groups: those which depend upon suture of the bowel to neighboring fixed structures and those in which there is a purposeful development of adhesions between the rectal wall and the presacral fascia. In either case when the forces causing the prolapse continue, the smooth muscle of the bowel wall and the artificial adhesions eventually will stretch so that fixation becomes ineffective. A search for better methods has continued. Recently RipsteinlO has modified the use of a fascia lata graft which is placed as a sling around the rectum and attached posteriorly to the presacral fascia. At present he is using a Teflon mesh sling and reports successful operations on 30 patients along with a previously successful experience with 45 patients using the fascia lata sling. Ripstein emphasizes that, in addition to accomplishing fixation of the rectum, this operation secures the rectum in the hollow of the sacrum, keeping it from falling forward and becoming a vertical tube over the anus and thus vulnerable to prolapse. Currently, this is a popular operation and in our opinion satisfies the requirements for fixation of the rectum as well or better than any other now available. An alternative method of fixation which is also used by other authors is to resect the redundant portion of the mobilized rectosigmoidcolon. 4 , 8, 9 The end-to-end anastomosis lies just below the sacral promontory and its posterior aspect is sutured to the presacral fascia. There is currently no unanimity of opinion as to whether or not a resection of itself is a necessary adjunct in order to prevent recurrent prolapse, provided the aims of mobilization, elevation and fixation are accomplished. As mentioned previously, other methods of fixation are described such as attachment of the elevated bowel to the left psoas minor tendon or to the left posterior rectus sheath. ll These methods secure only a small portion of the colonic circumference to a fixed structure in contrast to the Teflon sling which is secured to the entire circumference of the bowel and anchored posteriorly. We prefer the latter. Surgical repair of the muscular or hiatal defect in the pelvic diaphragm is highly desirable, as in the treatment of any hernia. Descriptions of the closing of the hiatus from the superior approach during a laparotomy include suture of the levator ani muscle in front of the rectum. 6 The necessary exposure is difficult to maintain and the levator muscle bands are hard to identify as they pass forward. However, such anteriorly placed sutures are most effective in supporting the hiatal defect. Where this can
1296
GEORGE
L.
WALKER, NORMAN
D.
NIGRO
be accomplished, it is the most satisfactory solution to the problem, but we find the procedure so difficult that for most patients it cannot be counted upon as significantly worthwhile. It is again to be noted that an effective degree of support of the anal opening can be accomplished by the insertion of a Thiersch wire, a helpful supplement to an abdominal operation done for a patient with prolapse and an attenuated weakened levator ani muscle. The elderly patient oftentimes presents an operative risk that determines the choice of management. Where no contraindication exists, the abdominal approach can be used as described for the young adult. For those elderly individuals in whom an operation of lesser magnitude is mandatory, a perineal operation as described by Dunphy 3 and modified by Altemeier1 is indicated. * The protruding rectum is amputated in a circular fashion. This exposes and opens that portion of the cul-de-sac which has been forced down between the inner and outer layers of the rectum anteriorly. The peritoneum is elevated and closed, following which the muscular hiatus is supported by an approximation of the levator muscles anteriorly. Finally, the rectum is re-united. In patients in whom support is difficult to obtain because of weakness of the stretched muscles, a Thiersch wire is recommended. Last to be considered are the elderly individuals, usually female, in whom neither an abdominal nor perineal operation can be well tolerated. For these patients, the insertion of a Thiersch wire under local anesthesiat is a very satisfactory solution to the problem. 2 , 5 A small radial skin incision is made over the perineal body anteriorly and a heavy gauge wire on a large curved needle is placed around one-half of the rectal opening within the substance of the sphincter muscle. The needle leading the wire is brought out through a posterior skin wound and reinserted through this wound to include the other half of the rectal opening in the ligature. The wire is tied so as to permit an opening for one and a half fingers and the knot is buried anteriorly. Postoperatively, those patients with a tendency toward constipation may require measures to avoid or correct an impaction. Recently, Khilnani 7 has reported two patients with obstruction of the rectum due to an intussusception of the rectal mucosa, relieved only by removal of the wire. The results of the current surgery for massive rectal prolapse are oftentimes open to criticism for an inability to restore and maintain normal anatomy and to obtain normal bowel function. Nevertheless, as far as the patients are concerned, these deficiencies are minor in comparison with the original disability. The majority of these patients are elderly and are
* EDITOR'S NOTE: The Dunphy-Altemeier operation has stood the acid test of time. Ripstein's modification of his own previously described technique is on trial at the present time. t EDITOR'S NOTE: Infiltration anesthesia is best avoided in order to prevent local sepsis.
THE CHOICE OF AN OPERATION FOR MASSIVE RECTAL PROLAPSE
1297
accustomed to inconveniences in maintaining excretory functions. They may have minor degrees of postoperative mucosal protrusion accompanying straining which is evident to the examiner but which the patient is not aware of. For these individuals, the overall management of massive rectal prolapse can be regarded as successful.
SUMMARY The surgical operations currently used in the management of massive rectal prolapse are grouped according to their complexity and the resultant surgical risk to which the patients are exposed. The aims and principles of each group of operations are presented. The requirements of patients are also different and can be grouped according to the patient's age so that an acceptable operation can be selected. Fortunately, the patients in whom operations with lesser risk are mandatory present a situation which responds very well to such lesser procedures.
REFERENCES 1. Altemeier, W. A., Culbertson, W. R. and Alexander, J. W.: One stage perineal repair of rectal prolapse. Twelve years' experience. Arch. Surg. 89: 6-16,1964. 2. Burke, R M. and Jackman, R. J.: A modified Thiersch operation in the treatmellt of complete rectal prolapse. Dis. Colon & Rectum 2: 555-561, 1959. 3. Dunphy, J. E.: A combined perineal and abdominal operation for the repair of rectal prolapse. Surg. Gynec. & Obst. 86: 493-498, 1948. 4. Frykman, H. M.: Abdominal proctopexy and primary sigmoid resection for rectal procidentia. Am. J. Surg. 90: 780-789, 1955. 5. Gabriel, W. B.: Thiersch's operation for anal incontinence and minor degrees of rectal prolapse. Am. J. Surg 86: 583-590, 1953. 6. Goligher, J. C.: Treatment of complete prolapse of the rectum by Roscoe Graham operation. Brit. J. Surg. 45: 323-333, 1958. 7. Khilnani, M. T., Lyons, A. S. and Turell, R: Intrarectal intussusception of the rectal mucosa. A complication of the Thiersch operation. Am. J. Surg. 107: 754756,1964. 8. Khubchandani, 1. T. and Bacon, H. E.: Complete prolapse of rectum and its treatment. Arch. Surg. 90: 337-340, 1965. 9. Muir, E. G.: Treatment of complete rectal prolapse in the adult. Proc. Roy. Soc. Med. 55: 1086-1087, 1962. 10. Ripstein, C. B.: Surgical care of massive rectal prolapse. Dis. Colon & Rectum 8: 34-38, 1965. 11. Steinberg, M. E.: An operation for the repair of massive rectal prolapse. Surg. Gynec. & Obst. 116: 756-760, 1963.
7815 East Jefferson Avenue Detroit, Michigan 48214
The occurrence of a protrusion at the rectal opening is common and yet the making of a correct diagnosis justifies comment. The most likely protrusion is that due to internal hemorrhoids in which the overlying mucosa is in radial folds. If such hemorrhoids become strangulated, the mucosa becomes edematous and the increased size of the mass may give rise to the erroneous impression that the entire rectal wall is protruding. The continued occurrence of radially placed folds in the edematous mass establishes the correct diagnosis as being hemorrhoidal. Next most probable is a protrusion of the mucosa alone which accompanies straining. The amount of protrusion is small, of the order of 0.5 to 1 cm., and it is evident that all layers of the rectum are not being everted but only the mucosa. This is termed simple mucosal prolapse or incomplete rectal prolapse. Less common in occurrence is massive or complete rectal prolapse in which all layers of the rectum are everted and protrude. The patient may be required to strain in a squatting position in order for the protrusion to be visible. It is differentiated from simple mucosal prolapse by its greater size of the order of 5 to 10 cm. and from strangulated hemorrhoids by the circular arrangement of the mucosal folds that overlay the everted muscular wall. These folds are oftentimes more prominent anteriorly, so that the bowel opening appears to be directed posteriorly. The replacement of such a protrusion may be difficult and is greatly assisted by inserting a finger in the anal canal and pulling towards the coccyx, thereby relaxing the contracted levator muscle. Replacement is no problem when the levator muscle has been stretched and weakened as in elderly patients, or in those individuals who have had the protrusion for long periods of time.
* Clinical Associate Professor of Surgery, Wayne State School of Medicine; Surgeon, Harper and Jennings Memorial Hospitals, Detroit, Michigan
** Clinical Associate Professor of Surgery, Wayne State School of Medicine; Chief of Proctology, Harper Hospital, Proctologist,. Jennings Memorial Hospital, Detroit, Michigan
1293
1294
GEORGE
L.
WALKER, NORMAN
D.
NIGRO
CLASSIFICATION OF METHODS OF TREATMENT
Many operations are available today for the management of complete rectal prolapse. All are deficient in some degree and it appears that the long-range cure rate is still not satisfactory. As in other physiological disturbances associated with anatomical defects, there is a need for knowledge of the pathogenesis of this condition in order to treat the patient successfully. This knowledge is improving but it is incomplete. Still lacking is an understanding of a particular quality of the rectum and its normal relationship to the levator ani muscle. In the meantime, acceptable surgical results are obtainable if one selects an operation to match the needs of the patient. The majority of patients with this affliction are elderly and any surgical procedure must be weighed against what the patient can stand. In children, the problem will usually be outgrown. The commonly used methods of treatment are listed in the order of their surgical magnitude: 1. Conservative nonsurgical treatment including linear cautery of the mucosa. 2. Narrowing of the anal canal by the insertion of a Thiersch wire under local anesthesia. 3. A perineal operation incorporating circular excision of the prolapsed bowel with elevation of the cul-de-sac and suture of the levator muscles anterior to the rectum. 4. An abdominal operation emphasizing complete mobilization of the rectum, elevation of the rectum and its fixation in an elevated taut position. A segmental bowel resection may be a part of this operation insofar as it is a method of maintaining the rectum in an elevated position.
CHOICE OF MANAGEMENT
In infants, nonoperative measures are frequently sufficient. Most important are the avoidance of the causes of unusual straining and, when necessary, the use of sclerosing agents injected submucosally or the application of linear cautery to the mucosa. The latter maneuvers increase the fixation of the rectum sufficiently until such time as the growth of the child relieves the problem. Rarely are more aggressive measures needed, in which case a Thiersch wire is recommended. * The young to middle-aged adult presents massive rectal prolapse infrequently but here the expectations placed upon surgery are the most demanding. These individuals are in the most physically active period of life and inconveniences in constipation, soiling and incontinence are disconcerting if not disabling. Surgically, this group will readily withstand major abdominal operations and every worthwhile measure can be applied to them. The current approach is an abdominal operation which has three objectives: (1) complete mobilization of the rectum as low as possible,
* EDITOR'S NOTE: Linear cauterization has been abandoned by most surgeons. The Thiersch operation, as a tempory procedure, is useful.
THE CHOICE OF AN OPERATION FOR MASSIVE RECTAL PROLAPSE
1295
(2) elevation of the rectum in a straightened position and (3) some method of fixation which will maintain the rectum in this elevated position. Ideally, the primary objective should be to close and support the defect in the pelvic diaphragm. To date it has not been possible to accomplish this objective readily and as a substitute we recommend the insertion of a Thiersch wire. This is a simple perineal procedure and oftentimes a worthwhile supplement to an abdominal operation. The methods of fixation of the elevated rectum can be divided into two large groups: those which depend upon suture of the bowel to neighboring fixed structures and those in which there is a purposeful development of adhesions between the rectal wall and the presacral fascia. In either case when the forces causing the prolapse continue, the smooth muscle of the bowel wall and the artificial adhesions eventually will stretch so that fixation becomes ineffective. A search for better methods has continued. Recently RipsteinlO has modified the use of a fascia lata graft which is placed as a sling around the rectum and attached posteriorly to the presacral fascia. At present he is using a Teflon mesh sling and reports successful operations on 30 patients along with a previously successful experience with 45 patients using the fascia lata sling. Ripstein emphasizes that, in addition to accomplishing fixation of the rectum, this operation secures the rectum in the hollow of the sacrum, keeping it from falling forward and becoming a vertical tube over the anus and thus vulnerable to prolapse. Currently, this is a popular operation and in our opinion satisfies the requirements for fixation of the rectum as well or better than any other now available. An alternative method of fixation which is also used by other authors is to resect the redundant portion of the mobilized rectosigmoidcolon. 4 , 8, 9 The end-to-end anastomosis lies just below the sacral promontory and its posterior aspect is sutured to the presacral fascia. There is currently no unanimity of opinion as to whether or not a resection of itself is a necessary adjunct in order to prevent recurrent prolapse, provided the aims of mobilization, elevation and fixation are accomplished. As mentioned previously, other methods of fixation are described such as attachment of the elevated bowel to the left psoas minor tendon or to the left posterior rectus sheath. ll These methods secure only a small portion of the colonic circumference to a fixed structure in contrast to the Teflon sling which is secured to the entire circumference of the bowel and anchored posteriorly. We prefer the latter. Surgical repair of the muscular or hiatal defect in the pelvic diaphragm is highly desirable, as in the treatment of any hernia. Descriptions of the closing of the hiatus from the superior approach during a laparotomy include suture of the levator ani muscle in front of the rectum. 6 The necessary exposure is difficult to maintain and the levator muscle bands are hard to identify as they pass forward. However, such anteriorly placed sutures are most effective in supporting the hiatal defect. Where this can
1296
GEORGE
L.
WALKER, NORMAN
D.
NIGRO
be accomplished, it is the most satisfactory solution to the problem, but we find the procedure so difficult that for most patients it cannot be counted upon as significantly worthwhile. It is again to be noted that an effective degree of support of the anal opening can be accomplished by the insertion of a Thiersch wire, a helpful supplement to an abdominal operation done for a patient with prolapse and an attenuated weakened levator ani muscle. The elderly patient oftentimes presents an operative risk that determines the choice of management. Where no contraindication exists, the abdominal approach can be used as described for the young adult. For those elderly individuals in whom an operation of lesser magnitude is mandatory, a perineal operation as described by Dunphy 3 and modified by Altemeier1 is indicated. * The protruding rectum is amputated in a circular fashion. This exposes and opens that portion of the cul-de-sac which has been forced down between the inner and outer layers of the rectum anteriorly. The peritoneum is elevated and closed, following which the muscular hiatus is supported by an approximation of the levator muscles anteriorly. Finally, the rectum is re-united. In patients in whom support is difficult to obtain because of weakness of the stretched muscles, a Thiersch wire is recommended. Last to be considered are the elderly individuals, usually female, in whom neither an abdominal nor perineal operation can be well tolerated. For these patients, the insertion of a Thiersch wire under local anesthesiat is a very satisfactory solution to the problem. 2 , 5 A small radial skin incision is made over the perineal body anteriorly and a heavy gauge wire on a large curved needle is placed around one-half of the rectal opening within the substance of the sphincter muscle. The needle leading the wire is brought out through a posterior skin wound and reinserted through this wound to include the other half of the rectal opening in the ligature. The wire is tied so as to permit an opening for one and a half fingers and the knot is buried anteriorly. Postoperatively, those patients with a tendency toward constipation may require measures to avoid or correct an impaction. Recently, Khilnani 7 has reported two patients with obstruction of the rectum due to an intussusception of the rectal mucosa, relieved only by removal of the wire. The results of the current surgery for massive rectal prolapse are oftentimes open to criticism for an inability to restore and maintain normal anatomy and to obtain normal bowel function. Nevertheless, as far as the patients are concerned, these deficiencies are minor in comparison with the original disability. The majority of these patients are elderly and are
* EDITOR'S NOTE: The Dunphy-Altemeier operation has stood the acid test of time. Ripstein's modification of his own previously described technique is on trial at the present time. t EDITOR'S NOTE: Infiltration anesthesia is best avoided in order to prevent local sepsis.
THE CHOICE OF AN OPERATION FOR MASSIVE RECTAL PROLAPSE
1297
accustomed to inconveniences in maintaining excretory functions. They may have minor degrees of postoperative mucosal protrusion accompanying straining which is evident to the examiner but which the patient is not aware of. For these individuals, the overall management of massive rectal prolapse can be regarded as successful.
SUMMARY The surgical operations currently used in the management of massive rectal prolapse are grouped according to their complexity and the resultant surgical risk to which the patients are exposed. The aims and principles of each group of operations are presented. The requirements of patients are also different and can be grouped according to the patient's age so that an acceptable operation can be selected. Fortunately, the patients in whom operations with lesser risk are mandatory present a situation which responds very well to such lesser procedures.
REFERENCES 1. Altemeier, W. A., Culbertson, W. R. and Alexander, J. W.: One stage perineal repair of rectal prolapse. Twelve years' experience. Arch. Surg. 89: 6-16,1964. 2. Burke, R M. and Jackman, R. J.: A modified Thiersch operation in the treatmellt of complete rectal prolapse. Dis. Colon & Rectum 2: 555-561, 1959. 3. Dunphy, J. E.: A combined perineal and abdominal operation for the repair of rectal prolapse. Surg. Gynec. & Obst. 86: 493-498, 1948. 4. Frykman, H. M.: Abdominal proctopexy and primary sigmoid resection for rectal procidentia. Am. J. Surg. 90: 780-789, 1955. 5. Gabriel, W. B.: Thiersch's operation for anal incontinence and minor degrees of rectal prolapse. Am. J. Surg 86: 583-590, 1953. 6. Goligher, J. C.: Treatment of complete prolapse of the rectum by Roscoe Graham operation. Brit. J. Surg. 45: 323-333, 1958. 7. Khilnani, M. T., Lyons, A. S. and Turell, R: Intrarectal intussusception of the rectal mucosa. A complication of the Thiersch operation. Am. J. Surg. 107: 754756,1964. 8. Khubchandani, 1. T. and Bacon, H. E.: Complete prolapse of rectum and its treatment. Arch. Surg. 90: 337-340, 1965. 9. Muir, E. G.: Treatment of complete rectal prolapse in the adult. Proc. Roy. Soc. Med. 55: 1086-1087, 1962. 10. Ripstein, C. B.: Surgical care of massive rectal prolapse. Dis. Colon & Rectum 8: 34-38, 1965. 11. Steinberg, M. E.: An operation for the repair of massive rectal prolapse. Surg. Gynec. & Obst. 116: 756-760, 1963.
7815 East Jefferson Avenue Detroit, Michigan 48214