This is a full thickness prolapse of the rectum through the anal canal. There are two approaches to the repair of a rectal prolapse; either a trans-abdominal or perineal. The trans-abdominal approach can be further subdivided into the traditional open and the newer laparoscopic method. Generally, younger patients may benefit from a trans-abdominal approach, given the lower risks of recurrence, whereas older patients may be more suitable for a perineal approach, given the higher morbidity associated with the trans-abdominal approach.
Perineal recto-sigmoidectomy (Altemeier’s procedure):
Indicated in patients with external full thickness prolapse. It is performed under regional or general anaesthesia. The rectum is withdrawn as fully as possible and an incision is made 1.5cm proximal to the dentate line and is continued through the full thickness of the bowel wall and extended circumferentially. The peritoneum is entered, the sigmoid colon is pulled down and the transection line determined. In general, 15-30cm of bowel is resected and a colo-anal anastomosis is performed.
Trans-abdominal Marlex Rectopexy (Ripstein’s procedure):
Is indicated in patients with rectal prolapse without constipation and a redundant sigmoid colon. It is performed under general anaesthesia. A midline incision is made and the abdominal cavity is entered. The rectum is mobilized down to the coccyx posteriorly often with division of the upper portion of the lateral ligament and the anterior cul-de-sac. The rectum is retracted and placed under tension. A non-absorbable Marlex (Permacol) mesh is then fixed to the presacral fascia and wrapped round and sutured to the anterior wall of the rectum to keep it in position.