Escolar Documentos
Profissional Documentos
Cultura Documentos
Prolapse
Dr T V Aditya Chowdary
Clinical Features
Mass PR
Bleeding
Constipation 67 %
Diarrhea
-- 15 %
Incontinence 70 %
Management
Abdominal Approach
Rectopexy
Ripstein
Wells
Resection
Resection Rectopexy
Fuykwan
Perineal Approach
Perineal
Proctosigmoidectomy Altaemeier
Anorectal Mucosectomy
With Muscular PlicationDelorme
Anal Encirclement Therisch
Preoperative workup
Document baseline anorectal anatomy and function
prior to repair
Anal manometry
Ultrasonography
Pudendal nerve terminal motor latency
Dvorkin LS, Chan CL, Knowles CH, et al: Anal sphincter morphology in patients with full-thickness rectal prolapse. Dis Colon
Rectum 47:198, 2004.
CONTROVERSIES IN SURGICAL
APPROACH
Neither the type of procedure (intra-abdominal
versus perineal) nor the approach (open versus
minimally invasive) has been identified as optimal
Suture or mesh rectopexy
Anterior or posterior mesh wrap
Rectopexy alone or with sigmoid resection
Extent of pelvic dissection and division of the lateral ligaments
Anterior versus posterior mobilization
Perineal approach in young men to spare risk of pelvic nerve
injury
Abdominal Vs Perineal
Recurrence Rates
Abdominal 0% to 5 % , Perineal 10% 15%
The perineal procedures are generally reserved for the most elderly
and
frail, particularly
who are an
notintra-abdominal
candidates for either
an
Comorbid
illnesses those
that preclude
procedure
open
or laparoscopic
approach
Failed
previous intra-abdominal
rectal procidentia repair procedure
Prior
surgery
Clark
CE, pelvic
Jupiter DC,
Thomas JS, Papaconstantinou. Rectal Prolapse in the Elderly: Trends in Surgical
and Outcomes from the American College of Surgeons National Surgical Quality
Management
Prior pelvic
radiation therapy
Improvement Program Database. JACS 2012;215:709.
Surgical
management
of rectal
prolapse.
Madiba TE, Baig
Wexner
SD Arch Surg.
2005
Young
males, in
order
to minimize
theMK,
risk
of erectile
dysfunction.
Jan;140(1):63-73
Mahmoud SA, Omar W, Abdel-Elah K, Farid M. Delorme's Procedure for Full-Thickness Rectal Prolapse;
Does it Alter Anorectal Function. Indian J Surg 2012; 74:381.
Anterior vs Posterior
Rectopexy
Resection Alone
Anterior resection alone associated with higher
recurrence rates and significant operative and
postoperative morbidity
Recurrence rate 9%
Deterioration of continence has been reported in 10
20%
Schlinkert R T, Beart R W Jr, Wolff B G, Pemberton J H.
Anterior resection for complete rectal prolapse. Dis Colon
Rectum 1985. (1985);28(6):409412.
Lap Vs Open
Minimally-invasive (eg, laparoscopic, laparoscopicassisted, or robotic-assisted) colon and rectal procedures
have the advantages of reduced postoperative pain,
early return of bowel function, and shortened length of
hospital stay
(Boccasanta 1998; Solomon 2002)
Lap = Open
rectopexy
RECURRANCE
Suture
26%
Resection Rectopexy
13%
Altemeiers
24%
Delormes
31%
QOL and
incontinance upto
3 years was
mostly equal