What are the different types of rectal prolapse and how do you compare surgeries and patient selection for each?

Types of Rectal Prolapse and Surgical Management

The surgical management of rectal prolapse should be individualized based on patient factors including age, surgical risk, coexisting functional symptoms, and surgeon expertise, with laparoscopic abdominal approaches generally preferred for younger, fit patients and perineal approaches reserved for elderly or high-risk patients. 1, 2

Types of Rectal Prolapse

Complete (External) Rectal Prolapse

• Full-thickness protrusion of the rectum through the anal canal
• Most severe form requiring surgical intervention
• Associated with incontinence, constipation, and quality of life impairment

Internal Rectal Prolapse

• Intussusception of the rectum that does not protrude externally
• May cause obstructed defecation syndrome
• Can progress to external prolapse if untreated

Mucosal Prolapse

• Only the rectal mucosa protrudes (not full thickness)
• Often confused with hemorrhoids
• Less severe but can cause bleeding and discomfort

Surgical Approaches

Perineal Approaches

Indicated for:

• Elderly patients
• Medically unfit patients
• High surgical risk
• Emergency presentations with strangulation

Key procedures include:

1. Thiersch Procedure (Anal Encirclement)

   • Simple encirclement of the anus
   • Indicated for very high-risk patients
   • High recurrence rate but low surgical risk

2. Delorme's Procedure (Mucosal Sleeve Resection)

   • Mucosal stripping and plication of rectal wall
   • Good option for elderly patients
   • Lower morbidity but higher recurrence than abdominal approaches

3. Altemeier's Procedure (Perineal Proctosigmoidectomy)

   • Full-thickness resection of prolapsed rectum with coloanal anastomosis
   • Indicated for irreducible or strangulated prolapse
   • Can be performed under regional anesthesia

Abdominal Approaches

Indicated for:

• Younger, fit patients
• When long-term recurrence risk is a concern
• Patients with concurrent pelvic floor disorders

Key procedures include:

1. Suture Rectopexy

   • Fixation of rectum to sacrum without mesh
   • Lower infection risk but potentially higher recurrence

2. Mesh Rectopexy

   • Several variations:
     • Ripstein's procedure (posterior fixation with anterior mesh sling)
     • Wells' procedure (posterior fixation with posterior mesh sling)
     • Orr-Loygue's procedure (ventral fixation with double anterolateral mesh)

3. Resection Rectopexy

   • Combines rectal fixation with sigmoid resection
   • Better for patients with constipation
   • Potentially higher complication risk due to anastomosis

4. Laparoscopic/Robotic Approaches

   • Modern preference for all abdominal techniques
   • Lower morbidity, faster recovery
   • Similar functional outcomes to open procedures

Patient Selection Algorithm

1. Emergency Presentation

   • With shock, gangrene, or perforation: Immediate surgical intervention 1
   • Reducible prolapse: Attempt manual reduction under sedation
   • Irreducible without ischemia: Thiersch or Delorme's procedure
   • With ischemia/gangrene: Urgent Altemeier's procedure 2

2. Elective Cases

   • High surgical risk (ASA III-IV, elderly):

     • Perineal approach (Delorme's or Altemeier's)

   • Low surgical risk (ASA I-II, younger):

     • With constipation predominant:

       • Resection rectopexy (preferably laparoscopic)

     • With incontinence predominant:

       • Rectopexy without resection

     • With both symptoms or neither:

       • Laparoscopic ventral mesh rectopexy

Outcomes and Considerations

• Recurrence rates are generally higher with perineal approaches (10-30%) compared to abdominal approaches (2-10%) 3, 4
• Functional outcomes (incontinence, constipation) improve with most procedures, but resection rectopexy may better address constipation 5
• The PROSPER study found no significant differences between abdominal and perineal approaches in randomized comparisons, with substantial improvements in quality of life following all procedures 1
• Laparoscopic approaches have gained popularity due to lower morbidity and similar functional outcomes to open procedures 3

Pitfalls and Caveats

• Avoid mesh rectopexy in cases of bowel perforation or contamination
• Consider pre-existing bowel function when selecting procedure (resection may worsen incontinence)
• Perineal procedures require specific expertise and may not be available at all centers
• Laparoscopic approaches have a learning curve and may not be suitable for emergency cases
• The Ivalon sponge rectopexy has largely been abandoned due to infectious complications 5
• Patients with pre-existing conditions (diabetes, vascular disease, IBD) have higher risk of post-surgical proctitis 2

The evidence suggests that while multiple surgical options exist, matching the procedure to the patient's specific characteristics remains the key to optimizing outcomes in terms of morbidity, mortality, and quality of life.