What are the indications for surgery in rectal prolapse?

Indications for Surgery in Rectal Prolapse

Surgery is indicated for patients with symptomatic grade 3-4 rectal prolapse, while asymptomatic grade 1-2 rectal prolapse should be managed conservatively with biofeedback therapy. 1

Primary Indications for Surgical Management

• Symptomatic grade 3-4 rectal prolapse requires surgical intervention using either an abdominal approach (resection, rectopexy, or both) or perineal resection 1
• Immediate surgical treatment is necessary for complicated rectal prolapse with signs of shock, gangrene, or perforation of prolapsed bowel 1
• Urgent surgical treatment is indicated for rectal prolapse with bleeding, acute bowel obstruction, or after failure of non-operative management 1
• Hemodynamic instability with complicated rectal prolapse requires immediate surgical intervention without delay for imaging or conservative measures 1

Conservative Management Before Surgery

• Asymptomatic grade 1-2 rectal prolapse should be managed with conservative and/or biofeedback therapy to correct underlying dyssynergia 1
• For incarcerated rectal prolapse without signs of ischemia or perforation, conservative measures with gentle manual reduction under mild sedation or anesthesia should be attempted first 1, 2
• Surgical management should not be delayed in hemodynamically unstable patients with complicated rectal prolapse 1

Surgical Approach Selection Criteria

• The decision between abdominal and perineal procedures should be based on patient characteristics and surgeon's expertise 1
• Abdominal procedures are recommended for younger, fit patients due to lower recurrence rates (0-8%) 1, 3
• Perineal procedures are better suited for elderly patients with significant comorbidities, offering lower perioperative morbidity but higher recurrence rates (5-21%) 1, 3
• In patients with complicated rectal prolapse and signs of peritonitis, an abdominal approach is recommended 1
• For hemodynamically unstable patients with complicated rectal prolapse, an abdominal open approach is strongly recommended 1

Special Considerations for Surgical Planning

• Bowel resection should be avoided in patients with preexisting diarrhea and/or incontinence as these symptoms may worsen with resection 1, 2
• Laparoscopic rectopexy is associated with fewer post-operative complications and shorter hospital stay than open rectopexy 1, 4
• Division of lateral ligaments is associated with less recurrent prolapse but more postoperative constipation 1, 5
• Posterior rectopexy can result in severe constipation in up to 50% of patients 1, 2
• In patients with strangulated rectal prolapse, empiric antimicrobial therapy should be administered due to the risk of intestinal bacterial translocation 1, 2

Pitfalls and Caveats

• Many patients undergo surgical therapy without a rigorous trial of conservative therapy; surgery is necessary in only a small fraction (perhaps <5%) of patients with defecatory disorders 1
• Pouch of Douglas protrusion can be confused with rectal intussusception and full-thickness rectal prolapse, requiring different surgical approaches 1, 2
• The correlation between symptoms and anatomic abnormalities is often weak; symptoms may improve despite modest effects on anatomic disturbances and vice versa 1
• Recurrence rates vary significantly between procedures: abdominal approaches have lower recurrence (0-8%) compared to perineal approaches (5-21%) 1, 3, 6