improved outcomes in colon and rectal surgery 113. Pinta T, Kylanpaa-Back ML, Salmi T, Jarvinen HJ, Luukkonen P. Delayed sphincter repair for obstetric ruptures: analysis of failure. Colorectal Dis 2003; 5: 73–8. 114. Evans C, Davis K, Kumar D. Overlapping anal sphincter repair and anterior levatorplasty: effect of patient’s age and duration of follow-up. Int J Colorectal Dis 2006; 21: 795–801. 115. Londono-Schimmer EE, Garcia-Duperly R, Nicholls RJ et al. Overlapping anal sphincter repair for faecal inconti- nence due to sphincter trauma: five year follow-up func- tional results. Int J Colorectal Dis 1994; 9: 110–3. 116. Halverson AL, Hull TL. Long-term outcome of overlapping anal sphincter repair. Dis Colon Rectum 2002; 45: 345–8. 117. Zorcolo L, Covotta L, Bartolo DC. Outcome of anterior sphincter repair for obstetric injury: comparison of early and late results. Dis Colon Rectum 2005; 48: 524–31. 118. Grey BR, Sheldon RR, Telford KJ, Kiff ES. Anterior anal sphincter repair can be of long term benefit: a 12-year case cohort from a single surgeon. BMC Surg 2007; 7: 1. 119. Jarrett ME, Varma JS, Duthie GS, Nicholls RJ, Kamm MA. Sacral nerve stimulation for faecal incontinence in the UK. Br J Surg 2004; 91: 755–61. 120. Leroi AM, Parc Y, Lehur PA et al. Efficacy of sacral nerve stimulation for fecal incontinence: results of a multicenter double-blind crossover study. Ann Surg 2005; 242: 662–9. 121. Holzer B, Rosen HR, Novi G et al. Sacral Nerve Stimulation in Patients with Severe Constipation. Dis Colon Rectum 2008; 51(5): 524–29. Surgery for rectal prolapse Steven R Hunt INTRODUCTION Rectal prolapse (rectal procidentia) is defined as the full thickness intussusception of the rectum through the anal canal. The annual incidence of rectal prolapse is estimated to be 2.5 per 100,000 pop- ulation.(1) The disorder tends to affect elderly women, psychiat- ric patients, and patients with neurologic disorders. Presenting symptoms are usually referable to the prolapse itself. Additional presenting complaints include constipation, straining, inconti- nence, and mucous soilage of the undergarments. Surgery remains the only definitive therapy for rectal prolapse. Over 100 operations have been described for the treatment of procidentia. Generally, these procedures can be divided into peri- toneal and abdominal approaches. The optimal procedure for each patient should be determined by presenting symptoms and patient comorbid disease. CLASSIFICATION In the strictest sense, rectal prolapse refers only to full thickness, circumferential protrusion of the rectum beyond the anal canal. While it is often clinically obvious, several other anorectal disor- ders can imitate the condition. Circumferential prolapsed internal hemorrhoids, when large, are frequently diagnosed as prolapse, and prolapse is often diagnosed as hemorrhoids. Rectal polyps or cancer can protrude through the anus and mimic prolapse. It is important to differentiate between true procidentia and mucosal prolapse, as the entities may have similar presenting symptoms. Patients with mucosal prolapse frequently have a history of prior anorectal procedures or trauma and the prolapse is often asym- metric. Solitary rectal ulcers and colitis cystica profunda can present with symptoms similar to rectal prolapse. These disorders are associated with internal intussusception of the rectum, but may coexist in patients with rectal prolapse. Both solitary rectal ulcer and colitis cystica profunda are hypothesized to result from repeated mucosal trauma and ischemia at the lead point of the prolase. Significant rectal bleeding is relatively rare in patients with procidentia, although it is a common presentation in soli- tary rectal ulcer syndrome and colitis cystica profunda. Internal rectal intussusception without prolapse may be a pred- ecessor to rectal prolapse, although this association has not been proven.(2) Rectal intussusception is frequently identified during defecography performed to evaluate obstructed defecation or con- stipation. It is also a common finding in asymptomatic patients. (3) While it is clear that surgery is the mainstay of treatment for complete rectal prolapse, the indications for surgical intervention in cases of internal intussusception are less clear. Some authors advocate surgical intervention in cases of symptomatic intussus- ception, while others are more cautious in their approach.(4, 5) In the author’s section, the initial approach to patients with rectal intussusception is dietary modification and pelvic floor retrain- ing through biofeedback. Surgery is generally reserved for patients with complications of internal prolapse (solitary rectal ulcers and colitis cystica profunda) who have failed conservative therapy. Patient Evaluation and Investigations As rectal prolapse is a benign disease, surgery need only be consid- ered if the symptoms are debilitating. Frequency of the prolapse and initiating factors (defecation, straining or standing) should be documented. The presence of severe constipation or symp- toms of obstructed defecation should be noted, as these patients may require further evaluation. Fecal incontinence occurs in 60–80% of patients, and a frank discussion should ensue regard- ing expected surgical outcomes with regard to continence. Most large series show improvement in fecal incontinence in >40% of procidentia patients after surgery, regardless of the approach.(6) Continence may continue to improve over the first 6 to 12 months postoperatively. A detailed surgical history should be obtained, with special attention to anorectal and pelvic operations, as this may influence the ultimate surgical approach. In patients with recurrent rectal prolapse, operative notes from the prior procedures should be obtained and scrutinized. Female patients may have a history of bladder or uterine prolapse, requiring consultation with a urogynecologist and a combined approach. All patients with prolapse should have a recent colonoscopy to rule out any mucosal lesions. Physical Exam The diagnosis of procidentia is made by demonstration of the prolapse in the surgeon’s office. Patients with advanced prolapse may be able to produce the prolapse on the examination table with minimal straining. If the patient cannot prolapse on the examination table, they should be examined after straining on the toilet. Once the prolapse has been achieved, the examiner should first differentiate between full thickness prolapse and hemorrhoi- dal or mucosal prolapse. Full thickness prolapse is characterized by concentric mucosal rings, as opposed to the radially oriented sulci seen with mucosal and hemorrhoidal prolapse. The digital rectal exam should exclude other anorectal pathol- ogy, and the sphincter tone and the squeeze pressure should be evaluated. Female patients should be evaluated for the presence of an enterocele or rectocele. Rigid proctoscopy should be per- formed in the office to rule out any rectal tumors, and to evaluate for solitary ulcer and colitis cystica profunda. Generally, a physical exam and demonstration of the com- plete prolapse in the office is sufficient evaluation before surgery. Additional studies are sometimes required in certain cases. Anal Physiology Patients with chronic severe straining at stool should be evaluated with anal physiology testing. Electromyography that demonstrates improved outcomes in colon and rectal surgery Figure 23.1 Perineal rectosigmoidectomy. (A & B) Incision of rectal wall. (C) Division of vessel adjacent to bowel wall. (D) Mesenteric vessels ligated. Stay sutures previously placed in distal edge of outer cylinder are placed in cut edge of inner cylinder. (E) Anastomosis of distal aspect of remaining colon to the short rectal stump. (From Beck DE, Whitlow CB. Rectal prolapse and intussusception. In Beck DE. Handbook of colorectal surgery. 2nd edition. Marcel Dekker: New York, 2003; 301–24. With permission.) (A) (B) (C) (E) (D) a nonrelaxing puborectalis should prompt initiation of biofeed- back therapy as an adjunct to surgery. Postoperative continence can also be predicted on the basis of a prolonged pudendal nerve terminal motor latency (PNTML) and poor resting sphincter tone.(7, 8) We do not routinely obtain physi- ologic studies in the evaluation of procidentia, as they are expensive and a prolonged PNTML is not a contraindication for surgery. Additional Studies When the patient is unable to reproduce the rectal prolapse in the office, defecography may be used to evaluate for internal pro- lapse or other defecatory pathology. In patients with severe con- stipation and prolapse, a colonic transit study may be obtained. Concentration of the markers in the left and sigmoid colon on day 5, in the setting of severe constipation, is an indication for a resection rectopexy. OPERATIVE REPAIRS Although the modern operative procedures for rectal prolapse are not particularly morbid, the patients are frequently elderly, and morbidity is not trivial. Some series report mortalities as high as 7%. These patients often have significant comorbid conditions, and the operative approach (perineal, open or laparoscopic) should take these factors into account. The choice of procedure is frequently dictated by surgeon preference and experience; however, a one- size-fits-all approach may not be suitable for all patients. In addition to the morbidity of the procedure, the evaluation of the various surgical approaches to rectal prolapse must take efficacy and surgery for rectal prolapse functional outcomes into account. Some techniques have excellent results in terms of recurrence, but can predispose the patients to con- stipation or evacuatory difficulties, trading one problem for another. Perineal Repairs The preponderance of the historical literature suggests that the abdominal approach to rectal prolapse is superior to the perineal approach in terms of recurrence rates. While most single institu- tion studies report better outcomes for abdominal procedures, this difference is not demonstrated in meta-analysis.(9, 10) The major advantage of the perineal approach is the ability to con- duct the operation under spinal or even local, anesthetic. The avoid- ance of general anesthesia and an abdominal dissection makes this the preferred approach for patients with significant comorbidities. Perineal Proctosigmoidectomy (Altmeier Procedure) The technique of perineal proctosigmoidectomy involves mobiliza- tion and resection of the prolapsed rectosigmoid colon via a perineal approach. Patients should have a complete mechanical bowel prepa- ration. The prone-jackknife or left lateral position is preferred over lithotomy, as it allows easy access to the operative field for the sur- geon and assistant. While general anesthetic provides more comfort for the patient, it is often necessary to use local or spinal anesthesia in frail patients. The buttocks should be taped apart and a Lonestar retractor is used to efface the anus and provide optimal exposure. The procedure is begun by recreating the prolapse. Once the bowel has been completely prolapsed, a circumferential incision is made in the rectum approximately 1.5–2 cm proximal to the dentate line. Using the electrocautery, this incision should be continued until the full thickness of the rectal wall has been incised circumferentially. The incised rectum is then everted and pulled downward. The vaginal wall is frequently adherent to the prolapsed segment and should be dissected away from the rectum to avoid the devastating complication of a postoperative colovaginal fistula. The peritoneal cavity is then entered by incising the peritoneum of the Pouch of Douglas anteriorly. Entrance into the peritoneal cavity facilitates Figure 23.2 Delorme’s procedure. (A) Subcutaneous infiltration of dilute epi- nephrine solution. (B) Circumferential mucosal incision. (C) Dissection of mucosa off muscular layer. (D) Plicating stitch approximating cut edge of mucosa, muscular wall, and mucosa just proximal to dentate line. (E) Plicating stitch tied. (F) Completed anastomosis. (From Beck DE, Whitlow CB. Rectal prolapse and intussusception. In Beck DE. Handbook of colorectal surgery. 2nd edition. Marcel Dekker: New York, 2003, 301–24. With permission.) (A) (B) (C) (D) (D) (E) improved outcomes in colon and rectal surgery Figure 23.3 Anal encirclement (Thiersch). (A) Lateral incisions with prosthetic mesh tunneled around the anus. (B) Mesh completely encircling the anal opening. (C) Completed anal encirclement procedure. (From Beck DE, Whitlow CB. Rectal prolapse and intussusception. In Beck DE. Handbook of colorectal surgery. 2nd edition. Marcel Dekker: New York, 2003, 301–24. With permission.) (A) (B) (C) delivery of the prolapsed rectum and division of the mesorectum. The mesorectum is then divided and ligated with ligatures, or alternatively, a vessel sealing device may be used. Division of the mesorectum should be continued, advancing proximally on the bowel until tension is encountered (Figure 23.1). Once the redundant rectosigmoid has been mobilized, the ante- rior peritoneum should be repaired, including seromuscular bites of the anterior bowel wall, with a running absorbable suture to oblit- erate the pouch. A levatorplasty should be considered if a defect is present in the pelvic floor. If the levator muscles can be identified without extensive dissection, plication should be performed ante- riorly and posteriorly. The redundant bowel is then divided and a hand-sewn anastomosis is fashioned using interrupted absorbable sutures. Alternatively, the anastomosis may be created using a cir- cular stapler with acceptable results.(11, 12) Generally, patients have minimal narcotic requirements post- operatively and ileus is exceedingly rare. Patients should be ambu lated and their diet is advanced on postoperative day 1. Constipating regimens have no proven beneficial results. It is the author’s practice to discharge patients after the first bowel move- ment, but in some centers, the Altmeier procedure is performed on an outpatient basis.(11) In experienced hands, the Altmeier procedure has excellent results, rivaling the abdominal procedures for recurrence rates. Several recent large series report recurrence rates ranging from 6% to 16%.(7, 9, 11) Both incontinence and constipation are also significantly improved after perineal proctectomy.(7, 9, 13) Some authors describe significant improvement in recurrence rates if a levatorplasty is performed.(14) Fortunately, major morbidity and mortality for this procedure are rare. The anastomotic leak rates are reportedly 1–2%, with signifi- cant bleeding occurring in a similar percentage of patients.(7, 9, 14) Delorme’s Procedure Delorme’s procedure offers another alternative to the Altmeier repair. The technique involves a submucosal resection of the prolapsed rectum, with plication of the muscularis propria. The submucosal nature of the dissection in this procedure does not allow for a concomitant levatorplasty. As with the Altmeier procedure, mechanical bowel preparation should be performed and the procedure conducted in the prone- jackknife or left lateral position with effacement of the anus. Again, local or spinal anesthesia may be used for infirm patients. The rectal prolapse is delivered, and the submucosal plane is infiltrated with local anesthetic containing epinephrine. A circumferential mucosal incision is made 1 cm proximal to the dentate line. The submucosal plane is identified and downward traction is applied to the mucosal tube. Dissection is carried out within this plane to the apex of the prolapsed segment of rectum. At this point, the exposed muscularis propria is plicated with multiple bites in four quadrants using an absorbable monofilament or braided suture. The redundant mucosa is then excised and the plication sutures are tied. The mucosal edges are then reapproximated using interrupted absorbable sutures (Figure 23.2). The recurrence rate in most recent large series ranges from 13–27%.(15–17) The morbidity and mortality rates are similar to those of the Altmeier repair. Improvement is reported in both continence and constipation in most series where these func- tional outcomes were evaluated.(16–18) Given the uniformly inferior results of Delorme’s procedure relative to the Altmeier repair, it is the author’s feeling that this approach should not be used as a first-line perineal procedure. Many advocate this procedure for the treatment of mucosal prolapse; however, other, less involved techniques exist for this disorder. Elastic rubber band ligation is frequently adequate for modest mucosal prolapse. The circular stapler technique used in surgery for rectal prolapse the treatment of hemorrhoids is a second appealing option for more advanced mucosal prolapse. Anal Encirclement (Thiersch Repair) Anal encirclement has almost reached the status of historical inter- est, as it has been replaced by other procedures with more favora- ble results. The procedure can be performed in a short period of time with only local anesthetic. The original repair described by Thiersch used a silver wire to encircle the anal sphincter complex. The wire encirclement has fallen out of favor as the wire can break or erode through the sphincters and anoderm. Marlex or Mersilene mesh are the preferred alternative to wire, as they are softer and less prone to breakage or erosion. The operation can be performed in the prone-jackknife or lithotomy position. After meticulous antiseptic preparation, small posterior and anterior incisions are made 1 cm outside the anal verge. A curved clamp is then tunneled through the ischiorectal fossa from the anterior incision to the posterior Figure 23.4 Mesh rectopexy (Ripstein). (A) Posterior fixation of sling on one side. (B) Sling brought anteriorly around mobilized rectum. (C) Sling fixed posteriorly on the opposite side. (D) Sagittal view of the completed rectopexy. (From Beck DE, Whitlow CB. Rectal prolapse and intussusception. In Beck DE. Handbook of colorectal surgery. 2nd edition. Marcel Dekker: New York, 2003, 301–24. With permission.) (A) (B) (D)(C) improved outcomes in colon and rectal surgery incision and one end of the mesh is then pulled through the tunnel. This is duplicated on the opposite side and the other end of the mesh is delivered. The redundant mesh is pulled through and the prosthetic is tightened around an 18F Hegar dilator. The mesh is then overlapped anteriorly and sewn to itself with a nonabsorbable suture. The small incisions are then closed with absorbable subcuticular sutures and the wounds are sealed with Dermabond, to prevent subsequent soilage of the wounds (Figure 23.3). Anal encirclement procedures do not repair the prolapse, but merely prevent external prolapse. Infectious complications are common with the synthetic mesh, occurring in up to 33% of patients.(19) Postoperatively, these patients frequently experience tenesmus and difficulty with evacuation.(20) This procedure should be reserved for patients who have significant contraindi- cations to more formal repairs. One relative indication for this repair is the patient with significant hepatic ascites (not amenable to transjugular intrahepatic portosystemic shunt) and debilitating rectal prolapse. Open Abdominal Repairs A prerequisite to the open approach is the patient’s ability to toler- ate a general anesthetic and laparotomy. A variety of abdominal repairs are described in the literature, but only a few have withstood the test of time. The common theme among these time-tested pro- cedures is complete rectal mobilization and fixation of the rectum to the sacrum. It is suggested that the fibrosis resulting from the rectal mobilization is responsible for the long term fixation of the rectum and avoidance of recurrence.(21) All of the large series involving abdominal procedures show improvement in fecal continence. The same cannot be said for constipation, as rectopexy alone tends to worsen constipation. In cases of severe constipation preoperatively, a sigmoidectomy may be combined with rectal fixation. The repairs discussed below all involve complete rectal mobili- zation. In all cases, the rectal mobilization should be carried out in the avascular plane outside the mesorectal fascia. The perito- neum at the sacral promontory is incised and the plane posterior to the superior rectal artery is identified. Great care should be taken to prevent injury to the hypogastric plexus and the ureters should be identified and avoided. When rectal fixation sutures are placed, the position of the ureters should be reconfirmed to prevent inclusion in the suture. These approaches are not immune to the usual pitfalls of open laparotomy, with compli- cations including small bowel obstruction, prolonged ileus, and wound complications. There is some controversy regarding the extent of rectal mobi- lization. While some authors advocate division of the lateral rectal ligaments to improve recurrence rates, there are some reports of worsening constipation if the lateral ligaments are divided.(22) In a small randomized prospective study comparing rectal mobiliza- tion with and without division of the lateral ligaments, Mollen et al. reported no difference between the two groups with regard to constipation scores or to total colonic transit time. Anterior rec- tal mobilization is recommended with all of these procedures, but this is generally a minimal dissection as these patients tend to have a deep Pouch of Douglas. Mesh Sling Repair (Ripstein Procedure) The Ripstein procedure involves the posterior mobilization of the rectum down to the pelvic floor followed by fixation of the rec- tum to the sacrum using a mesh sling. Before the advent of the laparoscopic approach, this procedure was one of the most com- monly employed abdominal techniques for rectal prolapse. Patients should undergo a complete mechanical bowel prepa- ration and the operation is performed in the lithotomy position. A complete rectal mobilization is carried down to the pelvic floor. A 3–4 cm wide piece of PTFE or polypropylene mesh is then fixed to the sacrum approximately 1 cm to the right of the midline using several nonabsorbable sutures. Traction is then applied to the rectum in a cephalad direction and the mesh is fixed at mul- tiple points to the anterior rectum by seromuscular bites of non- absorbable suture. The mesh is then secured to the left side of the sacrum approximately 1 cm off the midline, taking care to ensure that the mesh does not constrict the rectum (Figure 23.4). The results of the Ripstein repair are excellent in terms of recurrence, with recurrence rates of 0–7% reported in large recent series.(6, 23, 24) In spite of these enviable results, enthu- siasm for this procedure has waned because of reports of mesh erosion into the rectum, late colovaginal fistulas, stenosis, and significant constipation following the procedure.(23) In light of these complications and the success of other alternative therapies, the Ripstein procedure’s role in the modern treatment of rectal prolapse should be limited. Posterior Mesh Fixation (Wells Operation) The technique of the Wells operation is similar to that of the Ripstein procedure, except the mesh fixation to the sacral promon- tory is posterior. Theoretically, this posterior mesh orientation may reduce the problems typically associated with the anterior sling. The procedure was originally described using an Ivalon (polyvi- nyl alcohol) sponge. In the US, experience with the Ivalon sponge is limited, as it has not been approved for implantation. Instead, many centers perform the procedure using polypropylene mesh. Full mechanical bowel prep is performed and the patient is posi- tioned in lithotomy position. The rectum is mobilized down to the pelvic floor. Retracting the rectum anteriorly, a 5 × 8 cm piece of mesh is then anchored to the sacrum in the midline using non- absorbable suture. The rectum is then retracted cephalad and the redundancy is eliminated. With the rectum under traction, the mesh is sutured bilaterally to the lateral rectal mesentery. The mesh wrap forms a trough around the dorsal half of the rectum and does not cover the anterior rectal wall. The peritoneum is then closed over the mesh to exclude it from the abdominal cavity (Figure 23.5). With regard to recurrence, the Wells operation has exceptional results with recurrence rates generally between 0–5% for most large open series.(25–27) While there are fewer reported mesh compli- cations, these series uniformly show a worsening of constipation after the procedure.(25–28) Suture Rectopexy Before the laparoscopic era, suture rectopexy alone was not a common procedure. This technique involves rectal mobilization followed by suture fixation to the sacral promontory. Its appeal lies in the fact that no foreign bodies are used, thus negating surgery for rectal prolapse the complications of mesh infection and erosion. A prospective randomized trial comparing open suture rectopexy to the Wells operation found no difference in the two procedures in terms of recurrence.(25) This procedure will be described in more detail under laparoscopy, as it has evolved primarily as a laparoscopic technique. Resection Rectopexy (Frykman-Goldberg Procedure) Constipation clearly worsens after rectopexy alone. Many authors advocate sigmoid colectomy with rectopexy to alleviate postoper- ative constipation. This technique, termed the Frykman-Goldberg procedure, involves full rectal mobilization, sigmoid colectomy with colorectal anastomosis, and suture fixation of the rectum to the sacrum. Patients require a complete mechanical bowel preparation and are positioned in lithotomy. The rectum is completely mobilized to the pelvic floor posteriorly. The lateral stalks are left intact. The rectum is then retracted into the abdomen and the posterolateral mesorectum is fixed to the presacral fascia using nonabsorbable sutures. The sigmoid colon and upper rectum are then resected. Mobilization of the splenic flexure is usually not required as the redundant sigmoid colon allows for resection and subsequent anastomosis without tension. The anastomosis is created with cir- cular stapler. The original description of this procedure involved Figure 23.5 Ivalalon (polyvinyl alcohol) sponge rectopexy (Wells). (A) Polyvinyl sponge being fixed to the sacrum. (B) Sponge in place before fixation to the rectum. (C) Incomplete encirclement of the rectum anteriorly with the sponge sutured in place. (From Beck DE, Whitlow CB. Rectal prolapse and intussusception. In Beck DE. Handbook of colorectal surgery. 2nd edition. Marcel Dekker:New York, 2003, p301–324. With permission.) (A) (B) (C) improved outcomes in colon and rectal surgery fixation of the anterior rectum to the endopelvic fascia to eliminate the cul-de-sac. Most modern proponents of this operation have abandoned these anterior sutures as they have no proven benefit and can be difficult to place safely. The resection rectopexy has superior results with respect to both recurrence and constipation. Most large series report recur- rence rates in the low single digits.(9, 29–31) Morbidity rates range from 0 to 35% and mortality from this procedure is low.(9, 29) This remains the only commonly employed abdominal procedure with significant improvement in postoperative constipation. One relative contraindication to resection rectopexy is severe inconti- nence with compromise of the anal sphincter, as sigmoidectomy can worsen incontinence in this patient population. The addition of a sigmoid resection confers a significantly increased risk of anastomotic complications when compared to rectopexy alone. Careful adherence to the usual tenets of a safe colorectal anastomosis (a good proximal and distal blood supply, a tension-free anastomosis, and air testing of the anastomosis) should allow safe practice of this procedure. Laparoscopy Over the past decade, the laparoscopic approach to colorectal diseases has become pervasive. The literature has been flooded with series reporting the successful treatment of rectal prolapse through minimally invasive techniques. Rectal prolapse lends itself extraordinarily well to the laparoscopic approach, as the procedure is isolated to one sector of the abdomen, and there is frequently no specimen removal or anastomosis required, avoid- ing a conventional incision altogether. Recent reports compar- ing open to laparoscopic treatment of rectal prolapse find that there are significant patient benefits to laparoscopy, including decreased pain, quicker resumption of diet, earlier return of bowel function, shorter length of stay, reduced hernia rates, and a lower incidence of small bowel obstruction.(32–34) Mortality rates for the laparoscopic approach are low. All of the open pro- cedures discussed previously can be performed laparoscopically, however the Ripstein procedure has proven tedious to complete laparoscopically and is seldom performed. In general, these laparoscopic procedures require a steep Trendelenburg position to keep the small bowel and sigmoid colon out of the pelvis. The mesorectum is frequently elongated and thin in these patients. The mesorectal peritoneum is scored at the sacral promontory and the plane behind the superior rec- tal artery is identified with the aid of pneumoperitoneum. The hypogastric nerves should be spared and the ureters identified. The initial mesorectal mobilization should be posterior in the avascular plane. As with the open approach, division of the lateral ligaments is controversial. The author performs a circumferential mobilization to the pelvic floor, including division of the lateral ligaments. The editors prefer to leave the lateral ligaments intact. The Wells repair has proven more amenable to the laparoscopic approach than the Ripstein procedure. The laparoscopic technique is similar to the open technique. Three or four laparoscopic ports are required and the procedure is most easily accomplished with a 30° camera, to allow for visualization deep in the pelvis. This approach requires skill in laparoscopic sewing and knot tying. As with the open Wells procedure, the recurrence rate is excellent, with recurrence rates ranging from 0 to 4% in recent series.(35–37) Functional outcomes were also analogous to the open procedure in these series, with improvement in continence, but worsening of constipation. Morbidity and mortality are low. Laparoscopists, forever testing the premise that less is more, have trended toward more suture repairs without mesh. The laparoscopic suture rectopexy is more manageable, as it does not require challeng- ing manipulations of mesh and involves less suturing. Again, three to four ports are required and a 30° camera is recommended. After the rectum is mobilized, it should be pulled in a cephalad direction and the lateral stalks are sutured to the sacral promontory using nonab- sorbable sutures. One suture on each side of the rectum is generally sufficient. Patient’s diets may be advanced rapidly and they should be ambulated early after surgery. It has been our practice to discharge patients after their first bowel movement, however many centers per- form this procedure with only a short postoperative stay. The laparoscopic suture rectopexy has been proven effective in several recently published series, with recurrence rates from 0%to 6%.(38–40) Continence is improved postoperatively, but the benefit of this simple technique may be found in improvement in postoperative constipation.(38, 40, 41) These series provide hope that the suture rectopexy alone, without mesh, may rival the mesh repair in efficacy, without the long term complication of constipation. This may obviate the need for a concomitant resec- tion, and thus decrease the difficulty and morbidity of the repair. Some centers still favor laparoscopic resection rectopexy as the primary procedure for rectal prolapse. As with the open tech- nique, splenic flexure mobilization is usually not required. The addition of sigmoidectomy increases the operative time relative to suture rectopexy alone by nearly 100 minutes.(41, 42) Results, as with the open technique, are excellent, with recurrence rates from 0% to 2.5%.(4, 43) Both constipation and incontinence are improved postoperatively. No comparative studies between open and laparoscopic techniques have proven a significant reduction in morbidity or mortality for the laparoscopic approach, but trends seem to favor the laparo- scopic approach.(34, 44) What is clear from the literature is that the minimally invasive approach to rectal prolapse is not inferior. The clear benefits of the laparoscopic approach in terms of cost, length of stay, and decreased pain mandate consideration of this approach when it is feasible. RECURRENT PROLAPSE Recurrent rectal prolapse occurs with every procedure, and the sur- gical approach to repair of the recurrence requires consideration of the initial procedure. The mean time to recurrence is between 18 and 24 months. Patients who have recurred require physiologic testing and defecography to evaluate for anismus. If anismus is identified, these patients should be referred for biofeedback before any surgical therapy. There is no clear algorithm for management of recurrent pro- lapse. Some authors advocate for a change in approach, performing perineal procedures if the initial approach was abdominal, and vice versa. Others promote the use of the same approach for repair of the recurrence. No definitive published data exists on the proper selection of the second procedure. The only absolute principle in the treatment of recurrent prolapse is that if a resection is planned, surgery for rectal prolapse any prior anastomoses must be resected in order to avoid an inter- vening ischemic segment. Again, comorbid disease should play a role in the selection of the procedure. Patients unfit for general anesthetic should be offered a perineal approach if at all possible. The few published series on the treatment of recurrent prolapse offer little to no insight on the best approach. A series from the University of Minnesota suggests that the abdominal approach is superior to the perineal approach in terms of rerecurrence.(45) The Cleveland Clinic Florida has published one of the larger series on treatment of recurrent prolapse. Various surgical approaches were used and it is not clear how the procedures are selected. Compared to primary operations for rectal prolapse, there was no difference in terms of recurrence, morbidity, and bowel function.(46) A difficult situation arises in the patient who has had a prior abdominal resection rectopexy, but is now unfit for general anes- thetic. Before undertaking a perineal proctectomy in such a patient, the surgeon must be sure he can mobilize and resect the prior anas- tomosis. If not, the surgeon is left with three less than desirable options. The patient may be counseled that an operation is not in their best interest. A Delorme procedure may be performed, or the patient may be offered anal encirclement. CONCLUSION While many procedures exist for rectal prolapse, only a few offer acceptable results in terms of recurrence, postoperative bowel function, and morbidity. Of the perineal techniques, the Altmeier procedure appears to offer superior outcomes in terms of these principles. All of the described open abdominal approaches have satisfactory recurrence rates, but only the resection rectopexy shows improvement in postoperative bowel function. Laparoscopy, with all of its inherent advantages, may be the preferred approach. Of these procedures, the laparoscopic suture rectopexy appears to offer the best hope of achieving favored status, given the relative simplicity of the procedure and its exceptional outcomes with minimal morbidity. The surgeon who treats this disease should possess the flexibility and breadth of skills to tailor the procedure to the individual patient. Surgeon preference and experience should play a role in the choice of procedure, but should not justify a single procedure for a complex dis- ease. An algorithm used in our section is to offer laparoscopic suture rectopexy as the default technique. If a patient has severe constipa- tion, a laparoscopic resection rectopexy is performed. The patient with a hostile abdomen or the patient who is too infirm to undergo an abdominal procedure is offered a perineal proctosigmoidectomy. REFERENCES 1. Kairaluoma MV, Kellokumpu IH. Epidemiologic aspects of complete rectal prolapse. Scand J Surg 2005; 94(3): 207–10. 2. Mellgren A, Schultz I, Johansson C, Dolk A. Internal rectal intussusception seldom develops into total rectal prolapse. Dis Colon Rectum 1997; 40(7): 817–20. 3. Dvorkin LS, Gladman MA, Epstein J et al. 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