Rectal Prolapse Repair
What the Examiner Expects
Surgical correction of full-thickness rectal prolapse (procidentia), where the full thickness of the rectal wall protrudes through the anus. The examiner expects you to distinguish full-thickness prolapse (concentric mucosal folds) from mucosal prolapse (radial folds), confirm the diagnosis with examination (ask the patient to strain), and choose the approach based on patient fitness. Abdominal approaches (laparoscopic ventral mesh rectopexy or posterior suture rectopexy +/- sigmoid resection) have lower recurrence rates but require general anesthesia and abdominal surgery. Perineal approaches (Altemeier — perineal rectosigmoidectomy; Delorme — mucosal sleeve resection with muscular plication) can be done under regional anesthesia and are preferred for frail or elderly patients.
Key Examiner Focus Points
- Perineal approach (Altemeier, Delorme) for elderly/high-risk patients
- Abdominal approach (rectopexy +/- sigmoid resection) for fit patients
- Altemeier: perineal proctosigmoidectomy — full-thickness resection from below
- Distinguish full-thickness prolapse from mucosal prolapse (concentric vs radial folds)
- Evaluate for concurrent fecal incontinence and constipation
Common Curveballs
The patient also complains of significant fecal incontinence
Repair of the prolapse often improves continence over time as the sphincter recovers tone. If incontinence persists, consider adding a levatoroplasty to the perineal repair (Altemeier with levatoroplasty). Biofeedback therapy postoperatively can also help.
Recurrence after a perineal Altemeier procedure
Recurrence rates are higher with perineal approaches (10–20% vs 2–5% for abdominal). For a recurrence, consider an abdominal approach (ventral mesh rectopexy) if the patient can tolerate it. Repeat perineal procedures are possible but have progressively higher recurrence rates.
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