Transsacral
Repair of Patrick F.
Whatever the basic pathogenesis of rectal prolapse, the structural alterations invariably include a defect in the pelvic floor fascia, a deep pouch anterior to the rectum, a patulous anus, loose fixation of the rectum to the pelvic structures, and a long sigmoid colon. A variety of corrective procedures have been described for rectal prolapse, but all suffer from various disadvantages. The transsacral approach to the rectum has several advantages: (1) it is simple and safe even for the elderly, (2) it avoids an abdominal incision with its concomitant postoperative complications, (3) it will allow complete correction of all abnormalities, and (4) it has been performed with a low recurrence
rate.
the mechanism of
idopathic rectal prolapse sliding hernia is a moot ques¬ the following structural altera¬ tion. In variable tions are observed in idiopathic rectal prolapse: (1) a de¬ fect in the pelvic floor consisting of attentuated pelvic fascia and atonic pelvic floor muscles, (2) an abnormally deep rectovesical or rectovaginal pouch, (3) a patulous anus with atonic sphincteric mechanism, (4) loose fixation of the rectum to the pelvis with unusually redundant mesorectum and rectal stalks, and (5) a long sigmoid co¬ lon. Which among these are primary and which are sec¬ ondary to the continuing process has never been resolved and is subject to considerable speculation. Habitual straining with or without constipation over a long time undoubtedly plays a major role. Electromyographic study of the atonic pelvic floor muscles reveals disturbed reflex
Whether intussusception degrees, is
or
activities in the muscles. ·More than 50 corrective procedures have been described for this condition. Many of the earlier operations that were aimed at only one of the structural defects resulted in high recurrence rates. A number of later operative pro¬ cedures attempted to correct several or all of the above structural defects simultaneously. While this approach re¬ duced the incidence of recurrences greatly, the operations are of major proportions. Thus, some of the more recent types of repair have returned to the correction of only one of the above defects, and results thus far have been quite
encouraging.34 A variety of perineal procedures
have been described from the simplest Thiersch wire to a transanal repair with resection of the rectosigmoid, obviating a need for celi¬ otomy in high-risk patients. The method described here is a transsacral approach that permits repair of all defects and includes fixation of rectal stalks and anterior closure of the pelvic floor with or without resection of the sigmoid colon. It, too, avoids celiotomy. Accepted for publication Aug 12, 1974. From the Department of Surgery, University of Kentucky, Albert B. Chandler Medical Center, Lexington, Ky. Reprint requests to Department of Surgery, University of Kentucky, Albert B. Chandler Medical Center, Lexington, KY 40506 (Dr. Griffen).
Rectal
Hagihara, MD,
Prolapse
Ward O.
Griffen, Jr., MD, PhD
TECHNIQUE Intra-abdominal lesions should be ruled out. A barium enema should be routinely obtained in each case, not only to rule out coIonic lesions, but to estimate the degree of redundancy of the sig¬ moid colon. Electromyography of the external anal sphincter is helpful in studying the adequacy of the pelvic floor muscle func¬ tion in the continence reaction. Both mechanical and antibiotic bowel preparations are used. The patient is positioned prone following the induction of gen¬ eral anesthesia. A 10- to 15-cm incision is made in the midline through the skin over the coccyx and distal part of the sacrum. A transverse incision may be used if preferred. The tip of the coccyx is identified, and the anococcygeal raphe is detached from the coc¬ cyx. The periosteum is elevated from the coccyx, detaching the sacrotuberous and sacrospinous ligaments and a part of the ori¬ gins of the gluteus maximus and coccygeus from the lateral mar¬ gins of the coccyx (Fig 1, top). Coccygectomy is performed. The periosteum is then elevated from the last sacral segment and, with it, further portions of the same muscles and ligaments. This sacral segment is then removed by rongeurs. The fourth sacral segment may also be removed partially or completely if necessary, avoiding injury to the third sacral nerve. The fascia of Waldeyer or the posterior part of the parietal layer of the pelvic fascia, seen as a thick, white, opaque layer of tissue, is thus identified overlying the rectum cephalad to the ano¬ coccygeal raphe. This layer is incised in the midline and retracted laterally (Fig 1, middle). The underlying rectum, covered by a thin visceral layer of the pelvic fascia and showing the prominent ter¬ minations of the superior hemorrhoidal vessels on its surface, is easily identified. Cephalad to the rectal stalk, the lateral margin of the rectal wall is retracted and, by blunt dissection, the peri¬ toneal layer is identified. This peritoneal layer is incised and the cul-de-sac entered for closure of the defect in the pelvic floor ante¬ rior to the rectum (Fig 1, bottom). An alternate approach to the pelvic floor anterior to the rectum is via a limited dissection below the rectal stalk superficial to the puborectalis and lateral to the rectal wall. In either case, the rectum and the rectal stalk are re¬ tracted on one side and an incision is made in the peritoneal layer at the deepest point of the rectovesical pouch or pouch of Douglas. By blunt dissection, the medial borders of the levator ani and puborectalis muscles with pelvic fascia are identified immediately anterior to the rectum and are approximated with three or four interrupted sutures of 0 silk, taking deep bites (Fig 2, top). Following this, the sigmoid colon, if unusually redundant, is re¬ sected by withdrawing a loop of the sigmoid colon through the aforementioned peritoneal incision. Following the resection, an end-to-end anastomosis is completed and the peritoneal layer is sutured to the rectum circumferentially to obtain a complete peri¬ toneal closure around the rectum. If such resection is not contem¬ plated, the peritoneal opening is simply closed. The fixation of both rectal stalks to the periosteum of the anterior surface of the sacrum is obtained with three or four 2-0 nonabsorbable sutures on each side. The rectal stalks are also sutured to the sacrospinous and sacrotuberous ligaments (Fig 2, bottom left). The rectum may also be sutured to the parietal layer of pelvic fascia. Suction cathe¬ ters are placed in the pararectal space and brought out through separate stab incisions in the skin; the incision in the parietal
Downloaded From: http://archsurg.jamanetwork.com/ by a Western University User on 06/10/2015
Fig 1.—Top, Anococcygeal raphe is detached from tip of coccyx. Gluteus maximus, coccygeus, and sacrotuberous and sacrospinous ligaments are elevated off from coccyx and distal segment of sacrum. Middle, Parietal layer of pelvic fascia incised. Bottom, Culde-sac entered lateral to rectum above rectal stalk. Alternate ap¬ proach to cul-de-sac indicated.
layer
of
pelvic
fascia is then closed. The
periostea]
and
liga¬
then approximated over the closure. The skin incision is closed with No. 32 wire sutures (Fig 2, bottom right). The skin closure should be secure, protected from contamination, and the sutures left in for ten days or longer. The suction cathe¬ ters are removed in two or three days. mentous tissues
are
COMMENT The exposure of the rectum by the transsacral route is quite adequate. All of the identifiable defects in rectal prolapse can be repaired through this approach and an ab¬ dominal incision avoided. The Kraske approach to resect a short segment of the rectum and a large benign tumor within the rectum or for a pull-through procedure is well
known. The fixation of the rectal stalks and closure of the defect in pelvic floor anterior to the rectum as described herein are the same as in the procedure reported by Frykman and Goldberg.7' Moreover, since additional fixation of the rectum to the surrounding structures can be made eas¬ ily, a sigmoid resection may be unnecessary in most cases. If a resection is required, the lower part of the rectum is safely preserved just as in the transabdominal approach.
Fig 2.—Top, Rectum retracted laterally and rectal stalk down¬ ward. Pelvic fascia and medial borders of levator ani and puborec¬ talis are approximated anterior to rectum. Bottom left, Rectum sus¬ pended to periosteum of sacrum by suturing both rectal stalks to periosteum of sacrum. Bottom right, Conclusion of operation.
In the transanal approach, by contrast, an adequate fix¬ ation of the rectum may be difficult to achieve and the re¬ section, if contemplated, is limited to the distal part of the rectum. A similar procedure to the one described here has been reported by Thomas and Jenkins with excellent re¬ sults." To date, the procedure has been done at this institu¬ tion in only a few patients; the first patient was operated on two years and ten months ago. The repair and anal continence have been well maintained in all cases so far.
References 1. Porter NH: A physiological study of the pelvic floor in rectal Ann R Coll Surg 31:379-404, 1962. 2. Parks AG, Porter NH, Melzak J: Experimental study of the reflex mechanism controlling the muscles of the pelvic floor. Dis Colon Rectum 5:407-414, 1962. 3. Devadhar DSC: Surgical correction of rectal procidentia.
prolapse.
Surgery 62:847-852, 1967. 4. Ripstein CB: Surgical treatment of rectal prolapse. Pacif Med Surg 75:329-332, 1967. 5. Frykman HM, Goldberg SM: Surgical treatment of rectal procidentia. Surg Gynecol Obstet 129:1225-1230, 1969. 6. Thomas CG, Jenkins SG: Results of the posterior approach in the repair of rectal prolapse. Ann Surg 161:897-907, 1965.
Downloaded From: http://archsurg.jamanetwork.com/ by a Western University User on 06/10/2015
Repair of Patrick F.
Whatever the basic pathogenesis of rectal prolapse, the structural alterations invariably include a defect in the pelvic floor fascia, a deep pouch anterior to the rectum, a patulous anus, loose fixation of the rectum to the pelvic structures, and a long sigmoid colon. A variety of corrective procedures have been described for rectal prolapse, but all suffer from various disadvantages. The transsacral approach to the rectum has several advantages: (1) it is simple and safe even for the elderly, (2) it avoids an abdominal incision with its concomitant postoperative complications, (3) it will allow complete correction of all abnormalities, and (4) it has been performed with a low recurrence
rate.
the mechanism of
idopathic rectal prolapse sliding hernia is a moot ques¬ the following structural altera¬ tion. In variable tions are observed in idiopathic rectal prolapse: (1) a de¬ fect in the pelvic floor consisting of attentuated pelvic fascia and atonic pelvic floor muscles, (2) an abnormally deep rectovesical or rectovaginal pouch, (3) a patulous anus with atonic sphincteric mechanism, (4) loose fixation of the rectum to the pelvis with unusually redundant mesorectum and rectal stalks, and (5) a long sigmoid co¬ lon. Which among these are primary and which are sec¬ ondary to the continuing process has never been resolved and is subject to considerable speculation. Habitual straining with or without constipation over a long time undoubtedly plays a major role. Electromyographic study of the atonic pelvic floor muscles reveals disturbed reflex
Whether intussusception degrees, is
or
activities in the muscles. ·More than 50 corrective procedures have been described for this condition. Many of the earlier operations that were aimed at only one of the structural defects resulted in high recurrence rates. A number of later operative pro¬ cedures attempted to correct several or all of the above structural defects simultaneously. While this approach re¬ duced the incidence of recurrences greatly, the operations are of major proportions. Thus, some of the more recent types of repair have returned to the correction of only one of the above defects, and results thus far have been quite
encouraging.34 A variety of perineal procedures
have been described from the simplest Thiersch wire to a transanal repair with resection of the rectosigmoid, obviating a need for celi¬ otomy in high-risk patients. The method described here is a transsacral approach that permits repair of all defects and includes fixation of rectal stalks and anterior closure of the pelvic floor with or without resection of the sigmoid colon. It, too, avoids celiotomy. Accepted for publication Aug 12, 1974. From the Department of Surgery, University of Kentucky, Albert B. Chandler Medical Center, Lexington, Ky. Reprint requests to Department of Surgery, University of Kentucky, Albert B. Chandler Medical Center, Lexington, KY 40506 (Dr. Griffen).
Rectal
Hagihara, MD,
Prolapse
Ward O.
Griffen, Jr., MD, PhD
TECHNIQUE Intra-abdominal lesions should be ruled out. A barium enema should be routinely obtained in each case, not only to rule out coIonic lesions, but to estimate the degree of redundancy of the sig¬ moid colon. Electromyography of the external anal sphincter is helpful in studying the adequacy of the pelvic floor muscle func¬ tion in the continence reaction. Both mechanical and antibiotic bowel preparations are used. The patient is positioned prone following the induction of gen¬ eral anesthesia. A 10- to 15-cm incision is made in the midline through the skin over the coccyx and distal part of the sacrum. A transverse incision may be used if preferred. The tip of the coccyx is identified, and the anococcygeal raphe is detached from the coc¬ cyx. The periosteum is elevated from the coccyx, detaching the sacrotuberous and sacrospinous ligaments and a part of the ori¬ gins of the gluteus maximus and coccygeus from the lateral mar¬ gins of the coccyx (Fig 1, top). Coccygectomy is performed. The periosteum is then elevated from the last sacral segment and, with it, further portions of the same muscles and ligaments. This sacral segment is then removed by rongeurs. The fourth sacral segment may also be removed partially or completely if necessary, avoiding injury to the third sacral nerve. The fascia of Waldeyer or the posterior part of the parietal layer of the pelvic fascia, seen as a thick, white, opaque layer of tissue, is thus identified overlying the rectum cephalad to the ano¬ coccygeal raphe. This layer is incised in the midline and retracted laterally (Fig 1, middle). The underlying rectum, covered by a thin visceral layer of the pelvic fascia and showing the prominent ter¬ minations of the superior hemorrhoidal vessels on its surface, is easily identified. Cephalad to the rectal stalk, the lateral margin of the rectal wall is retracted and, by blunt dissection, the peri¬ toneal layer is identified. This peritoneal layer is incised and the cul-de-sac entered for closure of the defect in the pelvic floor ante¬ rior to the rectum (Fig 1, bottom). An alternate approach to the pelvic floor anterior to the rectum is via a limited dissection below the rectal stalk superficial to the puborectalis and lateral to the rectal wall. In either case, the rectum and the rectal stalk are re¬ tracted on one side and an incision is made in the peritoneal layer at the deepest point of the rectovesical pouch or pouch of Douglas. By blunt dissection, the medial borders of the levator ani and puborectalis muscles with pelvic fascia are identified immediately anterior to the rectum and are approximated with three or four interrupted sutures of 0 silk, taking deep bites (Fig 2, top). Following this, the sigmoid colon, if unusually redundant, is re¬ sected by withdrawing a loop of the sigmoid colon through the aforementioned peritoneal incision. Following the resection, an end-to-end anastomosis is completed and the peritoneal layer is sutured to the rectum circumferentially to obtain a complete peri¬ toneal closure around the rectum. If such resection is not contem¬ plated, the peritoneal opening is simply closed. The fixation of both rectal stalks to the periosteum of the anterior surface of the sacrum is obtained with three or four 2-0 nonabsorbable sutures on each side. The rectal stalks are also sutured to the sacrospinous and sacrotuberous ligaments (Fig 2, bottom left). The rectum may also be sutured to the parietal layer of pelvic fascia. Suction cathe¬ ters are placed in the pararectal space and brought out through separate stab incisions in the skin; the incision in the parietal
Downloaded From: http://archsurg.jamanetwork.com/ by a Western University User on 06/10/2015
Fig 1.—Top, Anococcygeal raphe is detached from tip of coccyx. Gluteus maximus, coccygeus, and sacrotuberous and sacrospinous ligaments are elevated off from coccyx and distal segment of sacrum. Middle, Parietal layer of pelvic fascia incised. Bottom, Culde-sac entered lateral to rectum above rectal stalk. Alternate ap¬ proach to cul-de-sac indicated.
layer
of
pelvic
fascia is then closed. The
periostea]
and
liga¬
then approximated over the closure. The skin incision is closed with No. 32 wire sutures (Fig 2, bottom right). The skin closure should be secure, protected from contamination, and the sutures left in for ten days or longer. The suction cathe¬ ters are removed in two or three days. mentous tissues
are
COMMENT The exposure of the rectum by the transsacral route is quite adequate. All of the identifiable defects in rectal prolapse can be repaired through this approach and an ab¬ dominal incision avoided. The Kraske approach to resect a short segment of the rectum and a large benign tumor within the rectum or for a pull-through procedure is well
known. The fixation of the rectal stalks and closure of the defect in pelvic floor anterior to the rectum as described herein are the same as in the procedure reported by Frykman and Goldberg.7' Moreover, since additional fixation of the rectum to the surrounding structures can be made eas¬ ily, a sigmoid resection may be unnecessary in most cases. If a resection is required, the lower part of the rectum is safely preserved just as in the transabdominal approach.
Fig 2.—Top, Rectum retracted laterally and rectal stalk down¬ ward. Pelvic fascia and medial borders of levator ani and puborec¬ talis are approximated anterior to rectum. Bottom left, Rectum sus¬ pended to periosteum of sacrum by suturing both rectal stalks to periosteum of sacrum. Bottom right, Conclusion of operation.
In the transanal approach, by contrast, an adequate fix¬ ation of the rectum may be difficult to achieve and the re¬ section, if contemplated, is limited to the distal part of the rectum. A similar procedure to the one described here has been reported by Thomas and Jenkins with excellent re¬ sults." To date, the procedure has been done at this institu¬ tion in only a few patients; the first patient was operated on two years and ten months ago. The repair and anal continence have been well maintained in all cases so far.
References 1. Porter NH: A physiological study of the pelvic floor in rectal Ann R Coll Surg 31:379-404, 1962. 2. Parks AG, Porter NH, Melzak J: Experimental study of the reflex mechanism controlling the muscles of the pelvic floor. Dis Colon Rectum 5:407-414, 1962. 3. Devadhar DSC: Surgical correction of rectal procidentia.
prolapse.
Surgery 62:847-852, 1967. 4. Ripstein CB: Surgical treatment of rectal prolapse. Pacif Med Surg 75:329-332, 1967. 5. Frykman HM, Goldberg SM: Surgical treatment of rectal procidentia. Surg Gynecol Obstet 129:1225-1230, 1969. 6. Thomas CG, Jenkins SG: Results of the posterior approach in the repair of rectal prolapse. Ann Surg 161:897-907, 1965.
Downloaded From: http://archsurg.jamanetwork.com/ by a Western University User on 06/10/2015
