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Transanal suture sacro-rectopexy for prolapse & intussusceptions of rectum

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Transanal suture sacro-rectopexy for prolapse & intussusceptions of rectum
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Objective;- To achieve simple transanal  fixation of rectum to the sacrum, without dissection.

Patients:- Twenty cases of complete prolapse of the rectum were treated, during the period from January 2009 to December 2012 at Jeevan Jyot Hospital, Thane. In series of 20 cases; 6 were females and 14 were males. Average age in females was 62, ranging from 49 to 81 and in males 42 was average age, ranging from 23 to 78 years. The length of prolapsed segment ranged from 8 to 25 cm. Incontinence was reported in 7 cases. Constipation was reported by 12 out of 20 cases.

Method:- A self illuminating 20 cms. long, operating proctoscope was used. The rectal wall was fixed to the pre-sacral fascia trans-anally by 3-4 PDS suture starting from S3 to Sacro-coccygeal junction.

Results:- Patients were followed up for a period of 24 to 36 months. During this period only in one case of recurrence of complete prolapse of rectum was revealed. Incontinence was corrected in 5 out of 7 incontinent patients.

Conclusion:- Simple procedure for most difficult problem of full thickness prolapsed of rectum, solved in 19 of 20 cases. Any how long follow up and wide use will prove its efficacy.

Introduction

Prolapse rectum is colourful entity but most distressing when associated with incontinence. Anatomically significant abnormalities are loss of adhesion to the sacrum, coccyx and pelvic wall, diastases in levater ani muscles, patulous anal sphincters, abnormally obtuse angle and redundant sigmoid colon. (1-6) Majority of surgeons are not still univocal that whether these defects are etiology or consequences. The defects are due to straining during bowel movement, child delivery & all relative chronic etiological factors increasing intra abdominal pressure. Intense straining will result in separation of the rectum from the sacrum, coccyx and pelvic wall; due to stretching and elongation of fibrous tissue resulting in loosing strength of fibrosis which adheres rectum to the sacrum. There may be familial collagen deficiency or developmental disorder responsible for genesis of rectal prolapse.  (7-9) Geographical variation in age and sex incidence indicates familial collagen disorder and different bowel habits in different countries. More than 145 procedures and their modifications are implemented to correct these defects and treat prolapse of rectum. (10) Large number of procedures suggest that none is well recognized for reconstruction. Importance was diverted to correct anatomical defects which have achieved far from desired effect. The removal prolapsed part will not cure prolapse permanently  The concept of recto-sigmoid or recto-rectal intussusceptions  recommended procedures involving fixation of prolapsed rectum to the sacrum.(11)  The survey of the huge literature and opinion of colorectal fraternities are in majority to accept the procedures involving fixation of rectum to the sacrum and coccyx either by laparotomy or laparoscopy. Amongst the choice between mesh and suture fixation most surgeons are inclined to suture rectopexy. (12-14) Some surgeons are confident in fixation even by a single suture. (16)  40 – 75 % cases of rectal prolapse are associated with varied degree of incontinence. (16-17 ) Out of these 50 -75 %  cases improve after correction of prolapse, suggesting effect like incontinence is correctable by mere correction of prolapse itself. (18-20) The remaining cases require supplementary repair for patulous sphincters and/or weak levator ani muscles. (21-22)

The old, frail medically unfit patients who could not tolerate procedures involving opening of abdomen or laparoscopy. The new procedure trans-anal suture sacro-rectopexy was performed in 6 cases that were medically unfit for any major procedure, in 2009. The promising results encouraged us to implement in all cases of rectal prolapse. The procedure was done in fit as well as unfit patients. The procedure is evaluated for recurrence, change in continence, constipation, pain in sacral region and retro rectal infection.

Patients

Twenty cases of complete prolapsed rectum were treated, during the period from January 2009 to December 2012 at Jeevan Jyot Hospital. The detail history, clinical examination, routine investigations, proctoscopy, colonoscopy anal manometry were recorded.

All cases with complete prolapse were included. In series of 20 cases 6 were females and 14 cases were males. Average age in female patients was 62 ranging from 49 to 81 and in males it was 42 ranging from 23 to 78 years. Duration of rectal prolapse was from 4 years to 22 years. Six patients were submitted to previous some procedure. The length of prolapse ranged from 8 to 25 cms. Incontinence was reported by 7 patients. Six female patients required levateroplasty.  ( Fig No. 4, 5, 6,)

Method

Patient was given clear liquids and Lactotol 45 ml. three times at interval of 4 hours; 24 hours prior to procedure. Broad spectrum antibiotics and metronidazole were administered.

Regional anaesthesia, spinal / saddle block was used. Lithotomy position was given and perineum was brought 15 – 20 cms. out of operation table. Operation table was turned down to steep head low position. In case of prolapse remaining outside was reduced in side. (Fig No. 1 )Rectum was washed with about 100ml. of normal saline and metronidazole. Rectum and anal canal was massaged to reduce edema and congestion of portal blood. Prolapse of rectum was assessed for its thickness and length.

A self illuminated proctoscope of 4 cms. in diameter and 20 cms. in length, with open space of 1/8 circumference which was covered by slide cover of same shape and size; was introduced in to the rectum (Fig No. 2 A -B). Usually sphincters are lax, In case narrow internal sphincterotomy may be required. As soon as proctoscpe is introduced slide flap was removed and operation is carried though open space.

Prolapsed, lax and edematous rectum, pouts into the proctoscope. In this case rectum is pushed back abreast to the sacrum with the help of Deavers retractor of 5 -7 cms. broad, through or outside of proctoscope was passed.( Fig No. 3) The rectum was pressed to the sacrum.  One zero PDS on 40 mm. ¾ circles curved cutting / true cut needle was used. A 30 cm long and thin tipped needle holder was used.

The needle holder with needle, was held in right hand with supine position so as the sharp tip of needle would touch to rectal mucosa. The needle was pushed in till it touched sacral bone then hand is turned from supine to prone position. The needle was passed through rectal wall and part of the pre sacral fascia. The rectal wall about 2/ 3 cm was fixed to the sacrum. Minimal 4 -5 sutures were taken to fix the rectum to the sacrum starting from the top of the proctoscpe in the central area of the sacrum.  ( Fig No 3) Fixity of the rectum was confirmed by movement of rectum by a sponge holderand as sutures were not moving along with the wall. The sacrum was fixed from sacral 3rd vertebra up to upper part of the coccyx.

All patients were admitted for 5 days as protocol and kept in head low position, only on oral and intravenous fluids. All of them were administered antibiotics, aminoglycosides and metronidazole. They were given only paracetamoland anti inflammatory agents, never required any sedatives.

LEVATOROPLASTY

A semicircular incision from one ischial tuberosity to other passing through perineal body was taken. The perineal body was explored and an artery forceps was inserted in to perineal body at the conglomeration of bulbous and anal sphincter muscles. The space between the prostate and rectum was opened. The rectum was carefully separated; it may be adherent due to prolapse. The Dononvillier’s fascia was dissected up to white shining peritoneum. The fascia was sutured from the peritoneum to the anorectal junction. The levator ani muscles were standing as gate keeper of the hiatus. The hiatus was closed with three 2/0 polyglycoid sutures.

In female patients posterior calporaphy incision was implemented and space between the rectum and vagina was explored. The vaginal flap was dissected up to the peritoneum. The Dononvillier’s fascia was sutured . The hiatus was closed. In case of wide rectocele  a soft biomesh of 5 x 5 cms. was used.

A Folley’s indwelling catheter was kept. Patient was given head low for 5 days. And liquid diet was advised for same period. Once full diet was started patient was given lactitol and isughgul for 3 months till regularization of bowel habit.

FRILL TEST FOR LAX RECTAL WALL

In per rectal examination the index finger of right hand is inserted completely. Whole rectum is palpated and patient is asked to strain. In case of intussusception the apex of inner tube will be felt at tip of finger. The index finger is firmly pressed and pulled against the sacrum, in case of intussusceptions,  the rectal wall will slide down by 2- 3 cms. in old age it will slide up to 1 cm. In case of full thickness complete proalapse of rectum it will slide up to dentate line. Usually prolapsed rectum was observed best during bowel movement and straining.

RECTOCELE

In pelvic examination, after rectal examination vaginal opening is observed. Posterior vaginal wall protrudes through vaginal opening. On cough or straining the roundish swelling will increase in size. The index finger in the rectum can be pushed in posterior wall of vagina; the finger will bring the protrusion more. If the swelling protrudes up to 2 cms, it will requires no treatment. Rectocele more than 3 cms. will require repair.

RESULTS

None of the patients had any retro rectal hematoma or infection, though we expected. All patients were followed first weekly for four weeks and later on every monthly for 4 months and later on every six monthly.

In the series out of 7 cases of incontinence 5 cases improved.  In remaining 3 cases, levatoroplasty and sphincter plication was performed. In all  6 female cases levateroplasty was done.  In those 3 patient with incontinence improved.  The continent patient did not develop incontinence. One patient presented recurrence after 18 months submitted to same procedure. Constipation  was present in 13 cases  improved in 9, but no fresh constipation was developed.