Rectal Prolapse Surgery: Choosing the Correct Approach

Surgical options for the management of rectal prolapse are extensive. Choosing the correct modality to suit patients needs requires an understanding of the principles of each approach and their benefits in correcting the underlying anatomical and functional defects. The abdominal approach has a lower recurrence rate and when performed laparoscopically, offers all the benefits of minimally invasive surgery including early return of bowel function, reduced analgesic requirements, and reduced time to discharge. The addition of resection to the rectopexy depends on the degree of constipation and redundancy of the sigmoid colon. It carries the risk of anastomostic leakage. The coexistence of slow-transit constipation or obstructed defecation will alter the management pathway. Patients with incontinence generally experience an improvement after the rectal prolapse is corrected unless they have significant pudendal neuropathy. Whether the rectopexy is performed with mesh, sutures, or tacks depends on surgeon preference. The technique applied for open or laparoscopic surgery is often determined by the surgeon's previous exposure and training. In patients with significant cardiorespiratory risk factors, a perineal approach consisting of a Delorme or Altemeier may be preferred. These techniques require a considerable skill base, and while there is a lower morbidity, this is at the expense of a higher recurrence rate. We would advise that repeat surgery for rectal prolapse be performed in a specialized center or by a surgeon with experience in the management of recurrent rectal prolapse.