Figure 70-23.Perineal rectosigmoidectomy. The patient is placed in the prone jack knife position with both legs in gynecologic

stirrups. A and B: A circular incision is made on the prolapsed rectum 2 cm proximal to the dentate line. C: The peritoneal

attachment is dissected from the anterior rectal wall, thus opening into the peritoneal cavity. D: The mesorectum or mesosigmoid

is clamped and divided laterally and posteriorly. E: This is followed by approximation of the puborectalis. F: The anterior wall of

the protruding rectum is cut 1 cm distal to the anal verge. G: Stay sutures of 2-0 synthetic absorbable material are placed in four

quadrants. H: Anastomosis with interrupted stitches; I: Colonic J pouch.

Transabdominal rectopexy involves a thorough mobilization of the rectum to the level of the pelvic

floor musculature, followed by fixation of the mesorectum to the presacral fascia below the sacral

promontory (Fig. 70-25). Fixation may be performed through a laparotomy or Pfannenstiel incision, or

with a minimally invasive approach (laparoscopic or robotic assisted). Fixation of the rectum can be

accomplished with suture, tacks, or the placement of a mesh (posterior to the rectum or as a supportive

sling around the rectum). In patients with a history of chronic constipation and evidence of slow transit

on colonic transit studies, rectopexy may be combined with resection of the sigmoid colon. In these

cases, the anastomosis should be performed above the level of the rectopexy to reduce the risk of

anastomotic complications. Recurrence rates following rectopexy are generally lower than 10%, and

many patients will have improvement in fecal continence. While division of the “lateral stalks” during

resection rectopexy seems to reduce recurrence rates, it may exacerbate constipation.

One multicenter cohort study of 643 patients who underwent an abdominal repair of rectal prolapse

demonstrated pooled 5- and 10-year recurrence rates of 7% and 29%, respectively.29 No difference was

identified based on the degree of mobilization or resection. In addition, similar recurrence rates were

seen in patients who underwent suture rectopexy and mesh rectopexy, and in patients who underwent

open or laparoscopic repairs. Another abdominal approach, ventral rectopexy, has also been recently

popularized for the treatment of rectal intussusception and prolapse. This procedure involves

mobilization of the anterior rectum, with no or minimal posterior dissection, followed by anterior mesh

placement and sacral fixation. This technique was devised in an effort to spare patients from the risk of

autonomic complications associated with complete rectal mobilization. Published recurrence rates are

similar to those for other abdominal approaches. The abdominal operations can be performed as open,

1872

laparoscopic, or robotic procedures.

Fecal Incontinence

Fecal incontinence is an embarrassing and socially devastating condition that affects up to 18% of the

population and up to 50% of nursing home residents.30 Incontinence may be as severe as the

involuntary passage of solid stool, but also includes patients who are unable to control the passage of

flatus and those who suffer from chronic leakage that requires the use of pads. It is important to

understand that fecal incontinence is not a diagnosis, but a symptom of which there are multiple

potential causes.

Figure 70-24. Modified Delorme procedure. Patient is placed in the prone position. A and B: With a Pratt speculum used for

exposure, a circumferential incision is made 1 cm proximal to the dentate line. The submucosa is dissected from the underlying

internal sphincter. At the level of the anorectal ring, the Pratt speculum is replaced by Lonestar (r) retractors placed at a right angle

to the dentate line. C and D: Proximal to the anorectal ring, the dissection continues in the mucosal plane until the mucosa resists

being pulled down. The mucosal tube is then cut. E and F: With 2-0 synthetic absorbable sutures, the mucosa at the upper cut end

is brought down to the mucosa at the lower cut end, taking along the denuded anorectal wall. Eight such sutures are placed all

around. G: At completion of the anastomosis, the anorectum is plicated.

Anal continence requires a complex integration of function between the anal sphincters and pelvic

floor (see Physiology), but is also dependent on the volume and consistency of the stool, the compliance

of the rectum, and normal neurologic function. It is for this reason that a large volume of diarrheal stool

entering the rectum may overcome anal continence, even in a healthy patient. Other disease states such

as inflammatory bowel disease and radiation proctitis, as well as central nervous system pathologies

such as spinal cord injury may also produce incontinence. Incontinence is far more common in female

patients, although obstetrical tears of the anal sphincter may not present as incontinence for two or

more decades following the injury. Injury to the pelvic floor muscles and pudendal nerves may also

result following childbirth. Damage to the sphincter complex can result from surgical intervention

(fistulotomy or internal sphincterotomy), trauma, or chronic stretching as seen in rectal prolapse.

1873