Prolapse Surgery (Perineal and Abdominal)

What is Prolapse Surgery (Perineal and Abdominal)?

Prolapse surgery is a surgical procedure to repair rectal prolapse. Perineal (also called rectal) and abdominal approaches are the two most common operative methods employed in the surgical treatment of rectal prolapse.

Rectal prolapse is a condition in which the lowest part of the large intestine, known as the rectum, gets displaced from its natural position within the pelvic region and starts to drop down towards and through the anus. The condition most commonly affects adults and women over the age of 50 are 6 times more likely to develop rectal prolapse than men.

The objective of both perineal (through the perineum) and abdominal (through the belly) approach is to prevent the prolapse from happening again and provide a notable improvement in the quality of life. The perineum is the region between the scrotum and the anus in the male and between the vulva and the anus in the female.

The abdominal approach is most commonly employed in medically fit and healthy individuals, whereas the perineal approach is employed in elderly patients or those with significant medical problems.

Indications for Prolapse Surgery (Perineal and Abdominal)

Rectal prolapse is the primary indication for prolapse surgery (perineal and abdominal). Some of the risk factors of rectal prolapse include:

• Chronic constipation or diarrhoea
• Long-term history of straining during bowel movements
• Weakening of anal sphincter muscles
• Weakening of pelvic floor muscles
• Past injury to the pelvis or anal area
• Advanced age

Preparation for Prolapse Surgery (Perineal and Abdominal)

Pre-procedure preparation for prolapse surgery (perineal and abdominal) will involve the following steps:

• A thorough examination by your doctor is performed to check for any medical issues that need to be addressed prior to surgery.
• Depending on your medical history, social history, and age, you may need to undergo tests such as blood work and imaging to help detect any abnormalities that could threaten the safety of the procedure.
• You will be asked if you have allergies to medications, anaesthesia, or latex.
• You should inform your doctor of any medications, vitamins, or supplements that you are taking.
• You should refrain from medications or supplements such as blood thinners, aspirin, or anti-inflammatory medicines for 1 to 2 weeks prior to surgery.
• You should refrain from alcohol or tobacco at least 24 hours prior to surgery.
• You should not consume any solids or liquids at least 8 hours prior to surgery.
• You will be placed on a special diet prior to surgery and laxatives may be used to clean out your bowel.
• You may be instructed to shower with an antibacterial soap the night prior to surgery to help lower your risk of infection after surgery.
• Arrange for someone to drive you home as you will not be able to drive yourself after surgery.
• A written consent will be obtained from you after the surgical procedure has been explained in detail.

Procedure for Prolapse Surgery (Perineal and Abdominal)

Abdominal Approach
The abdominal approach can be performed either through open surgery or laparoscopically and is usually performed under general anaesthesia.

• Open surgery: While you are under anaesthesia, your surgeon makes an incision in the abdomen and pulls up the rectum back in place and uses a mesh sling or sutures to fix the rectum to the back wall of your pelvis (sacrum) so that it does not prolapse again. This procedure is known as rectopexy. In some individuals with a long-term history of constipation, your surgeon may remove a section of the colon. The wounds are then closed with sutures or staples. 
• Laparoscopic (keyhole) surgery: Rectopexy can also be carried out laparoscopically through small keyhole incisions. In this method, a thin, flexible fibreoptic tube attached with a camera and lens at the end (laparoscope) is inserted into the abdominal cavity through one of the keyhole incisions and small miniature instruments are inserted through other keyhole incisions to repair the rectal prolapse with the help of magnified images of the abdominal cavity displayed on a large monitor.

Perineal approach
The two most common perineal approaches are the Delorme and Altemeier procedures that are usually performed under general anaesthesia.

• Delorme procedure: This procedure is typically done for short prolapses and involves removing the lining of the rectum and folding the muscular layer to shorten the rectum.
• Altemeier procedure: This is the most commonly performed perineal surgery and is also known as perineal proctosigmoidectomy. While under anaesthesia, your surgeon pulls the rectum via the anus, cuts off a section of the rectum and sigmoid, and connects the remaining rectum to the large intestine. This procedure is usually reserved for individuals who are not good candidates for laparoscopic or open repair.

Postoperative Care and Recovery

In general, postoperative care instructions and recovery after prolapse surgery (perineal and abdominal) will involve the following steps:

• You will be transferred to the recovery area where your nurse will closely observe you for any allergic/anaesthetic reactions to the medications and anaesthesia used. Your nurse will also monitor your blood oxygen level and other vital signs as you recover.
• You may experience pain, inflammation, and discomfort in the operated area. Pain and anti-inflammatory medications are provided as needed.
• Medications may also be prescribed as needed for symptoms associated with anaesthesia, such as vomiting and nausea.
• Walking and moving around in bed is strongly encouraged as it lowers the risk of blood clots and pneumonia. It also helps to stimulate your bowels and assist with passing gas.
• Antibiotics are prescribed to address the risk of surgery-related infection.
• Your diet is slowly advanced post surgery. You will start with nutrition through IV drips, then to clear liquids, and finally progress to having normal solid foods, as tolerated.
• It is important to keep the surgical site clean and dry. Instructions on surgical site care and bathing will be provided.
• Refrain from smoking for a specific period of time as it can negatively affect the healing process.
• Refrain from strenuous activities and lifting anything heavier than 10 pounds for the first couple of months. Gradual increase in activities over a period of time is recommended.
• Eating a healthy low fat, high fibre diet is strongly recommended to promote healing and a faster recovery as well as drinking 8 to 10 glasses of water daily to prevent constipation. Laxatives or stool softeners may also be recommended as needed.
• Most patients are discharged after 2 to 4 days of hospital stay depending on the type of surgery. You will need to take off work at least a week or two to rest and promote healing. You may take a couple of months until you begin to feel back to normal.
• Walking is a good exercise and is strongly recommended to improve your endurance. Some may require physical therapy to strengthen pelvic floor muscles.
• Refrain from driving until you are fully fit and receive your doctor’s consent. Most patients can resume driving around a couple of weeks following surgery.
• You will be able to resume your normal activities within a couple of weeks but may have certain activity restrictions.
• A periodic follow-up appointment will be scheduled to monitor your progress.

Risks and Complications

Prolapse surgery (perineal and abdominal) is a relatively safe procedure; however, as with any surgery, some risks and complications may occur, such as:

• Infection
• Bowel obstruction
• Damage to nearby nerves, vessels, and organs
• Recurrence of prolapse
• Intra-abdominal or rectal bleeding
• Urinary retention or inability to pass urine
• Fistula (an abnormal connection between 2 body parts, such as the vagina and rectum)
• Stricture or narrowing of the anal opening