Anorectal: Rectal Prolapse Procedures

Mucosal Sleeve Resection (Delorme’s Procedure)

Basics

  • Perineal Procedure
  • Circumferential Resection of Prolapsed Mucosa
  • Resection Not Full Thickness – Spares Underlying Muscle

Procedure

  • Positioning:
    • Prone-Jackknife
    • Left Lateral Decubitus
    • Lithotomy
  • Prolapse Redundant Rectum as Much as Possible
  • Inject Tumescent Saline & Epinephrine Circumferentially
    • Creates a Plane Between Submucosa & Muscularis Propria
  • Incise the Mucosa Circumferentially, Sparing the Underlying Muscle
  • Release the Sleeve of Mucosa from the Underlying Muscle Down to Just Proximal of the Dentate Line
  • Place 4-Quadrant Plicating Sutures
    • Sutures Extend Linearly from the Proximal Edge to the Distal Edge
      • Will Take 3-4 Bites Through the Muscularis Propria
    • Reduces Prolapse into the Anal Canal
  • Close the Mucosal Defect

Delorme – Mucosal Dissection 1

Delorme – Plication 1

Delorme – Closure 1

Perineal Rectosigmoidectomy (Altemeier’s Procedure)

Basics

  • Perineal Procedure
  • Rectosigmoid Resection with Coloanal Anastomosis
  • Full Thickness Resection Mn

Procedure

  • Positioning:
    • Prone-Jackknife
    • Left Lateral Decubitus
    • Lithotomy
  • Prolapse Redundant Rectum as Much as Possible
  • Incise 1-2 cm Proximal to Dentate Line (Full Thickness & Circumferential)
  • Enter Anteriorly & Release the Lateral Attachments
  • Withdraw the Bowel & Release the Posterior Attachments
    • Withdraw Rectum & Sigmoid Until All Redundancy Is Gone
  • Divide Bowel & Mesentery at the Proximal Extent
    • Once All Redundancy is Gone but Without Any Tension
    • Avoid Devascularization of the Left Colon
    • Attempt to Resect Entire Rectum & Sigmoid Colon
  • Preform a Levatorplasty
    • Using Permanent Figure-of-Eight Sutures Plicate the Levator Ani
  • Create the Coloanal Anastomosis (Straight or J-Pouch)
    • Confirm Orientation of Mesentery to Prevent Torsion
    • Hand-Sewn vs Circular-Stapled

Altemeier Procedure – Incision 2

Altemeier Procedure – Resection 2

Mnemonics

Delorme vs Altemeier

  • “AL-ALL”: Altemeier Takes All Layers
  • Delorme is Not Full-Thickness

References

  1. Fazeli MS, Kazemeini AR, Keshvari A, Keramati MR. Delorme’s Procedure: An Effective Treatment for a Full-Thickness Rectal Prolapse in Young Patients. Ann Coloproctol. 2013 Apr;29(2):60-5. (License: CC BY-NC-3.0)
  2. Bayar R, Djebbi A, Mzoughi Z, Talbi G, Gharbi L, Arfa N, Mestiri H, Khalfallah MT. Prolapsus rectal étranglé de l’adulte jeune: à propos d’un cas et revue de la littérature [Strangled rectal prolapse in young adults: about a case and review of the literature]. Pan Afr Med J. 2016 Oct 3;25:60. (License: CC BY-2.0)