Rehn-Delorme transanal mucosal resection - general and visceral surgery

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  • Findings

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    Inspection and digital rectal examination reveal a gaping anus and significantly reduced sphincter tone. After slow manual stretching of the sphincter, insert the Parks retractor. Withdraw the prolapsed rectum before the anus with Allis clamps. Even after removing the Parks retractor, the prolapse does not spontaneously reduce, but remains a few centimeters outside the anus. This confirms the diagnosis of a rectal prolapse grade III.

  • Inserting the anal retractor, incising the rectal mucosa

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    Expose the dentate line with a Lone Star retractor. Next, mark as a circle and incise the rectal mucosa 1-2 cm proximal to the dentate line with the monopolar needle electrode.

  • Dissecting the rectal mucosa off the muscle layer

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    After injection of physiological saline or Ringer solution, start the dissection anteriorly from the mucosa down to the muscularis propria. Then, step by step, after each injection and repeated hemostasis (sometimes monopolar, sometimes bipolar), dissect the mucosa off the muscle layer in circular fashion.

    Tip: Use a highly diluted blue solution for injection (add a few drops of toluidine blue to the NaCl/Ringer solution!). The mucosa takes up the stain well and can be better delineated against the muscularis.

  • Cylindrical dissection of the rectal mucosa

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    Step by step, slowly continue proximally the dissection technique presented in the previous step. This will expose the rectal wall quite well. The resulting mucosal tube should be at least 10 cm long.

  • Muscularis plication

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    Now preplace the sutures for muscularis plication. With 8 interrupted sutures (braided, absorbable sutures 2/0), suture ligate the resulting muscle cuff in the long axis to obtain circular muscular wall plication after tying.

    Note: This procedure shortens the muscle tube and pads the sphincter area.

  • Resecting the mucosa

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    Now remove the excess mucosa by first making a partial anterior resection (1/3 of the mucosal circumference). Preplace the sutures for the mucosal anastomosis (delayed absorbable monofilament suture, 3/0) and clamp in the retractor ring. Only then complete circular resection.

    Note: The resected specimen is at least 13 cm long.

  • Mucosal anastomosis

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    After preplacing the remaining mucosal sutures, tie all sutures to completely cover the muscularis plication with mucosa.

  • Reducing the muscle bulge, digital check

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    Complete the mucosal anastomosis with additional sutures in between and reduce the bulge. Digital examination should confirm that the muscularis cuff is wide enough and that the mucosal suture can just be reached with the tip of the finger. Finally, insert a compress with xylocaine gel soaked in adrenaline (1: 10,000).