Evidence - Perineal rectosigmoidectomy – Altemeier procedure

  1. Literature summary

    The precise pathogenesis and etiology of rectal prolapse is still uncertain: Is it a sliding hernia, intussusception or a combination of both mechanisms? The clinical picture includes the following functional anatomical abnormalities to varying degrees:

    • an abnormally deep Douglas pouch (3, 17, 24)
    • Diastasis of the levator ani limbs
    • Functional weakness of the inner and outer anal sphincters (3, 17)
    • Weak pelvic floor muscles
    • Pudendal neuropathy (17, 24)
    • Mobile mesorectum with inadequate posterior and lateral fixation of the rectum (17, 24, 34)
    • Elongated redundant sigmoid (17, 24, 34).

    In the end, which of the changes favors rectal prolapse and which are sequelae is ultimately unclear and almost impossible to establish during diagnostic work-up.

    Treatment aims to repair the prolapse and restore normal defecation and continence patterns. Treatment includes the following options (17, 24, 34):

    • Rectal fixation to the sacrum
    • Resection or plication of the redundant bowel.

    Access classifies the procedures as transabdominal or local.

    1. Transabdominal procedures (laparotomy, laparoscopy)

    1.1 Rectopexy
    The rectum is reattached to the presacral fascia, thereby repairing the inadequate suspension from the sacrum. Stretching the rectum relieves the load on the pelvic floor, which supposedly promotes recovery of the pelvic floor muscles. Rectopexy variants are the following: 

    1.1.1 Suture rectopexy
    Sudeck (29) was the first to perform this procedure, which mobilizes the rectum down to the pelvic floor and secures it to the promontory with interrupted sutures. The presacral fibrosis induced by this mobilization supposedly helps to stabilize the rectal fixation. Recurrence rates of up to 10 % have been reported, and data on postoperative dysfunction vary considerably (21).

    1.1.2 Rectopexy foreign material
    Foreign material is intended to result in more extensive presacral fixation of the mobilized and stretched rectum. Depending on the position of the material, the procedure is either classified as Ripstein (anterior loop rectopexy) (27), Orr-Loygue (lateral fixation) or Wells procedure (posterior mesh rectopexy) (31). Another variant is anterior rectopexy, which assumes that mobilization of the rectum results in postoperative defecation disorders (23, 28): therefore, the rectum is mobilized only in the rectovaginal space and anchored to the promontory with a mesh attached to the anterior rectum (8).

    The above procedures have recurrence rates of up to 12 %, and almost all patients with the Wells procedure complain of a tendency to constipation. The type of foreign material does not affect the recurrence rates (6, 25, 33); Marlex is superior in terms of infection rates (14, 18). However, the use of foreign material carries its own risks: Fistula formation, stenosis and erosion (12). Studies suggest that continence and constipation issues are more likely to be resolved by sole suture rectopexy than by rectopexy with foreign material (10).

    1.1.3 Resection rectopexy (Frykman-Goldberg)

    The procedure described by Frykman (11) combines rectopexy and sigmoid resection and has the following objectives:

    • Resection of the redundant sigmoid, which either exerts a caudad pressure or may kink against the rectum and thus have an obstructive effect.
    • More stable fixation of the stretched rectum
    • Scarred fibrous fixation of the rectum at the descendorectostomy
    • Improvement of any pre-existing constipation

    While the combined procedure has a low risk of recurrence and the improvement in continence is comparable to that of rectopexy without resection, the risk of postoperative constipation is significantly lower and apparently a result of the resection (19, 20).

    Surgical aspects of abdominal procedures

    The type of access - open or laparoscopic - has no impact on the recurrence rate and functional results (4, 14). Benefits of the minimally invasive procedure include reduced postoperative pain, faster convalescence and shorter hospital stays.

    When mobilizing the rectum, incomplete transection of the lateral attachments seems to increase the recurrence rate, but the functional results are more favorable (21, 23, 28).

    2. Local techniques (perineal, transanal)

    The original benefit of local procedures, avoiding laparotomy, must be reconsidered in view of the minimally invasive techniques available today. While wrapping the anus with subcutaneous foreign material or muscle has become obsolete due to considerable complication and recurrence rates, the following local measures may be considered in patients contraindicated for invasive procedures (26):

    2.1 Rehn-Delorme procedure

    In the procedure described by Rehn (9) and modified by Delorme, the mucosa is separated transanally from the sphincter and the muscularis propria and the latter is plicated in the area of the prolapsed rectum, thereby shortening the muscle tube. After resection of the now redundant mucosa, it is readapted. The procedure may be performed in analgesic sedation but is not suitable in pronounced prolapse. While studies showed an improvement in continence, they have also demonstrated a rather high recurrence rate.

    2.2 Perineal rectosigmoidectomy (Altemeier)

    In the Altemeier procedure (1, 5), the transanal resection of the rectum and parts of the sigmoid is followed by subsequent restoration of continuity at the level of the dentate line, comparable to a colon pouch (35). This procedure may be combined with a levatoroplasty (32). While the recurrence rate is lower compared to the Rehn-Delorme procedure, the functional results regarding incontinence and fecal spotting are less favorable.

    Choosing the technique

    Due to the inconsistent data situation in the treatment of rectal prolapse, no evidence-based recommendations can be given at present regarding the choice of procedure (2, 7, 15, 16). There is no clearly superior procedure in the treatment of rectal prolapse; each surgical technique has its own benefits and drawbacks:

    • Transabdominal procedures excel with their lower recurrence rates

    The efficacy of sole suture rectopexy is comparable to the procedures employing where foreign material

    • The use of foreign material carries its own risks
    • Resection rectopexy seems to be beneficial in pre-existing constipation, especially when the sigma is elongated.
    • The laparoscopic approach has no downsides; its benefits include less postoperative pain and faster convalescence.
    • Local techniques but less operative burden on the patients but have poorer functional results.

    The choice of procedure should therefore be governed by the patient's resilience, the size of the prolapse and medical history of functional disorders.

    Abdominal access not possible (multimorbid high-risk patient)

    > Small prolapse: Rehn-Delorme

    > Big prolapse: Altemeier

    > In case of incontinence: additional levatoroplasty

    Abdominal access is possible: Rectopexy, preferably laparoscopic

    > Suture rectopexy

    > Mesh rectopexy

    > Pre-existing incontinence: no resection

    > Pre-existing constipation with redundant sigmoid: Resection

  2. Ongoing trials on this topic

  3. References on this topic

    1. Altemeier WA, Giuseffi J, Hoxworth P (1952) Treatment of extensive prolapse of the rectum in aged or debilitated patients. AMA Arch Surg 65: 72–80

    2. Bachoo P, Brazzelli M, Grant A (2001) Surgery for complete rectal prolapse in adults (Cochrane Review). Cochran Libary, Issue 2

    3. Broden B, Snellman B (1968) Procidentia of the rectum studied with cineradiography. A contribution to the discussion of causative mechanism. Dis Colon Rectum 11: 330–347

    4. Bruch HP, Herold A, Schiedeck T, Schwandner O (1999) Laparoscopic surgery for rectal prolapse and outlet obstruction. Dis Colon Rectum 42: 1189–1194; discussion 1194–1195

    5. Cirocco WC. The Altemeier procedure for rectal prolapse: an operation for all ages. Dis Colon Rectum. 2010 Dec;53(12):1618-23.

    6. Corman ML (1988) Rectal prolapse. Surgical techniques. Surg Clin North Am 68: 1255–1265

    7. Deen KI, Grant E, Billingham C, Keighley MR. Abdominal resection rectopexy with pelvic floor repair versus perineal rectosigmoidectomy and pelvic floor repair for full-thickness rectal prolapse. Br J Surg. 1994 Feb;81(2):302-4.

    8. D’Hoore A, Cadoni R, Penninckx F (2004) Long-term outcome of laparoscopic ventral rectopexy for total rectal prolapse. Br J Surg 91: 1500–1505

    9. Delomre R (1900) Surle traitment des prolapses du rectum totaux pour lèxcision de la muscueuse rectale ou rectocolique. Bull Mem Soc Chir Paris 266: 499–518

    10. Duthie GS, Bartolo DC (1992) Abdominal rectopexy for rectal prolapse: a comparison of techniques. Br J Surg 79: 107–113

    11. Frykman HM (1955) Abdominal proctopexy and primary sigmoid resection for rectal procidentia. Am J Surg 90: 780–789

    12. Holmstrom B, Broden G, Dolk A (1986) Results of the Ripstein operation in the treatment of rectal prolapse and internal rectal procidentia. Dis Colon Rectum 29: 845–848

    13. Jarrett ME, Matzel KE, Stosser M et al. (2005) Sacral nerve stimulation for fecal incontinence following surgery for rectal prolapse repair: a multicenter study. Dis Colon Rectum 48: 1243–1248

    14. Kariv Y, Delaney CP, Casillas S et al. (2006) Long-term outcome after laparoscopic and open surgery for rectal prolapse: a case-control study. Surg Endosc 20: 35–42

    15. Kim M, Reibetanz J, Boenicke L, Germer CT, Jayne D, Isbert C. Quality of life after transperineal rectosigmoidectomy. Br J Surg. 2010 Feb;97(2):269-72

    16. Kim DS, Tsang CB, Wong WD, Lowry AC, Goldberg SM, Madoff RD. Complete rectal prolapse: evolution of management and results. Dis Colon Rectum. 1999 Apr;42(4):460-6; discussion 466-9.

    17. Kuijpers HC (1992) Treatment of complete rectal prolapse: to narrow, to wrap, to suspend, to fix, to encircle, to plicate or to resect? World J Surg 16: 826–830

    18. Kuijpers JH, Morree H de (1988) Toward a selection of the most appropriate procedure in the treatment of complete rectal prolapse. Dis Colon Rectum 31: 355–357

    19. Lee SH, Lakhtaria P, Canedo J, Lee YS, Wexner SD. Outcome of laparoscopic rectopexy versus perineal rectosigmoidectomy for full-thickness rectal prolapse in elderly patients. Surg Endosc. 2011 Aug;25(8):2699-702.

    20. Luukkonen P, Mikkonen U, Jarvinen H (1992) Abdominal rectopexy with sigmoidectomy vs. rectopexy alone for rectal prolapse: a prospective, randomized study. Int J Colorectal Dis 7: 219–222

    21. Madiba TE, Baig MK, Wexner SD (2005) Surgical management of rectal prolapse. Arch Surg 140: 63–73

    22. Marchal F, Bresler L, Ayav A et al. (2005) Long-term results of Delorme’s procedure and Orr-Loygue rectopexy to treat complete rectal prolapse. Dis Colon Rectum 48: 1785–1790

    23. Mollen RM, Kuijpers JH, Hoek F van (2000) Effects of rectal mobilization and lateral ligaments division on colonic and anorectal function. Dis Colon Rectum 43: 1283–1287

    24. Nicholls RJ (1994) Rectal prolapse and the solitary ulcer syndrome. Ann Ital Chir 65: 157–162

    25. Novell JR, Osborne MJ, Winslet MC, Lewis AA (1994) Prospective randomized trial of Ivalon sponge versus sutured rectopexy for full-thickness rectal prolapse. Br J Surg 81: 904–906

    26. Oliver GC, Vachon D, Eisenstat TE et al. (1994) Delorme’s procedure for complete rectal prolapse in severely debilitated patients. An analysis of 41 cases. Dis Colon Rectum 37: 461–467

    27. Ripstein CB (1952) Treatment of massive rectal prolapse. Am J Surg 83: 68–71

    28. Speakman CT, Madden MV, Nicholls RJ, Kamm MA (1991) Lateral ligament division during rectopexy causes constipation but prevents recurrence: results of a prospective randomized study. Br J Surg 78: 1431–1433

    29. Sudeck P (1922) Rektumprolapsoperation durch Auslösung des Rektum aus der Excavatio sacralis. Zentralbl Chir 20: 698–699

    30. Watts AM, Thompson MR (2000) Evaluation of Delorme’s procedure as a treatment for full-thickness rectal prolapse. Br J Surg 87: 218–222

    31. Wells C (1959) New operation for rectal prolapse. Proc R Soc Med 52: 602–603

    32. Williams JG, Rothenberger DA, Madoff RD, Goldberg SM (1992) Treatment of rectal prolapse in the elderly by perineal rectosigmoidectomy. Dis Colon Rectum 35: 830–834

    33. Winde G, Reers B, Nottberg H et al. (1993) Clinical and functional results of abdominal rectopexy with absorbable mesh-graft for treatment of complete rectal prolapse. Eur J Surg 159: 301–305

    34. Yakut M, Kaymakcioglu N, Simsek A et al. (1998) Surgical treatment of rectal prolapse. A retrospective analysis of 94 cases. Int Surg 83: 53–55

    35. Yoshioka K, Ogunbiyi OA, Keighley MR (1998) Pouch perineal rectosigmoidectomy gives better functional results than conventional rectosigmoidectomy in elderly patients with rectal prolapse. Br J Surg 85: 1525–1526


Albayati S, Chen P, Morgan MJ, Toh JWT. Robotic vs. laparoscopic ventral mesh rectopexy for externa

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