How does the abdominal approach compare to the perineal approach for the treatment of pediatric rectal prolapse?

Updated: Nov 12, 2018
  • Author: Jaime Shalkow, MD, FACS; Chief Editor: Carmen Cuffari, MD  more...
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Answer

Choosing between abdominal and perineal Surgery:

Since recurrence rates after abdominal repair are generally lower, this approach is commonly suggested. It is important to emphasize that the abdominal procedure is suggested for physically fit and stable patients. Concomitant rectopexy also has lower recurrence rates. [47]

Altemeier et al described their perineal approach in 1971. They used anterior closure of the pelvic diaphragm and transanal resection of the prolapsed segment, with primary end-to-end anastomosis. [3]  It is typically performed for rectal prolapse with a length greater than 3-4 cm.

In an Altemeier perineal rectosigmoidectomy, a full-thickness circumferential incision is made in the prolapsed rectum about 1-2 cm from the dentate line (see the image below). The hernia sac is entered, and the prolapse is delivered. The mesentery of the prolapsed bowel is serially ligated until no further redundant bowel can be pulled down. The bowel is transected and either hand-sewn to the distal anal canal or stapled with a circular stapler. Before anastomosis, some surgeons plicate the levator ani muscles anteriorly, which may help improve continence.

Ripstein and Lauter addressed the problem by suspending the rectum via an abdominal approach. [49]

Ashcraft and Holder reported their experience with posterior repair in 46 children over a period of 17 years, with resolution in 42 patients. [32] Three of the failures were attributed to sigmoid intussusception. Such outcomes highlight the importance of distinguishing this condition from true rectal prolapse preoperatively.

Surgical treatment can be accomplished either transanally (perineal approach) or transabdominally. In general, transanal approaches have lower morbidity, whereas abdominal approaches have lower recurrence rates. Laparoscopic repair provides rectal fixation equal to that achieved through open procedures, with less morbidity.

Abdominal repairs involve mobilization of the rectum and fixation to the anterior sacral wall, which can be achieved with sutures or with prosthetic material. Fixation with prosthesis carries a higher risk of stenosis and obstruction. A sling prosthesis should be tailored to the individual patient, taking growth into consideration. In general, resection rectopexy has an acceptable recurrence rate (2-8%), but it is associated with the added morbidity of a colorectal anastomosis.


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