The choice of common abdominal surgery for rectal prolapse

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0 IntroductionRectal prolapse of rectum and anal canal, is even part of the sigmoid colon and shift down off a disease. More common in young


0 Introduction

Rectal prolapse of rectum and anal canal, is even part of the sigmoid colon and shift down off a disease. More common in young and old, often causing symptoms such as pain and fecal incontinence. The first cause is still not very clear, there is much debate, but there are two kinds of theories of flow line, namely the theory of sliding hernia and the main means of intussusception theory. Surgery is the treatment of rectal prolapse, there are two ways of abdominal and perineum, but abdominal surgery methods more than 100 kinds, each has advantages and disadvantages, leading to difficult choice of clinicians, now common abdominal operation introduced below.

1 suture fixation

The suspended and fixed Pemberton and Stalker concept was first proposed in 1939. During this operation, the rectum was fully free, peritoneal fixed to the abdominal wall of sigmoid colon, the objective is to maintain an upward traction, the high recurrence rate of about 35%. in 1959, Cutait describes the retrorectal suture fixation. Into the abdomen after exposure of excavatio rectovesicalis, filed a sigmoid colon and rectum, rectum and pelvic floor to fully free the coccygeal tip plane, avoid the sacral plexus and venous plexus to prevent injury, will lift the rectum pull and suture in the periosteum of the sacral promontory.

2 anterior suspension fixation

Ripstein Ripstein (1965) [1] patients. The first is to illustrate the prolapse repair in sliding hernia Douglas through the closed cavity, hernia sac, levator muscle of anus with broad ligament fascia, folding bed, and then enhance the rectum on both sides of the fixed on the sacrum. Then he gave up the pelvic floor repair efforts. By using the Teflon patch complete suspension rectum itself. He will Teflon belt around the rectum, fixed to the posterior sacral anterior sacral fascia, and the anterior wall of the rectum and rectum suture, avoid abdominal pressure. The vertical acceptance operation for rectal sacral separation or severe rectal intussusception for. The mesh rectopexy, there are many types, such as polyvinyl alcohol (Ivalon), Teflon Marlex mesh belt, mesh belt (the operation of Hoffman1976 modified polyglycolic acid (polyglycolic), acid), polypropylene (polypropylene) and polyglactin meshes So, in the cure rate, reduce prolapse or postoperative constipation incidence, the research does not show what kind of mesh has more advantages. The surgery without bowel resection, he is sure for the treatment of fecal incontinence, but for serious constipation is not suitable for [1], the reason may be the mesh in front of the rectum can cause stricture of rectum aggravating constipation. This technique will improve the rectal suspension after fixed on the anterior sacral fascia, restored normal rectum close to sacral radian, operation is not complicated, the recurrence rate and mortality rate were low efficacy. Such as Tjandra [2] reported 142 cases of patients with this type of operation, the average follow-up a period of 4.2 years, recurrence in 8%, which is 1/3 after 3-14 years there, but more complications. In 1978 Gorden collected 129 doctors 1& #8197; 111 cases, 26 cases of recurrence, 183 cases of complications, the most common complications were 74 cases of fecal block plug , presacral hemorrhage 29 cases, stenosis in 20 cases, 17 cases of pelvic abscess, 15 cases of intestinal obstruction, the impotence, fistula, mesh belt slippage. In recent years Karagulle [3] reported the operation of 1 cases of rare complications: mesh invasive rectal wall; this patient before surgery had been suffering from rectal prolapse 6 years, his main complaint was abdominal discomfort, and anal tenesmus 2 years, colonoscopy and abdominal CT display network has penetrated into the rectum, rectum cavity, anus distance 7-8 cm.

3 through the posterior suspension fixation

Also called Wells surgery, Ivalon sponge implantation. The rear was originally described in 1959 Wells[4]. This kind of operation is more popular in the UK. Because of concerns about the front suspension rear suspension support block, many surgeons. Surgical Wells chose Ivalon sponge. Intraoperative free rectal anal ring to posterior wall. Cut off part of the lateral rectal ligaments the sponge sheet, cut into the shape of a cross, placed in the sacrum, sutured to the sacrum concave, rectum pull, the slice before suturing rectal wall and anterior wall sections, open 2-3 cm, so as to avoid the rectal stenosis, fecal block plug and obstruction. The treatment mechanism of suspension is generally considered after implantation of Ivalon and tissue incorporated in the organization, he stimulated fibrosis, fixation of the rectum to produce cartilage, harden, effectively prevent the formation of rectal intussusception and rectal prolapse occurred [1]. recurrence rate and surgical death The death rate was lower. Erne [5] 34 patients were followed up for 1972-1980 years, there were 2 cases of recurrence, noteworthy is to restore control function. Patients stool can not control the solid manure 60% before operation, and after operation to control the normal stool, and the follow-up or death. But the rectal function significantly fall, constipation and difficult defecation occurrence rate is still high. The most serious complication of pelvic suppurative infection caused by the implantation of sheet, sponge a foreign body, should be promptly removed. In addition, impotence, presacral hemorrhage. Novell [6] randomized 63 patients, suture (Goldberg) surgery group of 32 cases and Wells surgery group of 31 cases. The incidence of Goldberg in group 3/32 both after operation, Wells group 6/31, constipation occurrence rate of 10/32 Goldberg group, Wells 15/31.Goldberg group to avoid postoperative infection caused by exogenous substances, and can also cut part of the colon In addition, in order to improve the postoperative function, and the results with the traditional Wells technique is equal. So, Novell believes that "the latter can be canceled." Mann [7] reported 59 cases of enlarged abdominal rectal fixation. 44 cases (75%) patients were followed up for more than 2 years, all cure rectal prolapse. No death. This operation can lead to impotence, young patients should choose other surgery.

4 fascia rectal fixation

Also called Orr surgery, rectal sacral suspension technique. Orr [8] in 1947, the first in 4 cases of patients who achieved good results. This technique is based on the hypothesis of the rectum and the surrounding tissue fixed structure relaxation and deep Douglas cavity are the pathological features of prolapse both lead to rectal, too, so that the abdominal contents have a sustained pressure on the perineum. The surgical procedure is the first suspension to the rectum followed by the sacral promontory, eliminating Douglas cavity. With 2 lateral thigh fascia lata 10-12 long cm wide 1-2 cm, were fixed on the peritoneum of the rectum and the sacral promontory above the fascia, and close the bladder or rectum rectouterine pouch. Surgery need to do 2 incision. In 1951 Levy and Johnson also reported 2 cases, achieved the same good results. Moreno [9] reported 3 cases, including 2 cases of perineal surgery failure Also, the effect is significant. Loygue with nylon mesh belt instead of fascia lata.Portier [10] reported 73 cases of 1993-2004 patients were followed up for an average of 28.6 Mo, 3 cases of recurrence (4.1%), according to the satisfaction of patients with prolapse of improvement, incontinence, outlet obstruction, rated as 3 grade: 45 cases were cured (61.6%) (39%), 24 cases improved, 4 cases failed (5.5%). The results showed that Orr-Loygue abdominal rectopexy with limited anatomic rectal wall, before and after the retention of the rectal lateral ligament, is safe and effective for the treatment of complete rectal prolapse or prolapse with fecal incontinence or outlet obstruction, can prevent postoperative retention of lateral ligament constipation does not increase the risk of recurrence of.Amorotti prolapse [11] think this technique can treat genital prolapse. Douard [12] also believes that the application of this technique in patients with high satisfaction, control function improved, although postoperative defecation difficulties increased by 10%, but No significant significance

5 suspension of muscle of pubis and rectum

Also called Nigro operation. The first was Nigro in 1970 on [13]. is to use the Teflon network with the lower rectal suspension in the pectineal.Nigro because of puborectal muscle contraction will not lose, rectum pulled to the front, pelvic floor defects increase, anorectal angle disappeared, rectum in vertical position by rectal prolapse. So he advocated reconstruction of rectal sling with long forceps by PRVs, down to the left obturator level, lower rectum into the left rear of the retrorectal space, Teflon net with middle and lower rectum and lateral suture, and rectum pulled to the front, the tightness of the Teflon belt to just perfect, sutured to the pectineal ligament on the reconstruction, "anorectal angle". Rectal examination can touch the sling, but no contraction. Nigro reported 60 cases, 10 years of follow-up, no recurrence, this technique can improve bladder function. But the operation It is difficult to do so, and it is necessary for an experienced doctor to perform the operation

6 anterior resection and partial resection of the sigmoid colon

The Anterior resection operation. Anterior resection was first proposed by [14] Conyers in 1951, Muir[15], Bacon, Beahrs and Hill all support this type of operation that positioning intussusception and lengthy rectosigmoid colon is not appropriate anatomic defect first, pelvic floor muscle weakness and anal sphincter relaxation usually become surgery incentives. The lengthy resection of the sigmoid colon and rectum prolapse of the upper, and improve the symptoms of constipation and rectal tube, presacral drainage can promote fibrosis and scar formation, thereby fixing.Cirocco [16] rectum in 41 patients 1971-1991 years before resection, the average follow-up of 6 years, 3 cases of recurrence, the mortality rate was 0, the incidence rate is 15%, the complications included 3 cases of incisional hernia, 2 cases of intestinal obstruction, 1 cases of stroke, no sepsis, ulcer or anastomotic dehiscence occurred. Anterior resection without foreign body implantation or rectal suspension, for With the familiar and frequently used, is an important choice for the treatment of complete rectal prolapse, long-term effect is good. There are reports of application of stapler in anterior resection, the effect will be better [17].

7 transabdominal posterior fixation and left colectomy

Frykman-Goldberg surgery, anterior resection of rectum and rectal suspension suture fixation. Originally described by Karulf [18]1955, to the levator ani muscle free rectal surgery, keep adequate blood supply, and to keep the tension on the rectum fixed to the sacrum, the elimination of Douglas cavity, and continuous suture of rectum and pelvic cavity the excision fascia, elongated sigmoid colon and upper rectum, were anastomosed with the rectum, after fixation, strengthen the curative effect after operation, improve the postoperative function. The postoperative complications included anastomotic leakage, intestinal obstruction, hemorrhage of presacral venous plexus.Husa [19] reported after 30 d the mortality rate is 1%. on average 4.3 years of follow-up of 45 patients, 4 cases of recurrence (9%). No complications of.32 cases of incontinence because of intestinal resection or anastomosis caused in only 2 cases did not improve intestinal function. 23 cases (56%) used to improve, especially those Chronic constipation. This procedure does not involve the risk of infection caused by the introduction of foreign substances. Especially suitable for constipation and can tolerate abdominal surgery. Solla [20] for an average follow-up of 102 patients for 4 years, no death, only 4 cases had anastomotic minor complications, the recurrence rate is 1.9%. the operation of good clinical effect, low recurrence rate, generally well tolerated in patients selected by the surgeon is headed by the column. More and more applications.

9 Devadhar operation

Many surgical treatment of rectal prolapse is according to the theory of the implementation of sliding hernia, focuses on rectal fixation and excision, and as a cure for the.Mehendale [22] published his theory based on the treatment of prolapse of rectum intussusception in 25 years of experience in a text, this paper describes the procedure: patient supine spinal canal. Under anesthesia between two male or female pelvic margin of bladder cervical behind the peritoneal surface to make a transverse incision, excision of the rectoesical pouch of peritoneum, with a pair of pliers rectal wall repeatedly stimulate prolapse, find the maximum for prolapse prolapse starting point, labeled as "key point". With the key point as the center in between the lowest point and the prolapse of the distance of radius clockwise circular suture anterior and lateral wall of rectum. The ring to reverse rectal intussusception, assistant to the intestinal lumen to promote the rectal wall, tighten the ring suture. Doctor Tight line points to the rectum anterior and lateral wall as low as possible from the longitudinal folding suture, reconstruction of pelvic peritoneal cavity, eliminate Douglas. This type of operation to avoid the separation of the presacral space, so a lower risk of urinary and sexual dysfunction. 72 cases of reported patients, complications are only prolapse, have in 3 cases, follow-up 3-48 mo (average 10), 1 cases without erectile dysfunction, 40 cases of male retrograde ejaculation. All 2 cases of recurrent rectal prolapse, 4 patients still had constipation. The number of cases they are high, including 72 cases of patients, but the follow-up period is too short, can not accurately judge the real recurrence rate.

10 laparoscopic surgery

In the treatment of rectal prolapse in the evolution of laparoscopic surgery (laparoscopic surgery) is the latest progress. With laparoscopic surgery is widely used in clinical surgery, laparoscopic surgery in the treatment of rectal prolapse abroad many reports appeared in rectum and colon resection, rectal suture rectopexy and a variety of methods. This procedure support people think laparoscopic surgery, has simple operation, patient comfort, less bleeding, postoperative intestinal function recovery, beauty, shorter hospitalization time and fewer complications. Laparoscopic resection rectopexy and fixation for the treatment of prolapse of the results are very good, can the implementation of security in the frail elderly laparoscopic surgery. - shorten the hospitalization period, the elderly well tolerated [23].Kariv [24] 1991-12/2004-04 collection of all laparoscopic repair (laparoscopic repair, LR) of the rectum Prolapse during surgery, 86 patients were paired with LR, and open abdominal repair (open abdominal repair, OR), a case-control study was conducted. The results showed that: LR group than in OR group in short period, the average follow-up period of 5 years the function of the results of the two groups and full-thickness rectal prolapse the recurrence of similar individual. The main drawback is the laparoscopic operation for a long time, the operation effect is affected by the technique level of influence. Now, only limited data to support these claims, less data is not to evaluate the long-term recurrence rate and the function result. Laparoscopic repair of rectal prolapse, combined with the effect of abdominal open surgery and minimally invasive surgery the dual advantages of low complication rate, is likely to represent the future development direction of the rectal prolapse abdominal surgery, but is still an unproven hope, worthy of further research before being widely accepted.

11 conclusion

Rectal prolapse is still a difficult problem, because the incidence is the result of many factors, there is no clear and effective treatment options, surgery is still the main method to cure this disease, the basic principle of operation includes 6 points: (1) [25] and long drooping bowel resection (2) reduced; the anus; (3) reconstruction or strengthen the pelvic floor; (4) abdominal suspension or fixed bowel prolapse; (5) the elimination of Douglas cavity; (6) repair of perineal sliding hernia. Theuerkauf [26] integrated all kinds of surgical treatment of rectal prolapse results (Table 1). On the diversity of surgical methods have proven that no one a method suitable for all patients, for the evaluation of each methods need a large number of randomized controlled trials to prove that.Raftopoulos and [27] in 643 cases of complete rectal prolapse in adults after abdominal surgery recurrence rate for long-term multicenter follow-up observation, That after 1 years the average recurrence rate was 1.06%, 5 for 6.61% years, 10 years for 28.92%. and different medical units, surgical approaches, surgical methods, surgical techniques on postoperative recurrence rate had no significant effect. Abdominal surgery is not only a low recurrence rate, but also provides greater opportunity for function improved, is ideal for young patients. A strong suture fixation and mesh rectopexy effect. However, Ivalon sponge rectopexy increased the risk of infectious complications, abandoned to a great extent. In rectopexy with resection of the benefits is to reduce constipation, reduce the rate of recurrence. However, abdominal surgery should be free or fixed or resection of colon, rectum, or two patients had complications, so it is relatively high, such as infection, anastomotic leakage and death rate were relatively increased [28]. laparoscopic rectopexy and open rectopexy With similar results, and have all the advantages of laparoscopic surgery, is likely to represent the future development direction of the rectal prolapse surgery for rectal prolapse recurrence in patients with Pikarsky, [29] said the selection of surgery and the primary cases may be the same, the same type of surgery in two cases were effective, the two groups in the average hospitalization time, mortality, anastomotic leakage, anastomotic complications, wound infection, postoperative incontinence score and recurrence rate have no significant difference, Marzouk [30] will be divided into low rectal prolapse type (true prolapse) and high type (sigmoid and fixed or low rectal intussusception) the standard is fixed. Through clinical test simple digital rectal evaluation, to select the operation type. For example, the low type selection of perineal prolapse is more appropriate (Delorme surgery or rectosigmoid resection with or Without pelvic floor repair and high type prolapse), consider transabdominal rectopexy with or without anterior resection. Marzouk were retrospectively analyzed and 6 cases of perineal surgery treatment, the recurrence rate was 6%, abdominal surgery 0%. so they think through the testing and classification of this simple operation can. Better, and will minimize the risk of surgery, anesthesia, can achieve a lower recurrence rate.

Our country in the treatment of rectal prolapse, injection therapy has widely used, especially the Xiaozhiling injection treatment of complete rectal prolapse in adults [31,32], take the four step double injection therapy or perirectal injection, or injection combined with PPH surgery, anal tightening operation, which has achieved good results. But open surgery is still occupied plays an important role in the treatment of rectal prolapse, selective application were compared with using a single operation can greatly improve the individual treatment of rectal prolapse may be the key elements for future research. Background rectal prolapse is difficult for anorectal diseases, long-term risk of complete rectal prolapse will cause the pudendal nerve injury which causes incontinence, ulcer, bleeding, stenosis and necrosis, so the rectal prolapse is anorectal more hot Question

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