Occult Rectal Prolapse

1. Occult Rectal Prolapse M62 Course 2007 David Jayne St. James's University Hospital, Leeds

2. Occult Rectal Prolapse • Internal rectal prolapse • Rectal intussusception • Full-thickness invagination of the distal rectum during the act of defaecation

3. Occult Rectal Prolapse • Asymptomatic • 50 – 60% proctograms in normal volunteers • Symptomatic • Solitary Rectal Ulcer Syndrome • Obstructed Defaecation Syndrome (ODS) • Faecal incontinence

4. Obstructed Defaecation Syndrome (ODS) • Under-diagnosed • 15 – 20% women • More common in multiparous • Symptoms • Straining • Laxative / Enema dependency • Incomplete evacuation • Fragmented defaecation • Rectal pain • Perineal support / Digitation

5. Occult Rectal Prolapse • Central to the concept of ODS • Co-existent • Rectocele • Muco-haemorrhoidal prolapse • Enterocele / Sigmoidocele • Descending perineum • Urogenital prolapse

6. A unifying theory for ODS • Chronic straining produces a stretching and redundancy of the distal (subperitoneal) rectum • Rectal redundancy is the anatomical defect underlying ODS

7. Rectal Redundancy

8. Rectocele & Internal Prolapse

9. Rectal Redundancy • Internal prolapse – rectal invagination • Rectocele – transverse distension • Perineal descent – distal elongation • Initial compensatory mechanisms • Facilitate opening of the rectal lumen • Gradual impaired ability to generate intra-rectal pressure for evacuation

10. Rectal Redundancy • Dependency on extra-rectal forces to achieve rectal evacuation • Enterocele / Sigmoidocele • Descending perineum • May be dynamic or become stable

11. Enterocele

12. Enterocele

13. Concept • Correction of ODS requires excision of the redundant rectum and its associated structural abnormalities

14. STARR ProcedureStapled Transanal Rectal Resection • Aims to correct the anatomical defects associated with ODS by resection of the redundant distal rectum • Previously double stapling technique using x2 PPH-01 guns • New Transtar method

15. 33mm stapler Curved Cutter Reloadable staple cartridge Transtar stapler

16. CAD inserted & secured Transtar procedure

17. Leading edge of prolapse identified Transtar procedure

18. 4x gathering sutures 2, 10, 8 & 4 o’clock Traction 5th suture to aid first “radial cut” Transtar procedure

19. Radial cut Determines “height” of specimen Direct vision Traction of 2 & 4 o’clock gathering sutures Transtar procedure

20. 2nd firing Circumferential resection Direct vision Tension on 2 & 10 o’clock gathering sutures Transtar procedure

21. Circumferential resection Direct vision “Sausage” specimen Transtar procedure

22. Complete circumferential resection Beginning & end points meet up Prolapse excised Transtar procedure

23. Full-thickness circumferential resection of distal rectum Transtar procedure

24. Transtar procedure

25. Transtar procedure

26. Summary • Internal rectal prolapse, rectocele & muco-haemorrhoidal prolapse all manifestations of posterior pelvic floor dysfunction • Primary defect is redundancy of the distal rectum • Correction of rectal redundancy addresses the anatomical defect and is advocated for the treatment of ODS

27. Internal Rectal Prolapse M62 Course 2007 David Jayne St. James's University Hospital, Leeds

28. Internal Rectal Prolapse M62 Course 2007 David Jayne St. James's University Hospital, Leeds

29. Internal Rectal Prolapse Distal Rectal Redundancy M62 Course 2007 David Jayne St. James's University Hospital, Leeds