Intraoperative check for enterocele in perineal stapled prolapse resection
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Various surgical techniques have been described for the treatment of external rectal prolapse. However, there is no accepted standard surgical therapy. Generally, transabdominal rectopexy with or without sigmoid resection is distinguished from the perineal approach. For the perineal approach, the Rehn–Delorme technique involves mucosectomy with reinforcement of the rectal muscular tube, while the Altemeier technique consists of a full-thickness rectal resection. Perineal stapled prolapse resection (PSP) was proposed as an alternative by Scherer et al. .
PSP is a further development of stapled transanal rectal resection (STARR) for internal rectal prolapse in patients suffering from outlet obstruction. While originally two circular hemorrhoid staplers (PPH-01) were employed for STARR, the Transtar technique uses a specially designed curved cutter stapler (Contour Transtar™ 30 mm, Ethicon Inc., Somerville, NJ, USA) . Full-thickness resection of the prolapsing rectum is performed using several cartridges. In PSP, larger segments of externally prolapsing rectum are resected using the same curved stapler.
After complete exteriorization, the prolapse is fixed with Allis clamps. The prolapsed rectum is divided into an anterior and a posterior portion by cutting it open at the 3 and 9 O’clock positions using a linear stapler with the patient in the lithotomy position. Afterward, multiple cartridges of a Contour stapler are used to perform full-thickness resection of the anterior and posterior rectal prolapse in anticlockwise direction. Before resection, the anterior portion of the posterior wall of the vagina is checked for entrapment by direct vision and digital examination. The stapler lines are reinforced with a running suture to prevent stapler line bleeding.
Patients with rectal prolapse commonly have a descending perineum involving a deep enterocele. In PSP, as well as in STARR, resection of the invaginated anterior rectal wall entails the risk of entrapment of a deep pouch of Douglas and of an enterocele, if present, as well as injury of intraperitoneal organs such as the small intestine. Therefore, careful bimanual digital examination of the rectal wall before resection is generally recommended, together with placing the patient in a slight Trendelenburg position to free the pouch of Douglas . It has been discussed whether enterocele, detected on preoperative defecography, constitutes a contraindication to STARR. However, in a large series of patients who had undergone preoperative defecography, no difference in morbidity was demonstrated between those with and without enterocele after STARR .
Here, we describe a simple trick to safely exclude entrapment of intraperitoneal organs in a deep enterocele during PSP. After pulling the prolapse out (Fig. 1) and dividing it longitudinally into the anterior and posterior portions (Fig. 2), a small full-thickness incision is performed at the apex of the prolapsed anterior rectal wall and a small window is created (Fig. 3). The stapling field is checked visually and by digital examination for entrapment of bowel and the presence of an enterocele (Fig. 4). This small window is closed later by proximal stapling (Fig. 5).
This additional step in PSP is easy to perform, may increase the safety of the procedure, and does not increase the morbidity associated with the intervention. The same trick can also be applied in the STARR procedure for intussusception. It seems to be of high potential clinical benefit, as STARR and PSP are still commonly used techniques, especially in elderly and frail patients. These patients are preferentially treated under regional anesthesia, so the extent of tolerated intraoperative Trendelenburg position for repositioning of the enterocele is limited. This quick, easily performed maneuver helps to prevent an important intraoperative complication.
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Conflict of interest
The authors declare that they have no conflict of interest.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the local research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent to publication of the images in this article was obtained from the patient concerned.