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Home / Articles / New procedure Transanal suture sacro-rectopexy for prolapse & intussusceptions of rectum - Page 2
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New procedure Transanal suture sacro-rectopexy for prolapse & intussusceptions of rectum - Page 2

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New procedure Transanal suture sacro-rectopexy for prolapse & intussusceptions of rectum
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Patients

Twenty cases of complete prolapsed rectum were treated, during the period from January 2009 to December 2012 at Jeevan Jyot Hospital. The detail history, clinical examination, routine investigations, proctoscopy, colonoscopy anal manometry were recorded.

All cases with complete prolapse were included. In series of 20 cases 6 were females and 14 cases were males. Average age in female patients was 62 ranging from 49 to 81 and in males it was 42 ranging from 23 to 78 years. Duration of rectal prolapse was from 4 years to 22 years. Six patients were submitted to previous some procedure. The length of prolapse ranged from 8 to 25 cms. Incontinence was reported by 7 patients. Six female patients required levateroplasty.  ( Fig No. 4, 5, 6,)

Method

trans-suturePatient was given clear liquids and Lactotol 45 ml. three times at interval of 4 hours; 24 hours prior to procedure. Broad spectrum antibiotics and metronidazole were administered.

Regional anaesthesia, spinal / saddle block was used. Lithotomy position was given and perineum was brought 15 – 20 cms. out of operation table. Operation table was turned down to steep head low position. In case of prolapse remaining outside was reduced in side. (Fig No. 1 )Rectum was washed with about 100ml. of normal saline and metronidazole. Rectum and anal canal was massaged to reduce edema and congestion of portal blood. Prolapse of rectum was assessed for its thickness and length.

A self illuminated proctoscope of 4 cms. in diameter and 20 cms. in length, with open space of 1/8 circumference which was covered by slide cover of same shape and size; was introduced in to the rectum (Fig No. 2 A -B). Usually sphincters are lax, In case narrow internal sphincterotomy may be required. As soon as proctoscpe is introduced slide flap was removed and operation is carried though open space.

Prolapsed, lax and edematous rectum, pouts into the proctoscope. In this case rectum is pushed back abreast to the sacrum with the help of Deavers retractor of 5 -7 cms. broad, through or outside of proctoscope was passed.( Fig No. 3) The rectum was pressed to the sacrum.  One zero PDS on 40 mm. ¾ circles curved cutting / true cut needle was used. A 30 cm long and thin tipped needle holder was used

trans-sutureThe needle holder with needle, was held in right hand with supine position so as the sharp tip of needle would touch to rectal mucosa. The needle was pushed in till it touched sacral bone then hand is turned from supine to prone position. The needle was passed through rectal wall and part of the pre sacral fascia. The rectal wall about 2/ 3 cm was fixed to the sacrum. Minimal 4 -5 sutures were taken to fix the rectum to the sacrum starting from the top of the proctoscpe in the central area of the sacrum.  ( Fig No 3) Fixity of the rectum was confirmed by movement of rectum by a sponge holderand as sutures were not moving along with the wall. The sacrum was fixed from sacral 3rd vertebra up to upper part of the coccyx.

All patients were admitted for 5 days as protocol and kept in head low position, only on oral and intravenous fluids. All of them were administered antibiotics, aminoglycosides and metronidazole. They were given only paracetamoland anti inflammatory agents, never required any sedatives.

LEVATOROPLASTY

trans-sutureA semicircular incision from one ischial tuberosity to other passing through perineal body was taken. The perineal body was explored and an artery forceps was inserted in to perineal body at the conglomeration of bulbous and anal sphincter muscles. The space between the prostate and rectum was opened. The rectum was carefully separated; it may be adherent due to prolapse. The Dononvillier’s fascia was dissected up to white shining peritoneum. The fascia was sutured from the peritoneum to the anorectal junction. The levator ani muscles were standing as gate keeper of the hiatus. The hiatus was closed with three 2/0 polyglycoid sutures.

In female patients posterior calporaphy incision was implemented and space between the rectum and vagina was explored. The vaginal flap was dissected up to the peritoneum. The Dononvillier’s fascia was sutured . The hiatus was closed. In case of wide rectocele  a soft biomesh of 5 x 5 cms. was used.

A Folley’s indwelling catheter was kept. Patient was given head low for 5 days. And liquid diet was advised for same period. Once full diet was started patient was given lactitol and isughgul for 3 months till regularization of bowel habit.