Pelvic Floor Disorders: Surgical Approach

15. Delorme’s Procedure

Mario Trompetto  and Silvia Cornaglia

(1)

Colorectal Eporediensis Centre, Santa Rita Clinic, Polyclinic of Monza, Vercelli, Italy

Mario Trompetto

Email: trompetto.mario@libero.it

Abstract

Rectal prolapse is common and is associated with symptoms of obstructed defecation, straining, impaired continence, and anismus. It has an estimated incidence of 4 per 1,000 population [1]. The incidence is highest in elderly women, with a female:male ratio of between 6:1 and 10:1 in this age group. In younger patients the condition is much less common and is usually associated with evacuation difficulty; in this age group the sex ratio is approximately one [2]. Complete rectal prolapse is defined as a full-thickness protrusion of the rectal wall through the anal canal [3]. When the prolapsed rectal wall does not protrude beyond the anus it is referred to as intussusception or internal rectal prolapse. Mucosal prolapse is the protrusion of rectal mucosa only [45]. Whether a minor prolapse can lead to a complete prolapse remains the subject of debate.

15.1 Introduction

Rectal prolapse is common and is associated with symptoms of obstructed defecation, straining, impaired continence, and anismus. It has an estimated incidence of 4 per 1,000 population [1]. The incidence is highest in elderly women, with a female:male ratio of between 6:1 and 10:1 in this age group. In younger patients the condition is much less common and is usually associated with evacuation difficulty; in this age group the sex ratio is approximately one [2]. Complete rectal prolapse is defined as a full-thickness protrusion of the rectal wall through the anal canal [3]. When the prolapsed rectal wall does not protrude beyond the anus it is referred to as intussusception or internal rectal prolapse. Mucosal prolapse is the protrusion of rectal mucosa only [45]. Whether a minor prolapse can lead to a complete prolapse remains the subject of debate.

While a complete prolapse is easily diagnosed by clinical examination, an internal prolapse is more difficult to detect. Digital examination reveals an internal prolapse in only 40% of cases [67]. Preoperative assessment should include a complete evaluation of the colon with colonoscopy to exclude any coexisting condition. A colonic transit study is useful when rectal prolapse is associated with constipation. Obstructed defecation is usually investigated by defecography or dynamic magnetic resonance imaging, which can highlight other pelvic floor disorders.

The aim of treatment is to restore the normal anatomy, with the hope of improving function. When nonoperative therapy (including bulking agents, stool softeners, laxatives, or suppositories [6]) is unsuccessful, surgery should be considered. The available operations can be divided into perineal and abdominal. Of the former, Delorme’s procedure and perineal rectosigmodectomy (Altemeier’s procedure) are the most commonly performed.

15.2 Delorme’s Procedure

Delorme’s procedure was described in 1900 by the military surgeon Edmond Delorme as a well-tolerated procedure that could be carried out, if necessary, under local anesthetic [8]. Its main anatomical indication is a complete rectal prolapse not exceeding more than 10 cm [9].

15.2.1 Technique

Either the lithotomy position or the prone jack-knife position can be used. The rectum is prolapsed to its maximum extent by gentle traction. A circular incision of the mucosa is made 1–2 cm proximal to the dentate line. Submucosal infiltration with epinephrine (1:200,000) saline solution is used to raise the mucosa from the circular muscle and to induce vasospasm of the submucosal vessels. A cylinder of mucus membrane is dissected from the muscle layer by scissors or diathermy dissection. The mucosectomy is then taken as far proximally as the length of the prolapse, so that the length of the removed cylinder is twice the length of the clinical prolapse (Fig. 15.1). Before dividing the mucosa at the chosen level, stay sutures are inserted into the mucosa above the intended point of division. This prevents upward retraction of the upper rectum after division. The rectal muscle is then plicated by six or so longitudinally placed sutures to create a concertina-like effect (Fig. 15.2). These stitches are then tied to achieve mucosal opposition and plication of redundant rectal muscle. Further mucomucosal sutures may be necessary to complete the mucosal endorectal anastomosis [10].

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Fig. 15.1

Complete mucus membrane cylinder at the end of the dissection. (Reproduced from [9], with permission)

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Fig. 15.2

Rectal muscle plication and mucosal section. (Reproduced from [9], with permission)

Delorme’s procedure is a well-tolerated perineal operation for a full-thickness rectal prolapse. However, prolapse recurrence is common and the reported recurrence rate varies widely (Table 15.1) [81113]. Delorme’s procedure has low morbidity, and can be performed on unfit and frail elderly patients with significant comorbidities [14]. Good bowel function can be achieved [15], with incontinence reduction and improvement in rectal sensation [16]. Although abdominal operations have a lower recurrence rate, it is feasible to perform Delorme’s procedure again in cases of recurrence, without increased complications. Delorme’s procedure can achieve a favorable and better outcome for internal rectal prolapse treatment by applying stringent patient selection criteria [1718]. Pitfalls in performing the procedure relate primarily to associated perineal and colonic conditions. In fact, a data review showed that proximal internal prolapse with rectosacral separation at defecography, preoperative chronic diarrhea, fecal incontinence, weak sphincter tone, previous sphincter injury, and descending perineum (more than 9 cm on straining) were associated with poorer outcomes [18]. Inadequate mucosectomy because of extensive diverticular disease can prohibit effective and complete proximal mucosectomy, leading to early recurrence of the prolapse [19].

Table 15.1

Delorme’s procedure: results

Study [Reference]

N. pts

Recurrence (%)

Lechaux et al. (1995) [8]

85

13.5

Tsunoda et al. (2003) [11]

31

13

Pascual et al. (2006) [12]

21

9.5

Lieberth et al. (2009) [13]

66

14.5

15.3 Internal Delorme’s Procedure

A modified Delorme’s procedure has been designed to treat internal rectal prolapse in symptomatic rectal obstructed defecation.

15.3.1 Technique

With the patient in the lithotomy position under epidural anesthesia, a specially designed anoscope is inserted to visualize the distal rectum. The anoscope has the same characteristics of the procedure of prolapse and hemorrhoids (PPH) anoscope, consisting of a tube 30 mm long and 29 mm diameter. It is fixed to the perineum by four stitches. Rectal submucosa is infiltrated with epinephrine and saline solution (1:200,000). The operation starts with a circular incision of the mucosa at 2 cm proximal to the dentate line using monopolar electrocauthery. Mucosal circumferential dissection from the rectal muscle layer proceeds proximally upwards for 80–150 mm, until the surgeon can feel an increased resistance while tractioning on the redundant mucosa. At the level of the resistance the mucosa is divided and the muscle is plicated longitudinally by eight 2.0 absorbable sutures. An interrupted mucomucosal suture completes the endorectal anastomosis (Figs. 15.315.6) [20].

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Fig. 15.3

Mucosal circumferential dissection from the rectal muscle layer

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Fig. 15.4

Longitudinal rectal muscle plication

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Fig. 15.5

Mucosal section

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Fig. 15.6

Mucomucosal sutures complete the endorectal anastomosis

In cases of associated weak pelvic floor, or type II or III rectocele, a levatorplasty is performed through a posterior transverse vaginal incision [20].

In our institution, from October 2001 to March 2009, 167 consecutive patients underwent internal Delorme’s procedure, with or without levatorplasty, for symptomatic rectal obstructed defecation associated to rectal intussusception and rectocele. At a mean follow-up of.3.0 ± 1.5 years, fecal urgency changed from 22% to 17.6% (p = 0.754), and tenesmus fell from 53.9% to 17.1% (p < 0.001). The Cleveland Clinic Constipation Score (CCCS) and obstructed defecation syndrome score fell by 50% or more in 82% and 73.7% of cases, respectively. The CCCS did not worsen in patients who remained incontinent, while 45.7% of previously incontinent patients regained normal continence. The Patient Assessment of Constipation Quality of Life (PAC-QoL) showed a decline of the overall score preoperatively to postoperatively, with a reduction of anxiety/depression, and physical and psychological discomfort (p < 0.001). Seventeen patients (10.2%) developed a postoperative complication including anal fissure (4.2%), proctalgia (3%), suture line dehiscence with stenosis (1.8%), and Clostridium difficile colitis (1.2%) [20]. The recurrence rate of 5.4% is comparable with previously published large series of Delorme’s procedure [2122]. It is also comparable with the recurrence rate reported in stapled transanal rectal resection (STARR) and TRANSTARR procedure studies [2324]. Postoperative urgency decrease in internal Delorme’s procedure, although not statistically significant, is a crucial outcome compared with the potential complication and high urgency rate recorded after the STARR procedure [2426]. Therefore compared with other treatments, which are discussed in other chapters, internal Delorme’s procedure can be considered a cheap, effective, and safe procedure for rectal obstructed defecation that is caused by rectal intussusceptions, with or without rectocele.

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