Methods
Patient Recruitment
At Sulaimani Teaching Hospital (STH), we received 30 patients between the years 2005 and 2011. All had history of full-thickness rectal prolapse for at least 12 months period. The topography of the cases is summarized in Table 1. Male to female ratio was 2:1 and the average age was 21.5 years. Among these 11 were children, 3 adolescences, 15 adults and only one senior, the causes are summarized in Table 2. This research was carried out in accordance with the Declaration of Helsinki (2000) of the World Medical Association. To conduct this study, ethical permission was approved from Ethics Committee at School of Medicine, Faculty of Medical Sciences, University of Sulaimani, Kurdistan Region/Iraq. Full history was taken from each patient or the parents in cases of children. Complete physical examination was performed, including per rectal examination and colonoscopy for all patients to exclude other pathologies. Laboratory tests of hemoglobin level, packed cell volume and viral scan were done. Chest X-ray and electrocardiogram with blood chemistry were done for the adult patients. Written informed consent was taken from each patient, (or the parent in case of children), after a full discussion about this new management, method and the possible sequels. The adult patients were instructed to withhold oral intake, starting midnight before the operation. All of them were advised to evacuate the bowel just before entering the operating theater. The children were kept fasting for 3 hours preoperatively. They were operated upon with a single-handed surgeon, under general anesthesia.
All the operations were carried out as a day-case procedure. The operative time was variable, ranged between 20–61 minutes and the average duration was 31 (±2) minutes. Each patient started oral fluid after four hours from full recovery, and discharged after six hours postoperatively. All the patients were seen again in the follow up clinic one week after the operation, monthly for the next six months and then annually for two years.
Operative Procedure
Longitudinal plication (LP) The aim of this surgical technique is to obliterate the redundant rectal wall with subsequent shortening of the wall itself. It also aims to create three longitudinal pillars amend the rectal wall to prevent further intussusception. Prior to the procedure one dose of prophylactic broad spectrum antibiotic was given at induction of the general anesthesia. The patient was put in Lithotomy position (Figure 1A and the corresponding illustration diagram in Figure 2A). In the following steps, Figure 1 shows actual operation images and for clearer illustrations, corresponding diagrams were drawn in Figure 2. Two artery forceps were applied to 3 and 7 O′clock at the mucocutaneous junction (Figures 1B and 2B). This helps as the first step, allowing exteriorization of the prolapsed rectum by mechanical traction. Successive application of artery forceps in a longitudinal line facilitates the process. This mechanical traction and the gravity of the artery forceps help in taking the entire prolapse out (Figures 1C-F and 2C-F).
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Figure 1.
Longitudinal plication procedure for complete rectal prolapse management. (A) External view of the anal verge just after induction of the anesthesia before the longitudinal plication. (B) The prolapsed area is stretched out by traction and pulling apart through a pair of artery forceps at the mucocutanious junction. (C-F) Multiple pairs of artery forceps are used on two-opposite lines in parallel to the long axis of rectum. Step-by-step tractions with these artery forceps makes the prolaps completely exposed. (G) The first stitch of the longitudinal plication is inserted just proximal to the tip of the prolapse on the medial aspect at 3:00. (H) The longitudinal plication at 3:00 is continued, including 2–3 cm of whole thickness of rectal circumference. (I) Residual rectal-wall protrutions between the stitches are excised. (J) The longitudinal plication at 3:00 is completed, reaching the mucocutaneous junction. (K) The first stitch of the second longitudinal plication is inserted by taking a whole-thickness of the rectal wall medial and proximal to the tip of the prolapsed rectum at 7:00. (L) The longitudinal plication at 3:00 and 7:00 are completed. (M) The prolapsed part at 11:00 is dragged out. (N) The first stitch of the longitudinal plication at 11:00 is inserted, taking a whole-thickness of the rectal wall, at the medial and proximal to the tip of the prolapse. (O) The three longitudinal plication pillars at 3:00, 7:00, and 11:00 of the plolapsed rectal wall are completed.
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Figure 2.
Diagramatic illustrations of longitudinal plication to explain the sequence of the procedure. (A) The patient in lithotomy position and the prolapsed rectum is reduced. (B) The first step in pulling the prolapse out by traction through a pair of artery forceps fixed at the mucocutaneous junction of the anal canal. (C-F) Multiple pairs of artery forceps are used to pull the prolapsed rectum out successively. (G) Continous suturing of the first longitudinal plication (first pillar) is started at the most proximal part of the prolapsed rectum involving the entire rectal wall up to the mucocutaneous junction. (H) The longitudinal plication at 3:00 is completed and residual rectal-wall protrutions between the stitches are excised. (I) The longitudinal plication at 3:00 is completed, creating a pillar and contious suturing for the second pillar at 7:00 is started. (J) The second longtitudinal plication at 7:00 (second pillar) is completed. (K) sagital section shows the LP on 3:00 is completed and the anterior redundant rectal wall is still in. (L) sagital section shows the LP on 3:00 is completed with inserting the first stitch of the L.P. at 11:00, after its traction out through a sets of artery forceps. (M) the LPs on 3:00 and 11:00 are completed. (N) A cross-section shows a completed pillars at 3.00, 7.00 and 11.00, leaving the normal mucosa between pillars untouched. (O) An external view of the anal verge at the end of the procedure at the lithotomy position.
The second part of the technique is to obliterate the redundant tissue. It comprised inserting a stitch of braded polyglycolic acid – absorbable 1.0 at 3 00 o′clock at the most proximal part of the prolapse. The stitch involves the whole thickness of rectal wall of about 2–3 cm (even 4 cm) of the transverse circumference (Figures 1G and 2G). This is followed by successive 1–1.5 cm apart with similar transverse stitches in a spiral fashion towards the anal verge, ending at the mucocutaneous junction. The artery forceps were successively released and their grips were included in the plication (Figures 1H and 2H). Any protruded rectal mucosa between the stitches was cut to avoid swelling and edema in the lumen (Figures 1I and 2H). The same steps were repeated on 7 and 11 o'clock, reducing the rectal caliber to a point, allowing the surgeon to admit the index and middle finger in adults. After tightening up the rectal wall by these three longitudinal pleats, the wall-circumference shrinks longitudinally and circumferentially. The prolapsed rectal wall relocates (reverse) to its ordinary position, leaving normal wall with its mucosa in between the three tightening pillars (Figures 1J-O and 2I-O). In children two longitudinal plications were quite sufficient, instead of three plications, reducing the rectal caliber to a point admitting the index finger only.