Discussion
Our aim in this study was to use a less invasive perineal procedure. It can be performed in any surgical center, in all age groups as a day-case surgery. There was no mortality in our patient group in this study (Table 3). We excluded the Thiersch procedure, since it does not treat the real problem and nowadays, has been abandoned. Our method causes minimum inconvenience for the patients and hospital.
In this group, the recurrence rate was 3.33%, comparable and favorable to the abdominal as well as perineal operations (Table 3). The plications shrink the redundant rectal wall longitudinally and circumferentially, stabilizing the rectum. At the same time we buttressed the remaining rectal wall by two or three pillars of plicated full-thickness rectal wall. This prevents future intussusception of any redundant rectal wall left behind, which may be the precursor of future recurrent prolapse on straining.
There are numerous perineal procedures to treat rectal prolapse. They can broadly be classified into two groups. The first group aims to strengthen the rectal wall through inducing fibrosis, with or without reconstruction of the pelvic floor. They include mucosal cauterization, ligation and excision of the rectal mucosa at different points, or submucosal injection of different materials. In the perineal approach, pioneered by El-Sibai and Shafik on 28 patients, they cauterize the rectal mucosa and apply multiple vertical purse-string sutures. Their recurrence rate was 3.57% (n = 1/28). Their idea is to induce fibrosis as well as reducing the prolapsed rectal wall to inside the rectum. They reduce the prolapsed rectum longitudinally only, leaving the redundancy of the rectal wall protruding to inside its cavity. Also the entire pleated rectal wall accumulates near the anal verge. Our method differs through reduction of the redundant rectal wall longitudinally as well as circumferentially. We include the redundant rectal wall in longitudinal plications, keeping an empty space inside the rectum. The pleated rectal wall distributes up through the two or three lines of the longitudinal plications. All the pleated tissue layers are included in the plications, allowing introduction of two figures in adult and one finger in children into the rectal cavity. Our recurrence rate was 3.33% (n = 1/30), which was similar to the results achieved by El-Sibai and Shafik.
The second group of the perineal approaches, which have some similarity to our procedure aims to shorten the prolapsed rectum. They include transverse suturing of a longitudinal rectal wall incision, mucosal resection, Delorme's operation, and perineal amputation of the prolapsed rectum with end-to-end anastomosis. This group also includes stapler rectopexy. Pelvic floor reconstruction may be added to any one of these procedures. The most common performed perineal procedures nowadays are Delorme's operation, perineal rectosigmoidectomy, and stapled transanal rectal resection. Delorme's operation plicates the rectal wall muscles submucosally above the anal verge. It requires dissection and has a high recurrence rate as summarized in Table 3.
Removing the mass of the redundant and prolapsed rectal wall on the anal ring allows it to regain its turgor and continence. As mentioned above, our procedure does not accumulate the pleated rectal wall on the anal canal, it shifts the redundant wall through the longitudinal plications away from the anus. Each plication ends at the mucocutaneous junction, as we tightened the anal canal and reduced its caliber. We believe this will contribute further to help continence to be regained. Also we have left intact normal mucoca in-between the three longitudinal plications. We can say that our procedure combines both the two previous perineal approaches. We shorten the redundant rectal wall both longitudinally, as well as circumferentially. In addition we also keep the intact rectal mucosa in between the three pillars. This preserves the normal rectal sensation, which is another factor in regaining continence.
Compared to other methods, our technique is a simple perineal procedure, done as a day case surgery. We used this method for all the age groups (Table 1). Traditionally the perineal approaches are reserved for medically unfit patients. They have a higher recurrence rate, compared to the abdominal approaches. Also our procedure is performed through the rectum from inside, involving the rectal wall in the stiches. We didn't dissect the mucosa, which is associated with excessive bleeding, as well as it is time-consuming. In addition we didn't disturb the perirectal tissue, which can severe the rectal ligaments; leading to a decrease in the resting and squeezing pressure of the rectum. This may aggravate the pre-existing constipation. Our procedure can be performed, using simple instruments, which are used in any surgical unit.