The evaluation and treatment of patients with rectal prolapse

Many of the reported series have tended to concentrate on recurrence rates rather than functional outcome, and virtually all have short follow-up of clinical outcome. There have been very few randomised trials making interpretation of results more difficult. Our own practice has evolved to perform a suture rectopexy performed laparoscopically in those patients without preoperative evacuation difficulties for the previously outlined reasons. Where there is evidence of slow transit constipation, a sub-total colectomy performed as an open procedure is offered. Mesh rectopexy is a suitable, safe alternative, particularly in the absence of preoperative evacuation difficulties (3, 24). The primary problem with this approach is the subjective nature of the preoperative assessment in relation to the patient's (and doctor's) definitions of evacuation difficulty or constipation. While debate continues as to whether the lateral ligaments should be divided, a more practical approach would be to preserve these ligaments if a sutured or mesh rectopexy is to be used, with division of the lateral ligaments when a resection is performed. These manoeuvres would reduce the risk of troublesome postoperative constipation, although recurrent mucosal or full-thickness prolapses have been described. The final decision for the choice of procedure should take account of basic preoperative abnormalities being present, i.e. motility disorders, the presence of neurogenic injury to the pelvic floor etc., combined with the age, gender and medical condition of the patient (43).