Rectal Prolapse Surgery Types Recovery Risks

When surgery is needed for rectal prolapse

Rectal prolapse is a condition where the rectum slides down and protrudes through the anus. In adults, surgery is the only way to treat the condition because it will not go away on its own and tends to get worse over time without an operation.

In children, the prolapse often improves with treatment of the underlying cause, such as chronic constipation or diarrhoea, and surgery is rarely needed. Adults who delay surgery risk worsening faecal incontinence and more serious complications like strangulation of the bowel.

Symptoms that lead to a surgical referral include:

• Feeling tissue come out of the anus during straining
• Mucous drainage
• Rectal bleeding
• Anorectal pain
• Faecal leakage or constipation

The condition mainly affects elderly and parous women, with an estimated incidence of about 2.5 per 100,000 inhabitants. A complete external prolapse involves a full-thickness protrusion of the rectal wall and is considered a profoundly disabling, lifestyle-altering condition.

Before recommending surgery, the surgical team confirms the diagnosis with a physical examination and tests such as colonoscopy, anoscopy, anal manometry, or defecography. These tests help assess the pelvic floor and rule out other pathology. Your surgeon will discuss the findings and explain why an operation is advised for your specific situation.

How your surgeon chooses the surgical approach

There is no single accepted standard surgical treatment for rectal prolapse, and over 300 different procedures have been described. Your surgeon selects the approach based on your overall health, age, the size and type of prolapse, and test results.

The main decision is between an abdominal approach (through the belly) and a perineal approach (through the area between the anus and genitals).

Abdominal surgery generally offers a lower risk of the prolapse coming back but carries slightly higher surgical risks. Perineal surgery is often preferred for older patients or those with significant medical problems who may not tolerate abdominal surgery well. In a large trial, patients were randomised between these two broad approaches to compare outcomes.

If an abdominal route is chosen, your surgeon will advise between open, laparoscopic, or robotic techniques, and whether to use mesh or perform a bowel resection. For perineal surgery, the choice is typically between the Altemeier and DeLorme procedures.

The PROSPER trial and other studies aim to clarify which technique suits which patient, but current evidence shows no clear superiority of one method over another for all patients.

Abdominal rectopexy techniques explained

Abdominal rectopexy fixes the rectum to the back wall of the pelvis (the sacrum) using sutures or a mesh sling. The surgery can be done through one large incision (open), several small incisions with a camera and instruments (laparoscopic), or using a robotic system controlled by the surgeon from a console. An assistant surgeon stands by during robotic procedures.

During the operation, the rectum is mobilised and pulled up into position. If there are extra loops of colon above the rectum, a portion may be removed (resection rectopexy) to help with constipation. Studies show that adding resection to rectopexy is associated with lower rates of postoperative constipation compared to suture rectopexy alone. Division of the lateral ligaments during mobilisation is linked to less recurrent prolapse but more constipation.

Ventral mesh rectopexy (VMR) is a newer technique that places mesh on the front of the rectum, avoiding posterolateral dissection to minimise constipation risk. Laparoscopic or robotic VMR is increasingly performed. Evidence suggests VMR is effective with low recurrence and complication rates in the short to medium term.

In trials, recurrence rates for resection rectopexy were 13% compared to 26% for suture rectopexy, though the difference was not statistically significant. Laparoscopic rectopexy is associated with fewer complications and a shorter hospital stay than open surgery.

Perineal surgery options: Altemeier and DeLorme procedures

Perineal surgery is performed through the anus or a small incision in the perineal area, avoiding an abdominal cut. This approach is often chosen for patients who are frail, elderly, or have high anaesthetic risk. The two main techniques are the Altemeier procedure and the DeLorme procedure.

In the Altemeier procedure (also called perineal proctosigmoidectomy), the prolapsed rectum is pulled out through the anus, and the redundant rectum and lower colon are removed. The remaining colon is then reattached (anastomosed) to the anal canal.

In the DeLorme procedure, the inner lining (mucosa) of the prolapsed rectum is stripped away, and the muscular layer is folded and stitched to shorten the rectum. The mucosal lining is then stitched back over the repair. The DeLorme procedure is generally used for smaller prolapses.

In randomised trials, recurrence rates at three years were 24% for Altemeier and 31% for DeLorme, with no statistically significant difference between them. Perineal procedures overall are associated with higher recurrence rates than abdominal approaches. Your surgeon will explain which perineal technique suits the size of your prolapse and your general health.

Anaesthesia and what happens in the operating theatre

All abdominal rectal prolapse surgeries are performed under general anaesthesia, meaning you are completely asleep. For perineal surgery, the anaesthetist may use general anaesthesia or an epidural (spinal) anaesthetic, depending on your health and the surgeon's preference. The choice is discussed with you during the pre-operative assessment.

In the operating theatre, you are positioned carefully to allow access to the surgical site. For abdominal surgery, the team uses either an open incision or ports for laparoscopic or robotic instruments. The median operation time reported in studies is around 122 minutes.

Conversion from laparoscopic to open surgery is needed in about 1.8% to 2.9% of cases, usually due to difficult adhesions (scar tissue).

For perineal procedures, the surgeon operates through the anus or a small perineal incision. No mesh is typically used in standard Altemeier or DeLorme procedures. The surgical team monitors your vital signs throughout. After the repair is complete, the wounds are closed, and you are moved to the recovery area for observation before being transferred to a ward.

Recovery timeline and care at home

After surgery, you may stay in the hospital for two or three days after perineal surgery or up to a week after abdominal surgery. Your discharge time depends on several factors, like when you are able to have solid foods, pass gas and have a bowel movement.

The hospital stay after surgery is typically one to five days but will depend on the type of surgery. Recovery time varies by procedure: open rectopexy takes four to six weeks, while laparoscopic and robotic repairs take about four weeks. The Altemeier and DeLorme procedures usually need three to four weeks.

You should expect to feel some pain or discomfort in your rectal area after surgery. If you had an abdominal procedure, your abdomen may also be tender. The amount of pain depends on the extent of the repair and the size and location of the incisions. Pain pills may be given to take at home. Follow your healthcare provider's recommendations for pain relief. Plan rest times during the day as you will feel tired.

A low fibre diet is needed after leaving the hospital. Keeping stool soft prevents straining during bowel movements. Stool softeners or laxatives may be needed. Do not strain during bowel movements. Nothing more strenuous than walking should be done until okayed by the doctor. Check with your doctor before going back to work. No sex until okayed by the surgeon. No driving for three to four weeks or if taking narcotic pain pills. Wear loose clothes.

Two days after surgery, you may shower and gently wash incisions with mild soap and water. Do not soak in a hot tub, bathtub, or go swimming until incisions heal, which may be two weeks or longer. Do not put lotion, ointment, or powder on incisions. Small areas of bruising at the incision site are expected.

Check your incision daily for signs of infection. You will see your surgeon in two to three weeks after surgery. Bowel function after the surgery may be the same, worse or better. It sometimes takes several months to determine what bowel function will be like long term.

Risks and possible complications

All surgeries carry a risk of complications like bleeding, blood clots and scarring. Abdominal approaches are slightly riskier than perineal surgery but have a lower risk of the prolapse happening again. In studies, laparoscopic rectopexy was associated with fewer postoperative complications and shorter hospital stay than open rectopexy.

Conversion to open surgery was needed in about 2.9% of cases, most often due to difficult adhesiolysis. Major complications occurred in 4.8% of patients in one large series. The weighted mean complication rate across studies was 12.4%. No surgical mortality was described.

Most frequent complications were urinary tract infection and urinary retention. Division of the lateral ligaments was associated with less recurrent prolapse but more postoperative constipation. Bowel resection during rectopexy was associated with lower rates of constipation. Mesh-related complications were reported in 1.2% of cases.

Improvement of constipation ranged from 3% to 72% of patients, while worsening or new onset constipation occurred in 0% to 20%. Incontinence improved in 31% to 84% of patients who presented with faecal incontinence. The weighted mean rates of improvement in faecal incontinence and constipation after ventral mesh rectopexy were 79.3% and 71% respectively.

Perineal procedures are associated with a higher recurrence rate. Less than 5% of people who get abdominal rectopexy have another rectal prolapse, but as many as 1 in 4 people have another prolapse after perineal rectopexy. In one trial, Altemeier's recurrence rate was 24% and DeLorme's was 31%.

Resection rectopexy had a 13% recurrence rate compared to 26% for suture rectopexy. Male gender and length of the mesh may have a significant impact on recurrence after ventral mesh rectopexy. Without surgery, rectal prolapse in adults gets worse and can lead to serious complications like worsening faecal incontinence.

Comparing results: recurrence, bowel function and quality of life

There is no accepted standard surgical treatment for rectal prolapse. Despite the description of more than 300 different procedures, no clear superiority of one surgical technique has been demonstrated. In studies, recurrence rates were higher than anticipated but not significantly different in any comparison. Quality of life scores (Vaizey, bowel thermometer and EQ-5D) were not significantly different between the procedures.

Substantial improvements from baseline in quality of life were noted following all procedures. There were no differences in quality of life for patients who underwent the different kinds of prolapse surgery.

There is some evidence that abdominal rectal prolapse surgery provides better long-term results than perineal surgeries. Recurrence of full-thickness prolapse was greater for mobilisation of the rectum only compared with rectopexy. There were no detectable differences between the methods used for fixation during rectopexy.

Perineal versus abdominal recurrence rates were 20% and 26% respectively in one trial, a difference that was not statistically significant. The weighted mean rate of recurrence of full-thickness external rectal prolapse after ventral mesh rectopexy was 2.8% with a median follow-up of 23 months.

Ventral mesh rectopexy has proved effective in the treatment of internal and external rectal prolapse with low recurrence and complication rates.

Getting rectal prolapse surgery can stop symptoms and improve your quality of life. Your surgeon can put the tissue back where it belongs so you do not develop pain, problems with pooping (incontinence or constipation) or other serious complications.

The lack of high quality evidence on different techniques, together with the small sample size of included trials and their methodological weaknesses, severely limits the usefulness of reviews for guiding practice. It is impossible to identify or refute clinically important differences between the alternative surgical operations. Longer follow-up with current studies and larger rigorous trials are needed to define the optimum surgical treatment.

When to contact your surgeon after discharge

You should call your healthcare provider if you experience certain warning signs after discharge. Increased redness, swelling or warmth at the incision site may indicate infection. Drainage such as blood or pus at the incision site may also indicate infection. Fever over 38 degrees Celsius by mouth for two readings taken four hours apart may indicate infection. Signs of infection warrant calling your surgeon.

Painful bloating or cramping warrants calling your surgeon. Pain not controlled by pain pills warrants calling your surgeon. Return of the rectal prolapse warrants calling your surgeon. Unable to have a bowel movement warrants calling your surgeon. These symptoms need urgent review to prevent serious complications.