Occult Rectal Prolapse M62 Course 2007 David Jayne St. James's University Hospital, Leeds

Occult Rectal Prolapse Internal rectal prolapse Rectal intussusception Full-thickness invagination of the distal rectum during the act of defaecation

Occult Rectal Prolapse Asymptomatic 50 – 60% proctograms in normal volunteers Symptomatic Solitary Rectal Ulcer Syndrome Obstructed Defaecation Syndrome (ODS) Faecal incontinence

Obstructed Defaecation Syndrome (ODS) Under-diagnosed 15 – 20% women More common in multiparous Symptoms Straining Laxative / Enema dependency Incomplete evacuation Fragmented defaecation Rectal pain Perineal support / Digitation

Occult Rectal Prolapse Central to the concept of ODS Co-existent Rectocele Muco-haemorrhoidal prolapse Enterocele / Sigmoidocele Descending perineum Urogenital prolapse

A unifying theory for ODS Chronic straining produces a stretching and redundancy of the distal (subperitoneal) rectum Rectal redundancy is the anatomical defect underlying ODS

Rectal Redundancy

Rectocele & Internal Prolapse

Rectal Redundancy Internal prolapse – rectal invagination Rectocele – transverse distension Perineal descent – distal elongation Initial compensatory mechanisms Facilitate opening of the rectal lumen Gradual impaired ability to generate intra-rectal pressure for evacuation

Rectal Redundancy Dependency on extra-rectal forces to achieve rectal evacuation Enterocele / Sigmoidocele Descending perineum May be dynamic or become stable

Enterocele

Enterocele

Concept Correction of ODS requires excision of the redundant rectum and its associated structural abnormalities

STARR Procedure Stapled Transanal Rectal Resection Aims to correct the anatomical defects associated with ODS by resection of the redundant distal rectum Previously double stapling technique using x2 PPH-01 guns New Transtar method

Transtar stapler 33mm stapler Curved Cutter Reloadable staple cartridge

Transtar procedure CAD inserted & secured

Transtar procedure Leading edge of prolapse identified

Transtar procedure 4x gathering sutures 2, 10, 8 & 4 o’clock Traction 5th suture to aid first “radial cut”

Transtar procedure Radial cut Determines “height” of specimen Direct vision Traction of 2 & 4 o’clock gathering sutures

Transtar procedure 2nd firing Circumferential resection Direct vision Tension on 2 & 10 o’clock gathering sutures

Transtar procedure Circumferential resection Direct vision “Sausage” specimen

Transtar procedure Complete circumferential resection Beginning & end points meet up Prolapse excised

Transtar procedure Full-thickness circumferential resection of distal rectum

Transtar procedure

Transtar procedure

Summary Internal rectal prolapse, rectocele & muco-haemorrhoidal prolapse all manifestations of posterior pelvic floor dysfunction Primary defect is redundancy of the distal rectum Correction of rectal redundancy addresses the anatomical defect and is advocated for the treatment of ODS

Internal Rectal Prolapse M62 Course 2007 David Jayne St. James's University Hospital, Leeds

Internal Rectal Prolapse M62 Course 2007 David Jayne St. James's University Hospital, Leeds

Internal Rectal Prolapse Distal Rectal Redundancy M62 Course 2007 David Jayne St. James's University Hospital, Leeds