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

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

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

4. 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

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

6. 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

7. Rectal Redundancy

8. Rectocele & Internal Prolapse

9. 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

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

11. Enterocele

12. Enterocele

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

14. 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

15. Transtar stapler 33mm stapler Curved Cutter
Reloadable staple cartridge

16. Transtar procedure
CAD inserted & secured

17. Transtar procedure
Leading edge
of prolapse identified

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

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

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

21. Transtar procedure Circumferential resection Direct vision
“Sausage” specimen

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

23. Transtar procedure
Full-thickness circumferential resection of distal rectum

24. Transtar procedure

25. Transtar procedure

26. 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

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

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

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