The addition of rectal fixation to the sacrum may provide better results regarding the decrease in recurrence rate. This operation is safe and presents the lowest recurrence rate. The reported recurrence rate after sigmoid resection with proctopexy varies from 2% to 10%.1 Initial procedures used the circumferential wrap. However, postoperative complications, including constipation and obstruction have led surgeons to modify the technique leaving the anterior rectum free. Others avoid the placement of the mesh altogether, adopting the use of nonabsorbable sutures to fixate the rectum to the presacral fascia.We currently prefer the latter approach to treat surgically fitted individuals with rectal prolapse.
The management of recurrent rectal prolapse depends on the previous procedure. An abdominal approach must be avoided if the patient had previous perineal rectosig-moidectomy, especially if sigmoid resection is contemplated, because of the potential ischemia and necrosis of the intervening segment between anastomoses. However, a repeat perineal rectosigmoidectomy can be safely performed in this patient population. Moreover, if the patient's previous operation was sigmoidectomy with proctopexy, a repeat procedure to treat the recurrence is also feasible. Nonetheless, one must perform a complete presacral rectal dissection despite the difficulties caused by the prior dissection.
In summary, one must match the operation with the patient. Healthy individuals and/or patients with low comorbidity should undergo the abdominal approach (laparoscopic5 or open) for the treatment of rectal prolapse. Sigmoid resection with proctopexy seems to offer lower recurrence rates of the options described. However, compared with the perineal procedure, the abdominal operations are associated with a higher morbidity and mortality. Conversely, high surgical risk patients should generally be offered a perineal procedure, the best option of which is the perineal rectosigmoidectomy with levator-plasty. Compared with abdominal procedures, this operation has a significantly lower incidence of postoperative complications at the expense of a higher recurrence rate.
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