Surgical approaches for complete rectal prolapse

Abstract

Complete rectal prolapse, characterized by the protrusion of the rectal wall layers through the anal canal, poses significant treatment challenges, particularly due to controversies surrounding surgical approaches and the absence of a standardized assessment system. This study comprehensively reviews the main surgical techniques for complete rectal prolapse, categorized as transabdominal and transperineal/transanal procedures. Despite various techniques, challenges persist, including high recurrence rates and potential complications. Factors influencing the choice of the surgical approach include patient characteristics, symptomatology, and surgical expertise. With advances in medical technology, laparoscopic and robotic surgeries offer promising avenues, albeit with considerations of cost and accessibility. Ultimately, treatment plans tailored to the individual needs of the patient and surgical expertise are essential. Although controversies remain, the continued refinement of surgical techniques holds promise for improving outcomes in complete rectal prolapse surgery.

Key Words: Rectal prolapse; Surgery; Procedure; Treatment; Review

Core Tip: Selection of the appropriate surgical method depends on patient age, comorbidities, and prolapse severity when managing complete rectal prolapse. For high-risk patients, minimally invasive techniques like Delorme’s or Thiersch’s procedures offer quick recovery, but with a higher recurrence rate. In contrast, more invasive procedures like ventral mesh rectopexy provide durable results for severe cases. Postoperative follow-up is crucial to monitor for complications such as recurrence and bowel dysfunction. Tailoring the approach to individual patient characteristics is key to achieving the best outcomes and minimizing long-term complications.

INTRODUCTION

Complete rectal prolapse, also known as external rectal prolapse, refers to the protrusion of the full-thickness rectal wall through the anal canal[1]. Although prolapse is most common among older women, it affects individuals of all ages, including children[2,3]. The causes of complete rectal prolapse are multifactorial, including genetic factors, anatomical structure, and increased intra-abdominal pressure. Currently, surgery is the only treatment modality offering a potential cure for rectal prolapse. The three primary goals of surgery for rectal prolapse: (1) To eliminate the prolapse by resecting or restoring normal anatomy; (2) To address associated functional abnormalities, such as constipation or fecal incontinence; and (3) To prevent the development of new gastrointestinal dysfunction[4]. Several surgical techniques have been developed to achieve these goals, each with its own advantages and disadvantages. The current assessment system for complete rectal prolapse requires improvement, and selecting an appropriate surgical approach remains controversial[5]. This study organizes and reviews the main surgical approaches for complete rectal prolapse, aiming to provide surgeons with a deeper understanding of these techniques and to collectively enhance the therapeutic outcomes for rectal prolapse.

DEFINITION AND CLINICAL PRESENTATION OF COMPLETE RECTAL PROLAPSE

Complete rectal prolapse refers to the downward displacement of part or all of the rectal wall, which protrudes completely from the anus. Rectal prolapse includes complete or incomplete, external or internal, and adult or juvenile prolapse. Rectal prolapse can occur at any age[6]. In adults, complete prolapse occurs when the entire rectal wall protrudes from the anus and is often accompanied by anatomical and functional abnormalities of the pelvic floor, such as rectocele, enterocele, and perineal descent. This condition may lead to symptoms such as mucosal or bloody stools, difficulty defecating, and anal incontinence[7].

SURGICAL APPROACHES FOR COMPLETE RECTAL PROLAPSE

Surgery is the treatment of choice for patients with a complete rectal prolapse. Numerous surgical options exist for the treatment of complete rectal prolapse, which are categorized into transabdominal and transperineal/transanal approaches based on the surgical technique.

Transabdominal rectal fixation

Transabdominal rectal direct suture fixation: Abdominal rectopexy involves fixing the rectal mesentery to the sacral promontory and has been reported to have a relatively high postoperative recurrence rate[8]. The key steps in the rectopexy procedure include cleansing the prolapsed rectal mucosa with cold saline solution, removing any foreign bodies and debris adhering to the mucosa, disinfecting the prolapsed rectal portion with a 0.1% potassium permanganate solution, applying iodine glycerin, gently reducing the prolapsed rectal portion manually, and plugging it with a rubber rectal plug. A vertical incision approximately 5-10 cm in length, is made in the lower left abdomen, and the abdominal cavity is opened. The assistant brings the prolapsed rectum forward from the anus to the vicinity of the abdominal incision, whereas the surgeon pulls the rectum into the abdominal cavity and fixes it to the left abdominal wall. Fixation requires the needle penetrating the serosa and muscle layers without piercing the mucosa. The rectum is fixed to the peritoneum and abdominal muscles (abdominal wall) using the two- to three-stitch knotting method. Subsequently, the peritoneum, muscle layers, and skin are sutured sequentially, and the abdominal incision is closed.

Transabdominal rectal patch fixation surgery: The ventral mesh rectopexy (VMR) procedure involves freeing only the anterior aspect of the rectum to the perineum, placing a patch at the lowest point of the anterior rectal wall, and suturing it in place[4]. The rectum is then suspended and fixed to the sacral promontory using a patch. VMR avoids posterior and lateral dissections of the rectum, reducing the risk of pelvic nerve injury[9]. The recurrence rate after VMR is comparable to that after traditional suspension methods; however, VMR offers a higher rate of constipation relief, making it highly regarded. Currently, it is the preferred surgical procedure for rectal prolapse treatment among pelvic floor surgeons in Europe[10,11].

VMR rectopexy key points: At 1-2 cm above the umbilicus, a 1.2 cm incision is made to insert a trocar for insufflation, establishing a pneumoperitoneum at 11-13 mmHg. A 12 mm trocar is inserted at this site as the observation port, with the right McBurney’s point serving as the primary operating port for the surgeon, and the intersection of the right external border of the rectus abdominis muscle with the line of the umbilicus as the secondary operating port. The intersection of the left external border of the rectus abdominis muscle with the line of the umbilicus serves as the primary operating port for the assistant, whereas the left reverse McBurney’s point serves as the secondary operating port. After placing all ports, the patient is adjusted to a head-down, right-side position to explore the pelvis for any adhesions that may affect the surgery; if present, these adhesions must be separated first. The assistant raises the rectum with the left hand and pulls up the sigmoid mesocolon with the right hand to unfold the right sides of the rectum and sigmoid mesocolon, revealing a right-lateral rectal groove. The surgeon incised the peritoneum in the avascular area of the sacral promontory and then moves downward along the right lateral rectal groove to the lowest point of the Douglas pouch before turning to the left side. Attention should be paid to the sacral promontory to identify the right ureter and protect the inferior hypogastric nerve. In female patients, after incision at the lowest point of the Douglas pouch, the loose space between the rectum and vagina is located, and separation is carried out along this space until the lowest point of the rectovaginal septum is reached. In male patients, the posterior space of the prostate, known as the Denonvilliers’ fascia, is entered after incising at the lowest point of the Douglas pouch. The Denonvilliers’ fascia is then cut, entering the loose space between the Denonvilliers’ fascia and the anterior rectal wall, known as the rectal anterior space. The assistant performs a digital rectal examination to confirm that the rectum is dissected to the lowest point, and once confirmed, a patch is placed. A biological patch (7 cm × 20 cm) is used, which induces minimal tissue reaction and has a lower risk of postoperative erosion. After securing the patch to the rectum, it is wrapped around its proximal end. With appropriate traction and tension, the position for patch fixation is estimated. Once determined, the assistant exposes the right sacral promontory. The proximal end of the patch is fixed to the sacral promontory using nonabsorbable sutures or hernia tacks. After securing the patch, the pelvic floor is sutured continuously with 3-0 barbed sutures, and the peritoneum is closed. Closing the pelvic floor peritoneum prevents adhesion or erosion of the patch to the small intestine, thereby preventing intestinal obstruction or perforation.

Transabdominal rectal posterior patch fixation (Wells rectopexy)

Wells rectopexy involves fixing the mesh to the posterior and lateral rectal walls. Short-term follow-up after surgery revealed recurrence rates ranging from 6% to 12%[12]. With prolonged follow-up, the recurrence rate increased[13]. Studies comparing the recurrence rates between VMR and Wells procedures reveal that VMR has a lower recurrence rate[12,14].

Laparoscopic Wells rectopexy key points: At 1-2 cm above the umbilicus, a 1.2 cm incision is made to insert a trocar for insufflation, establishing pneumoperitoneum at 11-13 mmHg. A 12 mm trocar is inserted at this site as the observation port, with the right McBurney’s point serving as the primary operating port for the surgeon, and the intersection of the right external border of the rectus abdominis muscle with the line of the umbilicus as the secondary operating port. The intersection of the left external border of the rectus abdominis muscle with the line of the umbilicus serves as the primary operating port for the assistant, whereas the left reverse McBurney’s point serves as the secondary operating port. After placing all ports, the patient is adjusted to a head-down, right-side position to explore the pelvis for any adhesions that may affect the surgery; if present, these adhesions must be separated first. The left colon is mobilized internally: The midline of the sigmoid mesocolon is incised; with intestinal forceps gripping the rectum and pulling it toward the abdomen, the sigmoid mesocolon is stretched, and the incision begins at the sacral promontory, following the “white-yellow junction” as a guide, cutting from the caudal to the cranial direction along the sigmoid mesocolon to the root of the mesentery. Then, turning left, a loose space is visible, entering the fusion fascial space between the left colonic mesentery and the anterior renal fascia (Toldt’s space). Expanding Toldt’s space: The assistant pulls the upper segment of the rectum toward the abdomen, the right-hand intestinal forceps grasp the root of the mesentery artery toward the cranial and ventral directions, maintaining tension, and the surgeon carefully expands Toldt’s space: In this space, the surgical plane is expanded to the left to reach the Toldt line where the sigmoid mesocolon disappears. Care is taken to preserve the integrity of the left colonic mesentery and anterior renal fascia, leaving a transparent layer of the anterior renal fascia in front of the main iliac vessels. Through this fascia, the left ureter and genital vessels behind the root of the sigmoid mesocolon on the outer side can be seen (without damaging the inferior mesenteric plexus, left ureter, and left genital vessels). The dissection range extends from the center to the left, reaching the lateral gutter of the left colonic side, and from the caudal to the cranial side, reaching the root of the inferior mesenteric artery. The left colonic mesentery is mobilized externally, pulling the sigmoid mesocolon to the right, starting from the inherent adhesion band between the outer edge of the distal end of the sigmoid colon’s first flexure and the left abdominal wall, the peritoneal reflection of the left colonic gutter is incised along the white-yellow junction (Toldt line) toward the cranial direction. The sigmoid colon is flipped to the right, and in the space between the mesentery and anterior renal fascia, known as Toldt’s space, the left side is mobilized, ensuring protection of the left ureter and left genital vessels behind the anterior renal fascia. The left side of the sigmoid colon is completely opened to the midline and extended upward to the level of the lower sigmoid colon, ensuring the integrity of the anterior renal fascia, sigmoid mesocolon, and original descending mesocolon. Mobilization around the rectum: Starting from the sacral promontory level, in the loose connective tissue space behind the upper rectal mesentery, the surgical plane is expanded sharply to the posterior and lateral sides of the posterior rectal space until the gap between the rectal sphincter muscles is above. Posterior: Starting from the sacral promontory level and close to the rectal mesentery, the surgical plane is expanded caudally in the posterior rectal space between the rectal mesentery and presacral fascia, cutting the rectosacral fascia, entering the gap of the levator ani muscle, and approaching the levator ani muscle. Laterally: The space around the rectum is expanded to both sides using the posterior gap as a guide, and the space around the rectum is mobilized to both sides until the level of the gap is above the levator ani muscle. Without cutting the inferior mesenteric or superior rectal arteries, detaching the lateral ligaments of the rectum, or opening the peritoneal reflection in front of the rectum, the integrity of the pelvic autonomous nerves is protected throughout the entire process. Posterior suspension fixation of the rectum A mesh patch is selected, trimmed to a suitable shape, and placed behind the rectum, ensuring that the patch is fully unfolded and spread flat in the gap behind the rectum. After the assistant raises the rectum and corrects the prolapse, the upper segment of the mesh is fixed to the anterior rectal fascia using absorbable sutures, the patch is buried, and careful hemostasis is performed. On the left side of the rectum, continuous sutures with 3-0 Vicryl suture are used to wrap and bury the left lateral peritoneum, mesh, and inherent fascia, avoiding contact between the mesh and the rectal surface and ensuring peritonealization of the left rectal side. The left outer layer of the sigmoid colon muscularis is sutured to the right lateral peritoneum, and the sigmoid colon is fixed on the lateral abdominal wall.

Transabdominal anterior patch fixation (Ripstein rectopexy)

Suturing the mesh around the anterior rectal wall in the Ripstein procedure leads to a high incidence of postoperative complications. McMahan modified the Ripstein procedure by fixing the ends of the mesh to the sides of the rectum rather than to the anterior rectal wall. The recurrence rate of McMahan’s modified procedure is comparable to that of Ripstein surgery (2%-5%), with a complication rate of 20%[15]. The recurrence rate of rectal prolapse after Ripstein surgery and its modified procedures ranges from 4% to 10%[16]. Major postoperative complications are often related to the mesh, such as colorectal obstruction, mesh erosion into the intestine, ureteral injury or fibrosis, small bowel obstruction, rectovaginal fistula, and fecal impaction[17].

Laparoscopic Ripstein rectopexy key points: At a point 1-2 cm above the umbilicus, a 1.2 cm incision is made to insert a trocar for insufflation, establishing pneumoperitoneum at a pressure of 11-13 mmHg. A 12 mm trocar is inserted at this site as the observation port. At the same time, the right McBurney’s point serves as the primary operating port. The intersection of the right external border of the rectus abdominis muscle with the line of the umbilicus serves as the secondary operating port for the surgeon. The intersection of the left external border of the rectus abdominis muscle with the line of the umbilicus serves as the primary operating port for the assistant, whereas the left reverse McBurney’s point serves as the secondary operating port. After placing all ports, the patient is adjusted to a head-down, right-side position to explore the pelvis for any adhesions that may affect the surgery; if present, these adhesions must be separated first. Starting from the level of the sacral promontory, a sharp expansion of the surgical plane is performed posteriorly and laterally in the loose connective tissue space behind the upper rectal mesentery until it reached the space behind the rectum, up to the levator ani muscle space. Starting from the level of the sacral promontory, the surgical plane is expanded caudally in the posterior rectal space between the rectal mesentery and presacral fascia, cutting the rectosacral fascia, entering the space above the levator ani muscle and approaching the levator ani muscle. The space around the rectum is expanded on both sides using the posterior gap as a guide, the space around the rectum is mobilized on both sides until it reached the level of the space above the levator ani muscle. Without cutting the inferior mesenteric or superior rectal arteries, detaching the lateral ligaments of the rectum, or opening the peritoneal reflection in front of the rectum, the integrity of the pelvic autonomous nerves is protected throughout the entire process. Eventually, the posterior wall of the rectum is freed to the tip of the coccyx, raising the rectum. A 5 cm-wide mesh strap is placed around the upper rectum, and the mesh strap is fixed to the presacral fascia and periosteum under the sacral promontory using nonabsorbable sutures. The strap edges are sutured to the anterior and lateral walls of the rectum without repairing the pelvic floor. Finally, the peritoneum on both sides of the rectum is sutured, and the puncture holes are closed.

Transperineal rectal fixation

Transperineal resection for rectal prolapse (Mikulicz’s procedure): Mikulicz’s procedure can only remove the prolapsed portion of the rectum outside the anus and cannot address the underlying cause of the prolapse. Therefore, this surgery is only suitable for patients where the prolapsed rectum is severely swollen, adhered, cannot be reduced, or is already necrotic[18].

Mikulicz’s procedure key points: In the lithotomy position, the buttocks are raised to prevent the intestines from falling into the rectovesical or rectouterine fossa and to avoid intraoperative injury. First, two traction sutures are placed at the distal end of the prolapsed bowel, and a circumferential incision is made 2 cm from the anal margin of the outer layer of the bowel wall. If the prolapsed bowel is long and the incision has penetrated the peritoneum, entering the prevesical or pre-rectal space and communicating with the abdominal cavity, only the gap between the inner and outer bowel layers is incised without entering the abdominal cavity. After cutting the bowel wall, bleeding points are ligated. The seromuscular layers of the inner and outer bowels are intermittently sutured with fine silk thread (for short prolapsed bowels, only muscular layer suturing is performed), and the abdominal cavity is closed. To avoid contamination of the abdominal cavity, a small portion of the outer bowel wall can be cut open during suturing, and the abdominal cavity can be closed promptly. Using the same method, the seromuscular (or muscular) layer of the posterior wall of the bowel is sutured after the inner and outer bowel layers. By cutting and suturing simultaneously, the anterior half of the inner layer of the bowel is gradually cut off, and the inner and outer layers are sutured with 2-0 or 3-0 chromium-plated intestinal threads. This suture layer is placed at the distal end of the first layer. Using the same method, the full-thickness posterior wall is cut and sutured, the prolapsed bowel is removed, and the bowel is gradually inserted into the anus with fingers to complete the surgery. A piece of gauze is placed in the rectum with a 1 cm rectal tube inside and then bandaged with a sterile dressing.

Transanal rectal mucosal sleeve resection with muscular folding sutures (Delorme’s procedure): The Delorme procedure, a classic perineal procedure, was previously less commonly used because of its higher recurrence rate. However, it has gained increasing attention in recent years due to its simplicity, minimal invasiveness, and low requirement for patient surgical tolerance[19]. It is primarily suitable for older adult patients at high risk for anesthesia, pediatric patients with primary rectal prolapse, and young men concerned about potential nerve damage[20,21]. The Delorme procedure is suitable for older adult patients with a prolapsed rectal length of less than 5 cm[22]. However, studies have reported good efficacy in patients with a prolapse length of 5-10 cm[23,24]. The Delorme procedure is a viable option for repeat surgery[19,25].

Delorme’s procedure key points: After a successful epidural or general anesthesia, the patient is placed in the lithotomy position. At the 1, 3, 6, 9, and 11 o’clock positions, #7 silk sutures are used to suture and tract the perianal skin, thereby exposing the surgical field. Oval forceps are used to grasp the rectum, gradually pulling outward to expose as much of the intestine as possible. Silk suture #7 is placed at the 1, 3, 5, 7, 9, and 11 o’clock positions along the site of the lithotomy incision to suture the top of the prolapsed intestinal tube mucosa and serve as traction lines to pull the prolapsed rectum. At the point where the intestinal mucosa protrudes 1.5-2 cm below the dentate line, a circular mark is made using an electric knife. An electric knife is used to cut along the marked line to open the mucosal layer of the prolapsed intestine, sharply dissecting upward along the submucosal layer and exposing the rectal muscle. Circular dissection is performed to determine the length of the freed rectal mucosal tube based on the degree of rectal prolapse, which usually ranges from 6 to 15 cm above the dentate line. The rectal mucosal tube is incised at the 6 and 12 o’clock positions of the lithotomy site. A vertical folding suture of the rectal circular muscle is performed using 3-0 absorbable suture material to strengthen the pelvic floor muscle function. The rectal mucosa is severed, and closure is performed using 3-0 absorbable sutures.

Transperineal rectosigmoidectomy (Altemeie’s procedure): Altemeie’s procedure is characterized by its minimal trauma, quick recovery, and low incidence of complications[26,27]. Moreover, it has a minimal impact on sexual function and can be repeated in cases of recurrence. Its main indications include full-thickness rectal prolapse, typically with a prolapse length greater than 5 cm; rectal prolapse with incarceration; older adult and frail patients who cannot tolerate abdominal surgery; middle-aged and young patients who are unwilling to undergo abdominal procedures; and young men[28-30].

Altemeie’s procedure key points: The patient is placed in the lithotomy position under either spinal or general anesthesia. Sutures are placed at the 2, 4, 8, 10, and 12 o’clock positions around the anus to provide traction, open the anal canal, and allow the rectum to protrude externally. The dentate line is exposed, and a mark is made using an electrocautery device that measured approximately 1.5-2.5 cm from the dentate line as a cutting margin. The outer layer of the rectum is incised along this mark, followed by sequential layer-by-layer incisions down to the muscular layer. Care is taken during this step to avoid damaging the inner layer of the rectum. The rectal mesentery is dissected from the bowel, and the pelvic peritoneum is opened and flipped back to reduce the prolapsed rectum. Further dissection separates the inner rectal mesentery and part of the sigmoid colon, with careful ligation of the blood vessels to prevent bleeding. The upper pelvic peritoneum is sutured to the rectum or anterior wall of the colon to reconstruct the pelvic floor. After confirming the cutting line, the bowel is transected, and the cut ends are anastomosed end-to-end using absorbable sutures. A drainage tube is placed in the rectum and removed three days later if no abnormalities are observed. The wounds are inspected for signs of significant bleeding and dressed to complete the procedure.

Perineal stapled prolapse resection procedure: Perineal stapled prolapse resection (PSPR) procedure Scherer et al[31] performed the PSPR procedure for the first time in 2008 using a stapler to excise the excessively prolapsed rectum. Currently, it is recommended for older adult and frail patients who cannot tolerate abdominal surgery and have mild intestinal edema[32]. The PSPR surgery is characterized by its simplicity, short operation time, quick postoperative recovery, and minimal complications[33,34].

PSPR procedure key points: Before surgery, bowel preparation is performed, and the patient is placed in the lithotomy position under general anesthesia. Adequate exposure is ensured, and tissue forceps are used to pull out the prolapsed intestinal segment fully, confirming that no other organs are involved between the prolapsed intestinal walls. A linear cutting stapler is used to open the prolapsed intestine at the 12 o’clock position with an incision approximately 1 cm above the dentate line. Similarly, the opposite side (6 o’clock) of the prolapsed intestine is opened to separate the prolapsed rectum, resembling a French window. The separated intestinal segments are transected approximately 1 cm below the dentate line. Absorbable sutures are used to completely suture the anastomotic sites (1, 2, 4, 5, 7, 8, 10, and 11 o’clock positions) for reinforcement and hemostasis.

Anal austerity surgery (Thiersch’s operation): Thiersch operation strengthens the tension of the external anal sphincter, which is suitable for patients where the anal sphincter lacks contraction or has become lax due to rectal prolapse[35]. It is often used as an adjunct or transitional procedure to other surgeries[36,37]. Moreover, it can be used for the treatment of anal incontinence[38].

Thiersch operation key points: The procedure is performed under epidural or spinal anesthesia with the patient in the lithotomy position. A semicircular incision is made from the 3 to 9 o’clock positions at the upper margin of the anus, approximately 1 cm above the anal margin (white line), to reach the superficial component of the external anal sphincter for hemostasis and ligation. The upper edge of the incision is gradually dissected at the level of the dentate line. Tissue forceps grasp the upper edge flap at the 6 o’clock position and push it inward to convert the semicircular incision into a longitudinal incision. Excess skin corners are trimmed, and the muscle layer, mucosa, and skin are vertically sutured in layers. The tightness of the sutures allows the anus to stretch and accommodate two fingers under anesthesia.

DISCUSSION

Complete rectal prolapse can severely affect the quality of life of patients[11]. Statistical data showed that the incidence of complete rectal prolapse in the population is 0.5%, with women being approximately six times more likely to be affected than men[4]. The etiology of complete rectal prolapse is complex, and currently accepted theories include the sliding hernia theory, rectal intussusception theory, pudendal nerve injury theory, and theories involving pelvic floor tissue laxity and anal sphincter weakness[39]. The most common symptoms of complete rectal prolapse include protrusion, mucus secretion, bleeding, increased bowel movements, and a feeling of incomplete evacuation. It is often accompanied by constipation or fecal incontinence, and severe cases may lead to acute complications such as incarceration and necrotic rectal prolapse[40]. The diagnosis of complete rectal prolapse primarily relies on objective examination, and in emergencies, the possibility of an underlying malignancy should be considered[41].

Surgery remains the primary treatment for complete rectal prolapse[42]. The ideal surgical approach should correct these abnormalities, prevent prolapse, restore normal bowel function, and address fecal incontinence while alleviating constipation[43]. Table 1 summarizes the indications, advantages, and disadvantages of different surgical approaches. The perineal approach is recommended for older adult or frail patients to avoid general anesthesia and laparotomy, whereas abdominal approaches have gained popularity in recent years owing to their lower recurrence rates[44]. However, studies comparing the Altemeier and Delorme procedures have not observed significant differences in recurrence rates or postoperative complications[45]. Another multicenter randomized controlled trial comparing four surgical methods (Delorme, Altemeier, sutured rectopexy, and resection rectopexy) did not observe significant differences in the recurrence rates or complications[46]. Studies have suggested that the recurrence rate of perineal approaches is ten times higher than that of abdominal approaches[47]. Research has observed that in female patients with complete rectal prolapse, the incidence of complications is lower with the Altemeier procedure, which can improve bowel movements in constipated patients[48]. Meta analysis suggests that treatment of rectal prolapse in male patients undergoing abdominal procedures was associated with longer operative times, lower recurrence rates, and similar complications to perineal procedures[49]. Studies have shown that compared to laparoscopic suture rectopexy, laparoscopic mesh rectopexy is associated with a lower recurrence rate of rectal prolapse but a longer operative time[50]. These findings indicate that different surgical methods have widely varying outcomes in different individuals, and the optimal surgical approach for treating complete rectal prolapse remains elusive[51,52]. Postoperative care following rectal prolapse surgery plays an important role in the patient’s perioperative recovery. Key components of postoperative care include dietary guidance, wound management, and appropriate physical activity. By providing scientific and effective guidance during the recovery period, the occurrence of complications can be minimized, and the patient’s postoperative rehabilitation can be accelerated.

Table 1 Summary of surgery for complete rectal prolapse.

Surgical types	Surgical methods	Indications for surgery	Advantages	Disadvantages	Outcomes	Complications
Transabdominal rectal suture fixation	Transabdominal rectal suture fixation	Suitable for patients with complete rectal prolapse, no major comorbidities	Simple, effective in preventing prolapse recurrence	Higher complication rate, more invasive than other techniques	High success rate, effective in preventing recurrence. Recurrence rate 23.33%	Infection, bleeding, bowel injury, prolonged recovery
Transabdominal rectal patch fixation surgery	Ventral mesh rectopexy	Indicated for patients with rectal prolapse and multiple pelvic organs prolapse	Reduced recurrence rate, good outcomes in most cases	Risk of mesh-related complications, longer recovery time	Effective for complex cases, low recurrence. Recurrence rate 4%	Mesh infection, bowel injury, bowel obstruction, recurrence
	Wells rectopexy	Indicated for patients with extensive prolapse and poor pelvic support	Good for severe prolapse, restores rectal function	High complication risk, more invasive	Effective in severe prolapse cases, high recurrence rate. Recurrence rate 6% to 12%	Infection, bleeding, bowel injury, mesh-related complications
	Ripstein rectopexy	Suitable for patients with extensive anterior rectal prolapse	Effective for anterior prolapse, durable results	Longer operation, higher complication rate	High success rate, especially for anterior prolapse. Recurrence rate 2% to 5%	Bowel injury, recurrence, constipation, prolonged recovery
Transperineal rectal fixation	Mikulicz’s procedure	Recommended for elderly or high-risk patients	Minimal surgical trauma, quick recovery	Risk of prolapse recurrence, lower long-term success	Effective in short-term, high recurrence rate	Bleeding, infection, recurrence, incontinence
	Delorme’s procedure	Suitable for elderly, frail patients with non-complex prolapse	Minimally invasive, good for elderly patients	High recurrence rate, requires careful technique	High short-term success rate, but risk of recurrence	Rectal injury, bleeding, infection, incontinence, anastomotic stenosis and dehiscence
	Altemeie’s procedure	Ideal for patients with significant rectal prolapse and bowel dysfunction	Reduces prolapse, restores function	Risk of complications, more invasive compared to other perineal approaches	Effective in long-term management, reduces recurrence. Recurrence rate 0% to 29%	Infection, bowel injury, anastomotic leak, incontinence
	PSPR procedure	Suitable for patients with moderate prolapse who are poor surgical candidates	Minimally invasive, quicker recovery, low complication rate	Higher risk of recurrence compared to abdominal procedures	Effective in treating prolapse with good short-term results. Recurrence rate 12%	Staple line breakdown, recurrence, bleeding
	Thiersch’s operation	Best for patients with recurrent prolapse who are poor surgical candidates	Simple, low-risk procedure	Higher recurrence rate, limited applicability	High recurrence rate, not as effective for complex prolapse cases	Subcutaneous infection, anal stenosis

PSPR: Perineal stapled prolapse resection.

The therapeutic outcomes of surgery for complete rectal prolapse are unsatisfactory, primarily because of high recurrence rates. According to relevant data, the recurrence rate after surgical treatment can reach 10%-20% or even higher[53]. Additionally, surgical treatment may lead to complications, such as fecal incontinence and anal stenosis, thereby affecting the quality of life. How to further improve surgical efficacy, restore normal bowel function, reduce recurrence rates, and minimize complications remains a matter of concern[54]. Many factors influence the choice of surgical approach and method for complete rectal prolapse, including subjective factors such as regional customs, the expertise of specialized physicians, and the difficulty of the surgery, as well as objective factors such as the extent of rectal prolapse, the baseline conditions of the patient, assessment of anal function, sex, recurrence rates, intraoperative and/or postoperative complications, patient acceptance, and economic considerations[55-57]. The choice of the surgical method for patients with complete rectal prolapse primarily depends on the clinical characteristics of the patient and the experience of the surgeon. Currently, relevant treatment guidelines are available to assist surgeons in selecting the most appropriate surgical approach[10]. According to the guidelines, preoperative evaluation should include an assessment of anatomical defects, causes, degree, and symptoms of prolapse; consideration of comorbidities; evaluation of anal function; and the overall condition of the patient to determine the suitability for surgery and the optimal approach and specific surgical method[58].

With continuous advancements in medical technology, surgical methods for complete rectal prolapse are evolving. Currently, surgical approaches for complete rectal prolapse mainly involve laparoscopic and robotic surgeries. Laparoscopic surgery, characterized by minimal trauma, rapid recovery, and reliable efficacy, has become one of the main methods for complete rectal prolapse surgery[5,59]. El-Dhuwaib et al[60] analyzed the epidemiological trends of rectal prolapse surgery in the United Kingdom from 2001 to 2012 and observed that the popularity of laparoscopic rectopexy increased sharply. Compared with other rectal prolapse surgeries, this procedure showed better results in terms of hospital stay, mortality, and reoperation rates[60]. Robotic surgery is a novel surgical method developed in recent years, characterized by precise operation and smaller incisions; however, it is costly and has not yet been widely adopted[61,62].

This study reviews the main surgical methods for treating complete rectal prolapse and their key operative points to provide surgeons with a reference for selecting surgical approaches. By considering the basic condition of the patient and surgical indications, selecting surgical methods that meet the needs of the patient and the expertise of the surgeon, and advocating for minimally invasive and individualized treatment, personalized treatment plans can be developed, steering clinical treatment strategies for complete rectal prolapse toward individualization and customization.

CONCLUSION

In conclusion, the choice of surgical method for complete rectal prolapse remains controversial, and treatment outcomes are still not entirely satisfactory. However, with the continuous advancement in medical technology, the direction for development of complete rectal prolapse surgery has gradually become clearer. With the continuous improvement and refinement of surgical techniques, the efficacy of complete rectal prolapse surgery will continue to improve in the near future.