Rectal Prolapse, Perineal Repair (Perineal Rectosigmoidectomy: Altemeier Procedure)

Murat Cakir, MD, Mustafa Senturk, MD

Video Summary

Different surgical procedures have been described to correct rectal prolapse. One of these is the Altemeier procedure.1 The Altemeier procedure is mostly preferred in elderly patients with limited life expectancy and in patients with severe comorbidity who cannot tolerate general anesthesia or major abdominal surgery. We preferred general anesthesia because our patient’s general performance was good. Our patient is a 70-year-old woman. She applied to our clinic with concerns of bloody stool, rectal pain, and rectal prolapse for 2 years. The Altemeier procedure was applied with the diagnosis of rectal prolapse. Oral intake was started immediately after the surgery. The patient was discharged 2 days later. We recommended that she consume fiber-rich foods and plenty of fluids in the postoperative period. The patient has been followed for 1 year without any complications. This video shows the perineal rectosigmoidectomy applied to the patient with advanced age comorbidity.


Teaching Points

Patient Preparation

  • Colonoscopy or sigmoidoscopic examination are essential.
  • Use of a low-residue diet, cathartics, and enemas is necessary to obtain a clean and empty large bowel.
  • Preoperative intravenous antibiotic is necessary.

Anesthesia Options

  • General or spinal anesthesia is satisfactory; however, general is usually preferred.

Patient Position

  • The patient is placed in a lithotomy position.

Critical Steps

  • Incision of rectal wall.
  • Division of vessel adjacent to bowel wall.
  • Mesenteric vessels ligated. Stay sutures previously placed in distal edge of outer cylinder are placed in cut edge of inner cylinder.
  • Anastomosis of distal aspect of remaining colon to the short rectal stump.

Technical Pearls/Tips

  • Identification of the pectinate line is important, because the incision through the presenting rectal mucosa will be made 3 mm proximal to this anatomic landmark.
  • The resection may be started in the midline anteriorly, and the peritoneum is gently opened, and the pouch of Douglas is explored with the examining finger.
  • The incision through the outer sleeve should divide the full thickness of the bowel wall, including the mucosa as well as the muscularis.
  • The bowel has been divided without tension.
  • Sufficient intestines are removed to prevent recurrence.

Potential Areas for Injury/Complication

  • Infection, most notably perirectal abscess.
  • Bleeding, primarily from the sacral venous plexus, but also potentially from the mesenteric vascular supply divided as part of the procedure.
  • Anastomotic dehiscence.
  • Recurrence of rectal prolapse.
  • Loss of or failure to regain fecal continence.

Postoperative Course

  • The patient was discharged 2 days later.
  • Oral intake was started immediately after the surgery.
  • It was recommended to consume fiber-rich foods and plenty of fluids in the postoperative period.
Last updated: December 6, 2022