Video Summary

This is a video showing the critical steps in an Altemeier procedure for an elderly patient with rectal prolapse. Featured in the foreword of the video is unique footage of Dr Altemeier performing this procedure during his time at the University of Cincinnati in the 1970s.

Video

Teaching Points

Patient Preparation:

The day before surgery, the patient has a full mechanical bowel preparation.

Patient Position:

The patient is positioned in a prone jackknife position.

Critical Steps:

1) Circumferential incision through all layers of the rectal wall ≈1 cm proximal to the dentate line,

2) mobilization of the extraperitoneal redundant rectum,

3) opening of the peritoneum,

4) additional mobilization of the redundant rectum and sigmoid colon with careful division of the mesentery,

5) levator muscle plication, and

6) resection and coloanal anastomosis.

Technical Pearls:

The full redundant portion of the rectum and possibly sigmoid colon should be mobilized and resected to decrease the likelihood of recurrent rectal prolapse. When dividing the mesentery, it is important to preserve the blood supply to the colon conduit. One of the main challenges in this procedure comes from deciding how much bowel to resect. First, if the anterior peritoneal reflection is not located and opened, the full redundant segment will likely not be removed. Once the peritoneal reflection is opened, the surgeon carefully delivers the redundant segment out while sequentially dividing mesentery, thereby maintaining blood supply to the colon conduit. The surgeon should palpate with their index finger to feel whether there are any adhesive bands to the sigmoid mesentery causing additional redundancy. When the resected segment is straight and no longer redundant, the transection is done as shown in the video, taking care to do so in a tension-free manner.

Potential Areas for Injury/Complication:

The main potential for complication comes from failure to preserve an adequate blood supply to the colon conduit before anastomosis.