Video Summary

This video demonstrates a perineal proctosigmoidectomy with levatorplasty, the Altemeier procedure, for the management of rectal prolapse.

Video

Teaching Points

Patient Preparation

1. Cardiac clearance as needed (given patient population generally undergoing this procedure)
2. Preoperative bowel preparation per institutional protocol

Patient Positioning

1. Lithotomy
2. Arms tucked and padded
3. Adequately secured (straps, tape, etc) for Trendelenburg positioning

Critical Steps

1. Full exteriorization of prolapsing tissue
2. Circumferential scoring of mucosa with electrocautery 1 to 2 cm proximal to dentate line
3. Full-thickness proctotomy on anterior surface of rectum on premarked line
4. Circumferential proctotomy/rectal wall division on premarked line
5. Grasp distal rectum and evert/reduce prolapse
6. Sharp division of anterior peritoneal reflection
7. Reduction of any additional prolapsing colon
8. Division of mesentery flush with future colonic division site
9. Posterior levatorplasty
10. Full-thickness anterior colotomy with placement of coloanal Vicryl suture
11. Systematic circumferential colonic division with interrupted sutures placement in cardinal positions
12. Fill in remaining “gaps” with interrupted suture to complete coloanal anastomosis

Technical Pearls

1. Use lone-star retractor for optimal visualization
2. Scoring the rectal mucosa with electrocautery ensures even, circumferential rectal division
3. A Hill–Ferguson retractor can be used to improve visualization for full-thickness coloanal anastomosis

Potential Areas for Injury or Complications

1. Take care to not injure underlying rectosigmoid colon when making first full-thickness proctotomy
2. Ensure colonoic mesentery division is flush with colonic division to ensure adequate perfusion of the colonic conduit
3. Systematic division and suturing of coloanal anastomosis prevents retraction of entire colon into the abdominal cavity