Perineal Proctosigmoidectomy with Levatorplasty (Altemeier) Procedure for the Management of Rectal Prolapse
Video Summary
This video demonstrates a perineal proctosigmoidectomy with levatorplasty, the Altemeier procedure, for the management of rectal prolapse.
Video
Teaching Points
Patient Preparation
- Cardiac clearance as needed (given patient population generally undergoing this procedure)
- Preoperative bowel preparation per institutional protocol
Patient Positioning
- Lithotomy
- Arms tucked and padded
- Adequately secured (straps, tape, etc) for Trendelenburg positioning
Critical Steps
- Full exteriorization of prolapsing tissue
- Circumferential scoring of mucosa with electrocautery 1 to 2 cm proximal to dentate line
- Full-thickness proctotomy on anterior surface of rectum on premarked line
- Circumferential proctotomy/rectal wall division on premarked line
- Grasp distal rectum and evert/reduce prolapse
- Sharp division of anterior peritoneal reflection
- Reduction of any additional prolapsing colon
- Division of mesentery flush with future colonic division site
- Posterior levatorplasty
- Full-thickness anterior colotomy with placement of coloanal Vicryl suture
- Systematic circumferential colonic division with interrupted sutures placement in cardinal positions
- Fill in remaining “gaps” with interrupted suture to complete coloanal anastomosis
Technical Pearls
- Use lone-star retractor for optimal visualization
- Scoring the rectal mucosa with electrocautery ensures even, circumferential rectal division
- A Hill–Ferguson retractor can be used to improve visualization for full-thickness coloanal anastomosis
Potential Areas for Injury or Complications
- Take care to not injure underlying rectosigmoid colon when making first full-thickness proctotomy
- Ensure colonoic mesentery division is flush with colonic division to ensure adequate perfusion of the colonic conduit
- Systematic division and suturing of coloanal anastomosis prevents retraction of entire colon into the abdominal cavity
Last updated: December 6, 2022
Citation
Wright, Jesse P, et al. "Perineal Proctosigmoidectomy With Levatorplasty (Altemeier) Procedure for the Management of Rectal Prolapse." ASCRS Toolkit - FREE Resources, 2022. ASCRS U, www.ascrsu.com/ascrs/view/ASCRS-Toolkit/2851080/all/Perineal_Proctosigmoidectomy_with_Levatorplasty__Altemeier__Procedure_for_the_Management_of_Rectal_Prolapse.
Wright JP, Brady JT, Albert MR. Perineal Proctosigmoidectomy with Levatorplasty (Altemeier) Procedure for the Management of Rectal Prolapse. ASCRS Toolkit - FREE Resources. 2022. https://www.ascrsu.com/ascrs/view/ASCRS-Toolkit/2851080/all/Perineal_Proctosigmoidectomy_with_Levatorplasty__Altemeier__Procedure_for_the_Management_of_Rectal_Prolapse. Accessed December 9, 2023.
Wright, J. P., Brady, J. T., & Albert, M. R. (2022). Perineal Proctosigmoidectomy with Levatorplasty (Altemeier) Procedure for the Management of Rectal Prolapse. In ASCRS Toolkit - FREE Resources https://www.ascrsu.com/ascrs/view/ASCRS-Toolkit/2851080/all/Perineal_Proctosigmoidectomy_with_Levatorplasty__Altemeier__Procedure_for_the_Management_of_Rectal_Prolapse
Wright JP, Brady JT, Albert MR. Perineal Proctosigmoidectomy With Levatorplasty (Altemeier) Procedure for the Management of Rectal Prolapse [Internet]. In: ASCRS Toolkit - FREE Resources. ; 2022. [cited 2023 December 09]. Available from: https://www.ascrsu.com/ascrs/view/ASCRS-Toolkit/2851080/all/Perineal_Proctosigmoidectomy_with_Levatorplasty__Altemeier__Procedure_for_the_Management_of_Rectal_Prolapse.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC
T1 - Perineal Proctosigmoidectomy with Levatorplasty (Altemeier) Procedure for the Management of Rectal Prolapse
ID - 2851080
A1 - Wright,Jesse,MD
AU - Brady,Justin,MD
AU - Albert,Matthew,MD
Y1 - 2022/12/06/
BT - ASCRS Toolkit - FREE Resources
UR - https://www.ascrsu.com/ascrs/view/ASCRS-Toolkit/2851080/all/Perineal_Proctosigmoidectomy_with_Levatorplasty__Altemeier__Procedure_for_the_Management_of_Rectal_Prolapse
DB - ASCRS U
DP - Unbound Medicine
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