Classification and mechanisms of development
Surgical practice distinguishes four main types of the pathology:
- Isolated prolapse of the anus.
- Isolated rectal prolapse.
- Combined prolapse of the rectum and anus.
- Prolapse of an invaginated large intestine.
The pathogenesis of the disease is complex. Three factors play a leading role: relaxation of the external sphincter fibers, pronounced weakness of the levator ani muscle (m. levator ani), and loss of the normal anchoring apparatus of the rectum in the pelvic cavity.
Transperitoneal fixation (Zerenin — Kümmell — Herzen operation)
The intervention is a posterior rectocolopexy—suturing the bowel wall to the sacrum.
- Preparation: A lower midline laparotomy is performed. The patient is in the Trendelenburg position. The small intestine is retracted upward, and the large intestine to the left.
- Sacral Approach: The peritoneum is incised to the right of the sacral promontory (promontorium) down to the level of the 3rd sacral vertebra. The anterior surface of the sacrum is exposed.
- Fixation: Four sturdy silk sutures are placed into the anterior longitudinal ligament of the spine (mandatory inclusion of the periosteum). The rectum is pulled upward, after which the ends of these same ligatures are used to stitch its posterolateral wall, capturing the edge of the mesenteric peritoneum.
- Completion: Knots are tied from bottom to top, ensuring tension on the bowel. The right edge of the free peritoneal flap is sutured to the anterolateral surface of the fixed organ. A thick rubber tube is inserted through the anus so that its upper end lies above the sacral promontory (the tube is removed on days 2–3). The abdominal cavity is closed tightly.
Plastic reinforcement of the pelvic floor (Braitsev)
The goal of the surgery is anterior plasty and restoration of pelvic floor muscle tone.
- Access: An arcuate incision is made anterior to the anus, connecting both ischial tuberosities.
- Procedure: Tissues are dissected layer by layer to the posterior edge of the urogenital diaphragm. The surgeon penetrates to a depth of 4–7 cm. Here, the external sphincter is pulled posteriorly, and the anterior wall of the rectum anteriorly.
- Reinforcement: The medial edges of the m. levator ani are isolated. Four catgut sutures are placed on them and on the muscular layer of the rectum. After tying the ligatures, the wound is closed layer by layer.
Narrowing of the anal opening (Thiersch — Payr)
The technique aims to create an artificial ring around the anal canal.
- Graft Harvesting: A strip of the iliotibial tract (tractus iliotibialis) is excised from the middle third of the thigh. Required dimensions: length 8–10 cm, width 2–3 cm.
- Ring Formation: Two longitudinal skin incisions, each 1 cm long, are made anterior and posterior to the anus. Using a curved clamp, a subcutaneous tunnel is created around the bowel.
- Fixation: The aponeurotic strip is twisted into a cord, passed through the created tunnel, tied in a knot, and additionally sutured with a silk thread.
- Criterion for Correct Tension: The formed fascial ring must snugly fit the surgeon's finger inserted into the bowel lumen. Skin wounds are closed with silk.
Final stage of perineal operations
Upon completion of interventions on the rectum, the mucocutaneous margin is meticulously sutured to the bottom of the wound. The suture area is treated with a 1% iodine solution. In the early postoperative period, a flatus tube is placed in the bowel lumen and a tampon generously impregnated with Vishnevsky ointment is inserted.
Briefly: answers to topical questions
Which layers of the anterior abdominal wall are sequentially dissected during a lower midline laparotomy?
During a lower midline laparotomy, the following layers of the anterior abdominal wall are traversed sequentially:
- Skin
- Subcutaneous adipose tissue
- Linea alba (linea alba)
- Edges of the rectus abdominis muscles are retracted
- Transversalis fascia
- Preperitoneal adipose tissue along with the peritoneal transition fold is bluntly displaced upward.
Which arteries supply the rectum and must be accounted for during its mobilization in the lesser pelvis?
The blood supply to the rectum is provided by three arteries, whose topography must be considered during surgeries:
- Superior rectal artery (a. rectalis superior) — the terminal branch of the inferior mesenteric artery, running toward the ampulla of the rectum.
- Middle rectal arteries (aa. rectales mediae) — located on the pelvic diaphragm.
- Inferior rectal arteries (aa. rectales inferiores) — pass through the ischioanal fossa (fossa ischiorectalis) in the frontal plane.
The superior rectal artery forms anastomoses with the middle rectal and left colic (sigmoid) arteries.
Which muscles and fasciae form the urogenital diaphragm, reaching its posterior edge during the Braitsev approach?
The urogenital diaphragm is formed by the following muscular and fascial layers (from superficial to deep):
- Superficial muscle layer
- Inferior fascia of the urogenital diaphragm (fascia diaphragmatis urogenitalis inferior / membrana perinei)
- Deep transverse perineal muscle (m. transversus perinei profundus)—forms the basis of the diaphragm, its fibers encompassing the membranous part of the urethra.
- Superior fascia of the urogenital diaphragm (fascia diaphragmatis urogenitalis superior), which is part of the pelvic fascia.
The superior and inferior fasciae fuse at the anterior and posterior edges of the deep transverse muscle, forming a closed space.
To memorize the combined tactics, use the "Three Levels" rule: Upper level — sacral fixation (Zerenin), Middle level — levator approximation (Braitsev), Lower level — sphincter narrowing with fascia (Thiersch — Payr).
Class and exam questions
What anatomical prerequisites lead to rectal prolapse?
The pathology develops due to relaxation of the external sphincter, weakness of the levator ani muscle (m. levator ani), and loss of normal bowel fixation in the lesser pelvis.
To which structure is the bowel fixed during the Zереnin — Kümmell — Herzen operation?
The rectum is sutured to the anterior longitudinal ligament of the spine with mandatory capture of the periosteum at the level of the sacrum and promontory.
How is the correct tension of the fascia determined during the Thiersch — Pyrah operation?
The formed aponeurotic ring must snugly fit the surgeon's finger previously inserted into the rectal lumen.
Where is the plastic material harvested to narrow the anal opening?
An aponeurotic strip from the iliotibial tract (tractus iliotibialis) is used, harvested from the middle third of the thigh.
What else to study on this topic
- Topographic anatomy of the sacral promontory (promontorium) and sacral spine.
- Structure, functions, and fascial sheaths of the levator ani muscle (m. levator ani).
- Anatomy of the fascia lata and the iliotibial tract (tractus iliotibialis).
- Peculiarities of rectal blood supply and risks during its mobilization.
- Postoperative management and prevention of perineal infectious complications.
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