Overview
Definition:
The Altemeier procedure is a surgical technique performed via a perineal approach for the repair of complete rectal prolapse
It involves the resection of the prolapsed rectosigmoid, followed by an anastomosis between the remaining colon and the anal canal.
Epidemiology:
Complete rectal prolapse is more common in women, particularly multiparous women, with an incidence increasing with age
While not extremely common, it significantly impacts quality of life
The Altemeier procedure is one of several options for surgical management.
Clinical Significance:
Effective surgical management of rectal prolapse is crucial to alleviate symptoms such as rectal bleeding, mucus discharge, fecal incontinence, and the sensation of incomplete defecation
The Altemeier procedure offers a perineal option that may be preferred in select patient populations, particularly the elderly or those with comorbidities contraindicating abdominal surgery.
Indications
Primary Indications:
Complete rectal prolapse
Symptoms significantly impacting quality of life, including bleeding, mucus discharge, fecal incontinence, or difficulty with defecation due to the prolapse itself.
Patient Selection:
Especially favored in elderly patients or those with significant comorbidities that increase the risk of abdominal surgery
Also considered in patients with a very redundant colon or those who have failed previous abdominal rectopexy procedures.
Contraindications:
Absolute contraindications include unresectable malignancy of the rectum or sigmoid colon
Relative contraindications may include severe anal sphincter dysfunction not amenable to repair or significant inflammatory bowel disease that could compromise healing.
Preoperative Preparation
Patient Assessment:
Thorough evaluation of symptoms, duration, and impact on daily life
Assessment of anal sphincter tone and perineal anatomy
Evaluation of comorbidities, cardiac and pulmonary status.
Bowel Preparation:
Mechanical bowel preparation with clear liquids and laxatives is typically performed the day before surgery
Antibiotic prophylaxis, usually a broad-spectrum regimen covering gram-negative organisms and anaerobes, is administered intravenously.
Anesthesia Considerations:
Can be performed under general, spinal, or epidural anesthesia
The choice depends on patient factors, surgeon preference, and the planned extent of resection.
Procedure Steps
Exposure And Mobilization:
The patient is positioned in the lithotomy position
A circum-anal incision is made around the prolapsed rectum
The prolapsed segment is then mobilized by blunt and sharp dissection, with care taken to preserve the mesorectal vascular supply and avoid injury to adjacent structures like the vagina or prostate.
Rectosigmoid Resection:
Once adequately mobilized, the rectosigmoid segment is resected
The length of resection is determined by the extent of prolapse and redundancy
Stapled or hand-sewn anastomosis is then performed between the healthy sigmoid colon and the anal mucosa, aiming for a tension-free repair.
Anastomosis And Closure:
The bowel ends are carefully approximated and secured
Hemostasis is ensured
The perineal wound is typically closed in layers, or a drain may be placed if there is concern for pelvic hematoma or infection
A temporary diverting colostomy is rarely performed for this procedure.
Postoperative Care
Pain Management:
Adequate analgesia is crucial, often involving patient-controlled analgesia (PCA) or epidural pain relief
Sitz baths may be initiated once the initial wound pain subsides.
Dietary Advancements:
Patients are typically kept NPO initially and advanced to a clear liquid diet as tolerated
Gradual progression to a low-residue diet, followed by a regular diet, is guided by bowel function and wound healing.
Monitoring And Mobilization:
Close monitoring for signs of infection, bleeding, or anastomotic leak
Early mobilization is encouraged to prevent deep vein thrombosis and pneumonia
Regular assessment of bowel movements and wound status.
Complications
Early Complications:
Hemorrhage from the staple line or dissected planes
Wound infection or dehiscence
Rectal or anal canal stricture
Pelvic abscess or hematoma
Urinary retention
Transient fecal incontinence.
Late Complications:
Recurrence of rectal prolapse, although less common after the Altemeier procedure compared to some other techniques
Chronic perineal pain
Persistent fecal incontinence or urgency
Anastomotic stricture requiring dilation.
Prevention Strategies:
Meticulous surgical technique to avoid devascularization or injury
Adequate bowel preparation and antibiotic prophylaxis
Careful attention to hemostasis
Appropriate wound care
Patient education regarding diet and bowel habits post-operatively.
Prognosis
Factors Affecting Prognosis:
Patient's overall health status and comorbidities
Success of the anastomosis and absence of complications
Skill of the surgeon
Degree of preoperative anal sphincter dysfunction.
Outcomes:
The Altemeier procedure generally offers good symptomatic relief for rectal prolapse, with high success rates in reducing prolapse symptoms
Functional outcomes regarding continence can vary, and some degree of temporary or persistent incontinence may occur.
Follow Up:
Regular follow-up appointments are scheduled postoperatively, typically at 2 weeks, 1 month, 3 months, and 6 months, and then annually as needed
This allows for monitoring of wound healing, bowel function, and early detection of any recurrent prolapse or complications.
Key Points
Exam Focus:
Indications for Altemeier vs
abdominal rectopexy
Key steps of the perineal resection and anastomosis
Common complications and their management
Patient selection criteria, especially for elderly/debilitated patients.
Clinical Pearls:
Preserve the mesorectal vascular pedicle during mobilization to ensure adequate blood supply to the remaining bowel
Aim for a tension-free, well-approximated anastomosis
Recognize that some degree of fecal soiling or mild incontinence is not uncommon postoperatively and may improve with time.
Common Mistakes:
Inadequate mobilization leading to tension at the anastomosis
Excessive resection of the bowel, potentially causing afferent loop syndrome or ischemia
Failure to recognize or manage early signs of anastomotic leak or infection
Overlooking significant preoperative anal sphincter dysfunction which may not be fully corrected by prolapse repair alone.