Overview
Definition:
The Delorme procedure, also known as Delorme's enteroplasty or mucosal rectosigmoidectomy with primary suture, is a surgical technique used to treat full-thickness rectal prolapse
It involves invaginating the prolapsed rectum into the sacrum and excising the excess rectal mucosa, followed by plication of the muscularis propria and re-anastomosis.
Epidemiology:
Rectal prolapse affects approximately 0.01% to 4% of the general population, with a higher incidence in older women, particularly those with multiparity and chronic constipation
While rare in younger individuals, it can occur following spinal cord injury or neurological disorders
The Delorme procedure is typically considered for patients who are poor candidates for abdominal surgery or perineal procedures requiring a general anesthetic.
Clinical Significance:
Rectal prolapse can significantly impact quality of life due to symptoms such as fecal incontinence, tenesmus, bleeding, and a palpable mass
Effective surgical management is crucial to restore bowel function and prevent complications like incarceration, strangulation, and mucosal ulceration
The Delorme procedure offers a perineal approach, potentially avoiding abdominal surgery and its associated risks, making it a valuable option for select patient populations.
Indications
Absolute Indications:
Full-thickness rectal prolapse that is symptomatic and refractory to conservative management.
Relative Indications:
Patients who are poor surgical candidates for abdominal procedures
young patients who wish to avoid stomas
recurrent prolapse after other repairs
patients with significant perineal descent.
Contraindications:
Incarcerated or strangulated prolapse requiring immediate decompression
severe anal sphincter dysfunction
significant inflammatory bowel disease in the rectum
inability to tolerate local anesthesia or sedation.
Preoperative Preparation
History And Physical:
Thorough assessment of prolapse duration, symptoms (incontinence, constipation, pain), associated medical conditions, and previous surgeries
Physical examination should assess the degree of prolapse, sphincter tone, and presence of mucosal excoriation or ulceration.
Bowel Preparation:
Standard bowel preparation with oral laxatives and enemas is essential to clear the colon and reduce the risk of anastomotic leak
Antibiotic prophylaxis is recommended.
Anesthesia:
Typically performed under general anesthesia, spinal anesthesia, or regional anesthesia with sedation
The choice depends on patient comorbidities and surgeon preference.
Imaging:
While not always mandatory, defecography can assess the degree of prolapse and associated pelvic floor dysfunction
Anorectal manometry can evaluate sphincter function, which is important for prognosis.
Procedure Steps
Positioning And Exposure:
The patient is placed in the lithotomy position
The prolapsed rectum is reduced manually, and stay sutures are placed at the mucocutaneous junction to facilitate traction and exposure.
Mucosal Excision:
A circumferential incision is made at the mucocutaneous junction
The rectal mucosa and submucosa are then dissected proximally for a variable distance (typically 5-10 cm), taking care to preserve the muscularis propria.
Muscular Plication:
The exposed muscularis propria is then plicated and sutured sequentially using interrupted sutures (e.g., 2-0 or 0-0 absorbable sutures) to narrow the rectal lumen and anchor the rectum to the presacral fascia, effectively reducing the redundancy.
Anastomosis:
The trimmed mucosal edges are then re-anastomosed in a single layer using absorbable sutures, ensuring watertight closure and a smooth transition between the mucosa and perianal skin.
Postplication Reinforcement:
Some surgeons may add additional reinforcing sutures or buttress the suture line to further secure the repair and reduce recurrence risk.
Postoperative Care
Pain Management:
Adequate analgesia, typically with intravenous or oral opioids and NSAIDs, is crucial
Local anesthetic infiltration at the anastomosis can provide prolonged pain relief.
Bowel Management:
Early mobilization is encouraged
A clear liquid diet is initiated and advanced as tolerated
Stool softeners (e.g., docusate sodium) and laxatives (e.g., polyethylene glycol) are used to prevent straining and facilitate regular bowel movements.
Wound Care:
Perianal hygiene is emphasized
Sitz baths may be recommended
The anastomosis should be monitored for signs of infection or dehiscence.
Monitoring:
Patients are monitored for signs of infection, bleeding, anastomotic leak, urinary retention, and recurrence of prolapse
Follow-up appointments are scheduled to assess healing and functional outcomes.
Complications
Early Complications:
Bleeding from the anastomosis or suture lines
infection of the perineal wound or at the anastomosis
urinary retention
anastomotic leak or dehiscence
fecal impaction
pain
recurrent prolapse.
Late Complications:
Anastomotic stricture formation
chronic pain
persistent fecal incontinence or constipation
recurrence of prolapse
sexual dysfunction in men.
Prevention Strategies:
Meticulous surgical technique, adequate bowel preparation, appropriate antibiotic prophylaxis, careful handling of tissues, watertight anastomosis, and judicious use of stool softeners postoperatively
Careful patient selection is key.
Prognosis
Factors Affecting Prognosis:
The success of the Delorme procedure is influenced by the surgeon's experience, the degree of prolapse, the integrity of the anal sphincter, and the presence of associated conditions like constipation or neurological deficits.
Outcomes:
The Delorme procedure generally offers good functional outcomes with low recurrence rates, especially when performed in carefully selected patients
Significant improvement in prolapse symptoms and fecal continence is often observed.
Follow Up:
Long-term follow-up is recommended, typically including clinical assessment at 1, 3, 6, and 12 months post-surgery, and then annually thereafter
This allows for early detection of recurrence or complications and optimization of bowel function.
Key Points
Exam Focus:
Understand the indications, contraindications, and surgical steps of the Delorme procedure
Differentiate it from other rectal prolapse repairs (e.g., Altemeier, Ripstein, ventral rectopexy)
Be prepared to discuss potential complications and their management for DNB and NEET SS exams.
Clinical Pearls:
The Delorme procedure is a perineal repair that avoids abdominal surgery and stomas, making it ideal for high-risk patients
Careful plication of the muscularis propria is crucial for long-term success
Preserving the submucosa during dissection minimizes the risk of bleeding.
Common Mistakes:
Inadequate mobilization of the mucosa
insufficient plication of the muscularis propria leading to recurrence
too narrow an anastomosis causing stricture
poor distinction between mucosa and submucosa during dissection.