Annals of Pediatric Surgery, Vol 2, No 3-4, July- October 2006, PP 165-168

Original Article

Rectal Prolapse in Children: Rectopexy through Posterior Sagittal Approach

Amin M. Saleh
Pediatric Surgery Unit, Faculty of Medicine, Zagazig University, Egypt
Background/purpose: Rectal prolapse is a well recognized problem in infants and children for which many operations with
different approaches have been described. This multiplicity indicates that the best approach is currently controversial. The
aim of this study was to evaluate the outcome of posterior sagittal rectopexy approach for rectal prolapse in children.
Patients & methods: The study was carried out on twenty patients presented with rectal prolapse. Eight children had no
history of previous intervention, while the other 12 had history of failed injection of sclerosing material (n=2) or failed
circulage (n=10). All children were subjected to clinical assessment and proctosigmoidocopy before surgery. All patients
undergone rectopexy with plication, suspension and fixation of the rectum through a posterior sagittal approach. The coccyx
was removed to facilitate rectal exposure. The patients were kept on laxative postoperatively. Children were evaluated as
regards to the clinical presentation, operative details, postoperative complications and the outcome of rectopexy. The patients
were followed for 6-18 months.
Results: Twenty patients were operated for rectal prolapse over a period of 2 years and observed for a period of 6-18 months.
All patients were treated conservatively for 4-6 months before surgery. Bleeding per rectum, pain with defecation and
incontinence were the most common symptoms that associated rectal prolapse in 18 patients. All operated children showed no
recurrence of prolapse with complete absence of pain, bleeding per rectum, and improvement of fecal continence. Wound
infection was reported in 4 patients (20%) and constipation was observed in 3 patients (15%).
Conclusion: Posterior sagittal approach with plication, suspension and fixation of the rectum in children with rectal prolapse
is an effective technique, with no recurrence of prolapse and improvement of all associated symptoms without major
morbidities.
Index Words: Rectal Prolapse , Children, posterior sagittal approach

INTRODUCTION
ectal prolapse is a herniation of the rectum
through the anus. This herniation may be
merely mucosal or involve all layers of the
rectum. Rectal prolapse in children is almost full
thickness or complete prolapse.1 In cases of prolapse,
the rectum protrudes through the anus during or after
defecation, and this may occur infrequently but in
some children it may occur with every bowel
movement. 2

Prolapse of the rectum is usually a self limited

problem in preschool children. However, if prolapse
occurred after every defecation or if it usually
requires manual reduction, surgical management is
indicated. 3
The aim of this work was to evaluate the clinical
and functional results of plication, suspension, and
fixation of the lower rectum through the posterior
sagittal approach in children with rectal prolapse.

__________________________________________________________________________________________________
Correspondence to Amin Saleh MD, Pediatric Surgery Unit, Faculty of Medicine, Zagazig University, Egypt,
aminsaleh65@yahoo.co.uk

Saleh A.

MATERIALS AND METHODS

The study was performed in the pediatric surgery
unit of Zagazig University Hospital during the period
from May 2004 to May 2006. Twenty children with
rectal prolapse were included in this study. The age of
patients at surgery ranged from 10 months to 12
years. Thirteen patients were females and 7 were
males. All children were subjected to full history
taking, complete clinical examination and procto
sigmoidoscopy before surgery.
Operative Technique
Under general anesthesia the child was placed in a
jackknife position. Skin incision was made in the natal
cleft from just above the coccyx down to but not
through the external anal muscle complex. The levator
muscles and parasagittal fibers were divided exactly
in the midline using a diathermy. (Fig 1)
The coccyx was excised to facilitate exposure of the
lower 10-15 cm of the rectum. The posterior and
lateral walls of the rectum were then dissected well
for a length of about 10-15 cm. Horizontal plication
using 3-5 Vicryl sutures were then passed in the
seromuscular coat of the rectum passing in one side
then in the back then in the opposite side of the
dilated rectum. These sutures were tied while Hegar
dilator placed in the anus to avoid excess narrowing
of the rectum. In some patients' the rectum remains
hugely dilated after initial placation, further
dissection and plication, was performed in those
patients until the caliber of the rectum becomes
accepted. (Fig.2)

Fig 1. Exposure of the rectum and coccyx through a posterior

sagittal approach.

Fig 2. Plication of the dilated rectum.

Three fixing and suspending Prolene sutures were

then passed in the back and lateral aspects of the
sacrum then passed in the seromuscular coat of the
posterior and lateral surfaces of the rectum vertically
for 1-3 cm to shorten and suspend the elongated
rectum. The levators and parasagittal muscles of both
sides were then approximated in the midline by
interrupted Vicryl sutures that passed through the
seromuscular coat of the back of the rectum to fix it.
Lastly, the skin incision was closed without drain.
(Fig. 3).
In the postoperative period laxative was given to
avoid constipation and excessive straining during
defecations. Also special wound care by frequent
dressing was made to avoid wound contamination
and infection.

Annals of Pediatric Surgery

Fig 2. Fixation of the rectum to the sacrum.

166

Saleh A.

RESULTS
Fourteen children had complete prolapse (more
than 5cm length with concentric folds), 6 children
showed partial rectal prolapse (less than 5cm length
with radial folds).
The main complaint was bleeding per rectum in
12 children, incontinence in 9 while pain at
defecations was the presenting complaint in 15
children. Ten children presented with recurrent
prolapse after circulage and 2 children gave history of
previous injection of sclerosant material. Eight
children showed persistent prolapse inspite of
medical treatment for a period varied from 4-6
months, those latter patients needed frequent manual
reduction of the prolapsed rectum after defecations.
In the post operative follow up period all operated
children showed complete cure with no recurrence of
prolapse, improvement of the bleeding per rectum,
absence of soiling and no pain at defecation.
Apart from constipation that developed in 3
patients (15%) who did not take the recommended
regimen of laxative after the operation, and wound
infection that occurred in 4 patients (20%), no other
complications were reported.

DISCUSSION
Rectal prolapse is a well recognized problem in
infant and children that produces a great distress to
both parents and children. Many operations have
been described for the treatment of rectal prolapse.
The ideal procedure for correction of rectal prolapse is
still unknown. The operations for rectal prolapse are
classified into two groups based on the anatomic
approach, either transabdominal or perineal.4
There are certain anatomic features found in most
patients with rectal prolapse These features include a
patulous or weak anal sphincter with levator
diastasis, poor posterior rectal fixation with long
rectal mesentry and dilated elongated rectum.
Whether those anatomic features are the causes or the
results of the prolapsing rectum is not known.5
Thiersch perianal suture that encircle the anus to
narrow the orifice simply hides the prolapse, but is
not correcting any of the anatomical changes that
occurs in patients with prolapse. Many surgeons
reported a high rate of recurrence after this circulage.6
Winston et al,7 reported a recurrence rate of 36% after

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single injection of sclerosing material and 16% after 3

injections.
Whitlow et al.8 stated that perineal approach for
repair of rectal prolapse have lower operative
mortality and morbidity than the abdominal
approach.
In posterior sagittal approach the plane of
dissection remain strictly in the midline so no injury
to
pelvic
sympathetic
and
Parasympathetic
innervations, and possible complications that can
occur in abdominal approaches as bladder
dysfunction, impotence, and constipation, are not
seen in any of the operated patients.
The narrowed and shortened rectum in this
procedure not only prevents recurrence of prolapse
but also allows the stretched tonic anal muscle
complex to recover its tone and improves the state of
continence.
In the follow up period that lasted for 6-18 months
no recurrence of prolapse were reported in any of the
operated 20 patients. These results goes with the
results reported by Chikara et al 1995 9 who reported
no recurrence of prolapse in any of the 14 patients
corrected by posterior plication of the rectum in their
work. All other symptoms that associated rectal
prolapse as bleeding, soiling, incontinence, and pain
during defecations had disappeared after surgery
with no recurrence of rectal prolapse.
Apart from constipation that developed in 3
patients who forgotten to take laxatives after surgery,
and wound infection that was reported in 4 patients
and improved with frequent dressing, no other
serious complications were reported as in cases of
abdominal repair or injection treatment for rectal
prolapse.

CONCLUSION
Plication, suspension, and fixation of the rectum in
children with rectal prolapse through a posterior
sagittal approach is a safe and an effective technique
The technique is associated with excellent clinical
results without major complications.

Vol 2, No 3-4, July - October 2006

Saleh A.

REFERENCES
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5. Daley BJ, Talarera F, David L, etal: Rectal prolapse.

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Annals of Pediatric Surgery

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