Preprocedural Planning
A thorough history and a careful physical examination are essential, with special emphasis on cardiopulmonary status so as to optimize the patient's ability to tolerate surgical stress. Pelvic floor dysfunction should be studied with anal sphincter function testing and defecography. If colon dysmotility is suspected, a sitz marker or equivalent nuclear imaging study should be obtained.
The diagnosis of rectal prolapse is made through physical examination. Patients are usually able to force the prolapse out. The authors often have them push out the prolapse while on a commode and then confirm the diagnosis. Video or magnetic resonance defecography may be necessary to confirm the diagnosis. All patients should then undergo colonoscopy to rule out any occult pathology.
For patients with constipation, colonic transit studies (sitz markers or nuclear scan) should be performed to check for colonic inertia. For patients with fecal incontinence and obstructed defecation, anal manometry and endoanal ultrasonography (EAUS) can provide documentation of their preoperative physiologic status. Patients should receive counseling about the risks and complications of the surgical procedure.
Patient Preparation
Mechanical bowel preparation with a Nichols prep (oral antibiotics) is required. This is started on the day before the operation to clear the bowel of fecal material and decrease the bacterial load in the colon. The authors also perform rectal irrigation in the operating room. All oral intake is stopped the night before the procedure, and only essential medications are allowed on the morning of the operation with a sip of water. A standard enhanced recovery pathway should be followed. [16]
Preoperative intravenous (IV) antibiotics, which cover gram-negative and anaerobic organisms, are given within 1 hour of the incision time. Preoperative prophylaxis for deep vein thrombosis is imperative.
Anesthesia
After the patient is induced under general anesthesia, a muscle relaxant is administered, and an endotracheal tube is placed.
Positioning
A Foley catheter is inserted into the bladder for accurate measurement of urine output during the procedure and for decompression of the bladder. The authors remove the Foley catheter 24 hours after surgery. An orogastric tube is placed to decompress the stomach during the operation.
The patient is placed in a lithotomy Trendelenburg (modified Lloyd-Davis) position, with both arms tucked. The legs are placed on stirrups with adequate soft padding to prevent pressure sores on the skin and pressure-related nerve injury to the common peroneal nerves. Antiembolic stockings or compression devices are applied to the legs.
The entire abdomen is prepared with chlorhexidine antiseptic solution. Sterile draping is applied, ensuring adequate exposure of the abdomen and perineum.
For laparoscopic procedures, the operating surgeon and assistant stand on the patient's right side after the ports are placed. The cords should be run off the left side to allow free range of motion. The scrub nurse or technician is at the foot of the bed.
