Which operation is most effective for complete rectal prolapse?

Rectal prolapse affects about 2.5 per 100 000 people each year in the United Kingdom.1 It is more common in women.2 Risk factors include multiple deliveries, straining, anorexia, traumatic vaginal delivery, and old age.3 Protrusion of the rectum through the anal canal can be distressing for the patient, causing discomfort and embarrassment. Complications include bleeding, constipation, incontinence, rectal ulcers, and, rarely, rectal ischaemia, which is an emergency.

Complete (full thickness) rectal prolapse involves protrusion containing all the layers of the rectal wall through the anus (fig 1). A mucosal prolapse occurs when mucosa alone protrudes through the anus. Internal intussusception is a prolapse of the rectum into the distal rectum or anal canal but without protrusion outside the anus.

Surgery is the definitive treatment and can provide complete resolution of full thickness rectal prolapse.4 Some patients, however, experience recurrence and complications such as constipation and faecal incontinence and may require further surgery.3 A minority of patients prefer symptom control, or are unfit for surgery, and are treated with laxatives and manual reduction.

In this article we focus on surgical management of full thickness rectal prolapse. There are a range of surgical techniques available (box 1),23 but there is no consensus on which is the most effective.5 Traditionally, the open abdominal procedure was reserved for younger, fitter patients, …