Altemeier's Procedure (Rectosigmoidectomy)

General remarks

• Rectal prolapse is associated with feacal incontinence in about 50-70%
• Mucosal prolapse should be distinguished from a rectal prolapse. A careful examination during straining should be performed
• The aim of the treatment is to control the prolapse and to restore continence
• Rectopexy is the treatment of choice for rectal prolapse. Those abdominal repairs involve fixing the rectum to the sacrum by using either mesh or sutures, and tend to have the lowest recurrence rates (<10%)
• Perineal surgical repairs are well tolerated, but are generally associated with higher recurrence rates
• The Altemeier procedure can be considered for elderly patients who are most likely unfit for a major abdominal procedure (e.g. rectopexy)
• The perineal approach for an Altemeier's procedure also creates the possibility to repair the pelvic floor muscles when necessary
• Recurrence rates for the Altemeier's procedure vary from 3 to 43%

Step by step

1. Place patient in lithotomy position (or in prone jack-knife position)
2. Prolapse should be delivered on to the perineum
3. The mucosa is divided transversely at the dentate line
4. While dividing the muscle layer, the submucosal vessels should be carefully cauterized
5. The rectum is then withdrawn to expose the rectovaginal peritoneal pouch
6. The peritoneum should be opened anteriorly and lateraly and the sigmoid colon can now be exposed
7. Posterior transection of the rectum can be completed
8. Mesorectum is divided and ligated
9. Sigmoid colon is pulled down and the transection site can be determined
10. Sigmoid mesentery is divided and ligated
11. The anterior aspect of the sigmoid colon is opened
12. Now the first (i.e. anterior) anastomotic suture can be placed
13. The lateral aspect of the sigmoid colon is opened and the lateral anastomotic sutures can be placed
14. Transection of the sigmoid colon can then be completed
15. The coloanal anastomosis can now be completed with a total of about eight sutures

References

Let us shorten antibiotic prophylaxis and therapy in surgery. Wittmann DH, Schein M. Am J Surg. 1996 Dec;172(6A):26S-32S. Optimum duration of prophylactic antibiotics in acute non-perforated appendicitis.Mui LM, Ng CS, Wong SK, Lam YH, Fung TM, Fok KL, Chung SS, Ng EK. ANZ J Surg. 2005 Jun;75(6):425-8 Minimum postoperative antibiotic duration in advanced appendicitis in children: a review.Snelling CM, Poenaru D, Drover JW. Pediatr Surg Int. 2004 Dec;20(11-12):838-45. Antibiotics versus placebo for prevention of postoperative infection after appendicectomy. Andersen BR, Kallehave FL, Andersen HK. Cochrane Database Syst Rev. 2005 Jul 20;(3):CD001439. Review Gangrenous and perforated appendicitis: a meta-analytic study of 2532 patients indicates that the incision should be closed primarily. Rucinski J, Fabian T, Panagopoulos G, Schein M, Wise L. Surgery. 2000 Feb;127(2):136-41. Safety and efficacy of antibiotics compared with appendicectomy for treatment of uncomplicated acute appendicitis: meta-analysis of randomised controlled trials. Varadhan KK, Neal KR, Lobo DN. BMJ. 2012 Apr 5;344