Perioperative management - Delorme’s procedure in rectal prolapse

• Symptomatic anterior rectoceles not amenable to nonsurgical treatment.

• Local inflammatory changes

• Basic proctological examination: Anoscopy, proctoscopy, rectoscopy
• Further specific diagnostic work-up depending on the concomitant changes

• Enema on day of surgery
• Option: Intestinal lavage (not evidence-based)

General:

• Bleeding
• Thrombosis
• Embolism etc.

Specific:

• Rectovaginal fistula
• Stenosis:
• Wound dehiscence with secondary healing

Depending on the general condition of the patient:

• General anesthesia (General anesthesia, Laryngeal mask airway anesthesia)
• Regional anesthesia (Epidural anesthesia, Caudal block)

• Lithotomy position

• The surgeon sits facing the patient in the lithotomy position, with the first assistant to his/her left. The scrub nurse stands or sits on the right side behind the surgeon.

• Not necessary
• An instrument holding arm may be helpful

Postoperative analgesia:
Nonsteroidal anti-inflammatory drugs usually suffice; if necessary, they can be enhanced by opioid analgesics.
Follow this link to PROSPECT (Procedures Specific Postoperative Pain Management)

Follow this link to the current German guideline Behandlung akuter perioperativer und posttraumatischer Schmerzen [Treatment of acute perioperative and posttraumatic pain].

Postoperative care:

During the first few days showers or warm sitz baths may be experienced as pleasant.

Deep venous thrombosis prophylaxis:

Unless contraindicated, the moderate risk of thromboembolism (surgical operating time > 30 min) calls for prophylactic physical measures and low-molecular-weight heparin, possibly adapted to weight or dispositional risk, until full ambulation is reached.

Note: Renal function, HIT II (history, platelet check)

Follow this link to the current German guideline Leitlinie Prophylaxe der venösen Thromboembolie [Guideline on prophylaxis in venous thromboembolism].

Ambulation: Unrestricted, possibly restraint in physical exercise

Physical therapy: Not necessary

Diet: Unrestricted, optionally a low-residue diet for a few days (not evidence based)

Bowel movement: Keep stool soft to avoid unnecessary pressing. Best by ingesting enough fiber regularly (e.g. psyllium husks). Rather restrained administration of 20ml lactulose, possibly Movicol, as this may often result in unplanned mushy stools or diarrhea.

Work disability: Hospital stay 2-5 days, work disability 2-3 weeks