Emergency management of incarcerated rectal prolapse: combined Altemeier and Thiersch procedures in a surgical emergency

Abstract

Incarcerated complete rectal prolapse is an uncommon but potentially life-threatening colorectal emergency because delayed treatment may lead to vascular compromise, bowel gangrene, and perforation. Surgical management depends on the patient’s physiological status, bowel viability, and anal sphincter function. A 59-year-old man presented with abdominal pain, recurrent vomiting, abdominal distension, constipation, and a protruding rectal mass. He had type 2 diabetes mellitus and hypertension and appeared cachectic. Examination revealed gross abdominal distension, absent bowel sounds, and bilious aspirate following Ryle’s tube insertion. Per rectal examination demonstrated a 15 cm irreducible prolapsed rectum that was edematous, congested, and non-reducible. Concentric mucosal folds confirmed incarcerated procidentia with impending ischemia. Emergency perineal proctosigmoidectomy (Altemeier procedure) under regional anesthesia was performed, followed by hand-sewn coloanal anastomosis. Because of marked anal sphincter laxity, a Thiersch repair using polypropylene encirclement suture was added. The postoperative course was uneventful, with early return of bowel function and no evidence of anastomotic leak, wound complication, or early recurrence. The patient was discharged on postoperative day 3. In emergency incarcerated rectal prolapse, a combined perineal approach using Altemeier resection with Thiersch reinforcement can provide safe and effective treatment, particularly in patients with redundant bowel and significant anal sphincter weakness.