New Indications for STARR
One of the most difficult management problem is patients with symptomatic colopouch or ileoanal pouch internal prolapse. Traditional management has comprised biofeedback reserving pouch advancement in well motivated patients who have failed to respond. The prolapse allways occurs anteriorly! We have used STARR technology in these patients to very good effect; W ileoanal pouches have been considered a contraindication.
- Persistent neo-rectal or vaginal symptoms – pain, urgency, bleeding, mucus, soiling
- Incomplete, prolonged, difficult evacuation
As in PPH and standard STARR we always use antibiotics, general anaesthesia (full paralysis) and lithotomy using hydraulic boots (allows you to check vagina and sphincters and the small bowel to fall away). We always give our patients a phosphate enema 30 minutes before surgery. Not only does this purge the left colon but it allows the surgeon to view the prolpase at its worst!
Gently dilate the anal canal and insert the CAD obturator; fix as normal. Observe the prolapsing colopouch.
Place a series of full thickness sutures (2/0 vicryl) at 10, 12 and 2 o'clock at the apex of the intussusception. Start with a loose suture, or us a Babcock retractor, at the 12 o,clock position to pull down the intussusception (see below). Some digital pressure on the back wall of the vagina will help. Tie the two 10 o'clock and one of the 12 o'clock threads together (rpt with the 2 o'clock ties).
Introduce a 10mm Davis Brain Spatula (Codman & Shurtleff, ref., 075308) through the posterior opening of the CAD to prevent stapling of the posterior wall. A cheap alternative is a wooden tongue depressor.
Pull the ends of the threads caudally and insert the opened PPH03 circular stapler so that its head is positioned above the prolapse. Finally pull out the ends of the threads through the lateral hole of the stapler. Slowly close the stapler and gently pull on the purse strings pushing the stapler into the rectum. Ensure that the stapler casing is above the levators and that the vagina is freely mobile. Close completely and fire. Remove the stapler.
Check the staple line for haemostasis.
Remove the CAD. Infiltrate around the sphincter and pudendal nerve with local anaesthetic. Prescribe oral morphine for take home analgesia.