Perineal rectosigmoidectomy (Altemeier operation) has become the perineal procedure of choice (237). Among 12 studies, performance of full thickness excision of the rectosigmoid was associated with recurrence rates from 0% to 16% and mortality rates of 0% to 5%. Patients generally have minimal pain and a relatively uneventful postoperative course. Recurrent prolapse probably reﬂects inadequate resection. Incontinence results are modest at best but seem to improve substantially with the addition of levatorplasty. The addition of levatorplasty also appears to decrease the short-term recurrence rate, but there is no significant change in constipation with this procedure (238). Most agree that perineal rectosigmoidectomy with levatorplasty is the best procedure for very elderly patients and those with profound comorbidity. This is the preferred approach for patients with incarcerated, strangulated, or even gangrenous prolapsed rectal segment who are not candidates for abdominal rectopexy. Although there is a general consensus that abdominal rectopexy is better than perineal rectosigmoidectomy, there is only one small, prospective, randomized controlled trial comparing these procedures. This study did not have the power to detect a difference in recurrence rates but found that patients undergoing abdominal resection rectopexy had less fecal incontinence and better physiological results than patients who had perineal rectosigmoidectomy (233,239).
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