This method is very successful in the treatment of complete prolapse of the first degree during the early stages, before there is great thickening of the tissue in the prolapse itself, and a weakening of the sphincter muscle. The operation is almost always successful in children and in many adults, when applied to the first degree of complete or an incomplete prolapse. In my experience the best method in the application of the clamp and cattery operation is to push the prolapse back into its proper place, and after having determined the amount of tissue necessary to cure the prolapse, remove three or four strips of mucous membrane from various portions of the circumference within the clamp.

Duet’s Operation, or Historiography, is similar to that for prolapses vagina. The mucosa is dissected out in the form of elliptical flaps extending from the summit to the base, leaving two lateral pillars. The muscular walls are then folded in by buried silk or catgut sutures and the edges of the mucous membrane are brought together by superficial sutures. Durer removes triangular flaps of skin from the margin of the anus and sutures the edges of the wound together. In this manner the orifice is narrowed both anterior and posterior In this operation the cavity of the ampul la is made into a cylinder of smaller caliber the same as would result from a combined choreography and cinematography

This operation accomplishes little more than the clamp and cattery and has the disadvantages of a greater liability to infection, followed by abscess and fistula

Whitehead Operation. The application of the principles of the Whitehead operation for hemorrhoids is made use of by some surgeons. In this procedure the mucous membrane is dissected from the prolapse at the much-cutaneous junction and drawn down, excised and the cut borders sutured to the margin of the anus. The muscular walls of the gut are thus tucked or folded and held in position above.

PE Informer advises this operation in prolapses of four to six inches in extent, and it is described as a distinct operation under his name. He claims that this reduplication produces a narrowing of the canal and increases the strength of the sphincters. The operation has all the disadvantages of the Whitehead operation as applied to hemorrhoids, namely, stricture at the lower end of the rectum, and sepsis.

Tattle claims that one advantage in this operation is that in cases of prolapse due to hernias through the rectal cool-de-sac, the thickened ring will furnish an obstacle to the descent of the peritoneal pouch, and in this manner prevent recurrence of the prolapse.

Operations so far enumerated are limited to the mucous membrane and are chiefly applicable to the incomplete and the first degree of complete prolapse, but might be applied in the judgment of the operator with success to many of the mild second degree prolapses.

The operations suggested in the following list involve the deeper tissue, and are applicable to cases of severe second degree and third degree complete prolapse.

The Diefenbaker and Roberts Operation consists in the removal of a triangular section of the gut at the posterior commissary An incision is made, extending from one and one-half inches upward in the bowel, with the base of the triangle about one inch in width, which includes the excision in rant of both sphincters at this point. The operational for its object the reduction of the caliber of the lower end of the rectum and anus. The success of the procedure is dependent upon primary union, which is very uncertain. Should failure occur, an increased prolapse is almost a certainty, together with incontinence of feces. This operation does not accomplish any more than those before mentioned, and is of value only in conjunction with sigmoid fixation or sigmoid, Peters' infolding of the gut. rectory or suspension of the rectum upon the sacrum.

Lane’s Operation. The rectum is scarified and narrowed by buried sutures, which produce an infolding in the lumen of the rectal ampul la The operation consits of making an incision from the posterior margin of the anus upward alongside the coccyx, and dissecting off the elevators an then infolding the gut by a line of Alembert’s sutures through the muscular coats.

Peters' Operation is somewhat similar to Lane’s, only he makes an abdominal incision, large enough to draw up the sigmoid and infolds the lower portion of the gut on its anterior surface with Alembert’s sutures. The ends are left long enough to pass through the abdominal wall, forming support or suspension for the rectum.

Amputation. Amputation of the prolapsed mass of gut has been practiced for many years, both by the ancient and recent surgeons. The knife, clamp, cattery, elastic ligature, or gatecrash are employed for amputations. The knife is preferable where the removal and excision of a part of the entire circumference of the gut is intended in contradistinction to resection.

Fig. 33. Peters' operation for rectal prolapse. Smaller picture allows cross-section of infolded gut,

Resection and Excision Operations are both accompanied by the dangers of hemorrhage, stricture, infection of the peritoneal cavity, and injury to the small or large intestine, if a rectal hernia coexists. There is always the difficulty to determine how much bowel should be respected Either of these operations can be avoided in the majority of cases, and might conservatively be relegated to only those cases where gangrene or extreme strangulation make it imperative.

Willies’s Operation. In this operation the patient is best placed in the lithology position, not only to facilitate operative procedure, but to reduce a hernia, should it be contained within the prolapse. The field of operation is thoroughly cleansed and the gut brought down as far as possible by traction forceps, or grasped with Volstead forceps by an assistant. At this stage of procedure it is wise to see that any coils of intestine, which may have been contained within the prolapsed gut. are reduced. A packing should be inserted into the gut to plug the field of operation from further discharges from the intestine. Incision is then made through the mucous membrane on the anterior surface of the prolapse. This in-vision is carried through the entire thickness of the outer cylinder until the peritoneal cavity is opened. All bleeding should be controlled at once. Continuous sutures are then put through the peritoneal ends, closing that cavity at once from the possibility of further infection at that point. The incision is then carried down through the inner cylinder until the mucous membrane is again encountered. The muscular layers and mucous membrane are then united, making a complete end-to-end Anastasia at the point of amputation. These incisions should be made in sections dependent upon the extent which will facilitate the technique during the operation.