Correct Answer: C. Thiersch wiring
Thiersch wiring (also called Thiersch encirclement or subcutaneous wire encirclement) is a minimally invasive surgical technique for rectal prolapse that involves placing a non-absorbable suture or wire (typically 2-0 prolene or mersilene tape) in a subcutaneous plane around the anal verge, creating a restrictive band that prevents prolapse. The postoperative image showing a circumferential wire/suture placed subcutaneously around the rectum at the dentate line level is pathognomonic for Thiersch wiring. This procedure is particularly suited for elderly, frail, or medically unfit patients (common in Indian rural populations with limited access to advanced surgical facilities) because it avoids major abdominal surgery, has low morbidity, and can be performed under local or spinal anesthesia. The mechanism works by mechanically restricting anal canal diameter to prevent intussusception and prolapse. While recurrence rates are higher than abdominal approaches (15–30%), it remains a valuable option in resource-limited settings and for patients unfit for major surgery. The wire is placed via a small perineal incision, making it an attractive first-line option in Indian tertiary centers managing high-volume prolapse cases.
Why the other options are wrong
A. Stapled hemorrhoidopexy — This is wrong because stapled hemorrhoidopexy (PPH) is designed for internal hemorrhoids, not rectal prolapse. It uses a circular stapling device to resect mucosa above the dentate line and reduce hemorrhoidal tissue. The postoperative image shows a circumferential wire/suture at the anal verge, not staple lines in the mucosa. NBE may trap students who confuse prolapse management with hemorrhoid surgery. B. Altemeier repair — This is wrong because Altemeier repair (perineal proctosigmoidectomy) is a perineal approach for full-thickness prolapse that involves excision of the prolapsed bowel segment with primary anastomosis. It requires full-thickness dissection and bowel resection, producing a different surgical anatomy than the simple wire encirclement seen in the image. Altemeier is reserved for severe, recurrent prolapse in fit patients, not first-line management. D. Well's procedure — This is wrong because Wells procedure (abdominal rectopexy with mesh or fascial sling) involves an abdominal approach with fixation of the rectum to the sacrum via laparoscopy or open surgery. The postoperative image shows a perineal wire, not abdominal mesh or sacral fixation. Wells is a major procedure for fit patients; the image clearly demonstrates a simple perineal encirclement technique.
High-Yield Facts
- Thiersch wiring uses non-absorbable suture (2-0 prolene/mersilene) placed subcutaneously around anal verge to restrict anal canal diameter and prevent prolapse.
- Indications for Thiersch: elderly, frail, medically unfit patients, or those unfit for major abdominal surgery—common in Indian rural populations with limited surgical access.
- Recurrence rate of Thiersch wiring is 15–30%, higher than abdominal approaches but acceptable given low morbidity and local/spinal anesthesia feasibility.
- Contraindications: active infection, fecal incontinence (worsens continence), and patients requiring future colonoscopy (wire must be removed).
- Postoperative image hallmark: circumferential wire/suture visible at anal verge in subcutaneous plane, distinguishing it from stapled, mesh, or resective approaches.
Mnemonics
THIERSCH = Tight Encirclement for High-risk Elderly Thiersch wiring = Tight subcutaneous Encirclement for Elderly/unfit patients. Simple perineal wire, no major surgery, local anesthesia possible. Use when patient cannot tolerate abdominal approach. Prolapse Surgery by Fitness Fit patient, recurrent prolapse → Abdominal rectopexy (Wells/Ripstein). Unfit/elderly → Thiersch wiring (perineal, wire). Severe, full-thickness → Altemeier (perineal resection). Quick rule: fitness determines approach.
NBE Trap
NBE pairs rectal prolapse with abdominal approaches (Wells, Ripstein) to lure students into overlooking the simple perineal wire technique. The postoperative image is the discriminator—students must recognize the subcutaneous wire at the anal verge, not mesh or staples.
Clinical Pearl
In Indian tertiary centers managing high-volume prolapse cases, Thiersch wiring remains first-line for elderly patients with comorbidities (diabetes, hypertension, cardiac disease) because it avoids general anesthesia and major abdominal surgery—critical in resource-limited settings where postoperative ICU beds are scarce. A 70-year-old farmer with COPD and prolapse is ideal for Thiersch rather than Wells.
_Reference: Bailey & Love Ch. 72 (Rectum and Anal Canal); Sabiston Textbook of Surgery Ch. 51_