Transanal evisceration in a patient with rectal perforation and full thickness rectal prolapse: what has prolapsed into what?

These images show a 72-year-old female with full thickness rectal prolapse scheduled for surgery. She presented in the Emergency Room with irreducible prolapse, abdominal pain and signs of shock. Examination revealed the presence of small intestine prolapsing from the anus. Due to the presence of hemodynamic instability, the patient underwent emergency surgery without further diagnostic testing. At laparotomy, a perforation of the superior rectal wall was found with a 120 cm loop of small intestine prolapsing through it. The ileum was reduced in the abdomen with rapid resumption of perfusion and motility and a Hartmann procedure was performed. The postoperative course was uneventful and the patient was discharged after 6 days