Tips & Tricks in Common Surgeries: Rectocele

Rectocele or Posterior Vaginal Wall Prolapse Repair

The current terminology for rectocele is posterior compartment prolapse. Surgical repair is recommended for symptomatic women where conservative management has failed or been refused, or in cases of advanced stage 3 or 4 prolapse. Surgery in asymptomatic patients may lead to unexpected complications and is unethical. The problem does not usually develop in isolation but in association with apical and/or anterior compartment prolapse. Posterior prolapse is less common than anterior prolapse (7% vs 40% [Olsen et al]). The surgical repair is directed to the specific defect of supporting tissues causing the prolapse. The upper fourth of the posterior wall is supported by the cardinal-uterosacral complex, the middle half by the arcus tendinous fascia pelvis proximally and the arcus tendinous rectovaginalis distally, and the lower fourth by the perineal body. The defects sequentially lead to enterocele, sigmoidocele, or rectocele and developed due to tearing of the Denonvilliers fascia.

Proper evaluation of the defects is necessary before planning the surgery. In cases where there is doubt, perineal cystopectography can be done. Planning the surgical repair can be done through the transvaginal or transanal approach. Evidence shows that the transvaginal approach is superior to the transanal approach using native tissue repair. Use of mesh has no superiority; many countries have restrictions or ban the use of synthetic mesh due to mesh complications. Pre-operative investigations must be completed prior to surgery. Posterior colpoperineorraphy may be done to correct rectocele by traditional approach or site- specific repair method. There is no evidence of significant differences, thus, the procedure selected is the surgeon’s choice.

Steps of Posterior Vaginal Wall Repair

1. Patients are informed of the treatment options and the risks and benefits of each. The procedure can then be selected based on the patient’s choice.
2. The surgery is usually done under regional anesthesia.
3. The patient is placed in dorsal lithotomy position and the site of operation is properly exposed using appropriate retractors and good light.
4. The incision site is marked by marker pen on the vaginal wall.
5. The operating area is infiltrated with saline mixed with lidocaine and adrenaline or vasopressin to facilitate hydro-dissection.
6. A vertical incision is made on the marked area extending from the highest point of rectocele up from the proximal to its distal part or base near the introitus, in appropriate depth.
7. The vaginal wall is dissected from the underlying rectovaginal septum and rectum. Then proceed laterally to reach the lateral margin of the levator ani muscle. Perform a rectal examination to identify the defect and exclude rectal injury. Plicate the levator ani muscles in the midline. Care should be taken not to make the vaginal calibre too narrow which may result in dyspareunia.
8. The rectovaginal fascia is identified and in the midline it is fixed with the cervix or apex of the vault. Laterally, from both sides, sutures are taken from the septum using PDS 2-0 sutures and plicated in the midline. Be careful not to take a bite through the rectum. Each defect identified needs to be addressed specifically, such as suturing the septum and the perineal body.
9. Redundant vaginal wall tissue is excised, bulbocavernous and transverse perineal muscles from both sides are plicated and attached with the rectovaginal septum using interrupted PDS or vicryl 2-0 suture.
10. The vaginal wall is then closed by continuous vicryl 2-0 suture.
11. Hemostasis has to be secured throughout the whole process.
12. A vaginal pack is inserted to prevent hemorrhage, if any, and Foley’s catheter placed for drainage of urine. After reconstruction, the vagina should be at least three fingers wide.
13. The pack and Foley’s catheter may be removed the following day.
14. The patient should be advised to avoid lifting heavy weights, constipation, and sexual activity for at least for 6 weeks.
15. A prophylactic antibiotic is usually used, but this depends on the surgeon’s choice and the facility’s infection prevention policy.

Tips & Tricks for Posterior Vaginal Wall Repair

1. The surgeon should choose the type of surgery based on his or her experience, as evidence has failed to show any significant difference between traditional repair and defect-specific repair.
2. Levator plication should be done only in sexually inactive women, as it may cause de novo dyspareunia.
3. Blanching of the vaginal wall indicates adequate infiltration.
4. Excess trimming of vaginal tissue may lead to post-operative dyspareunia.
5. Optimum correction is desired and over correction leads to sexual difficulties.
6. Routine post-operative rectal examination should be done to exclude dyspareunia or ensure a bite was not taken through the rectal wall.
7. The vaginal wall should be closed by absorbable suture to avoid dyspareunia.

REFERENCES

Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol. 1997;89(4):501.