Posterior colporrhaphy is commonly performed in conjunction with a perineoplasty to address a rectocele or relaxed perineum and widened genital hiatus. Preoperatively, the severity of the rectocele is assessed, and the desired final vaginal caliber is determined. Allis clamps are placed on the hymen remnants bilaterally and approximated in the midline such that the resultant vagina should loosely admit two to three fingers. The skin is infiltrated with a dilute epi-nephrine solution. A triangular incision over the perineal body is made between the Allis clamps, and sharp dissection is then performed to separate the posterior vagina from the underlying rectovaginal fascia. A midline incision is made along the length of the vagina to a site above the superior edge of the rectocele.
The dissection is carried laterally to the lateral vaginal sulcus and medial margins of the pub-orectalis muscles (Fig. 19.5). The rectovaginal fascia with or without the underlying levator ani muscles is then plicated with interrupted sutures while depressing the anterior rectal wall (Fig. 19.6). The plication is begun at the level of the levator muscles. Typically, absorbable sutures (No. 1 Vycril) are placed along the length of the
rectocele until plication to the level of the perineal body is complete. In the presence of a large rectocele, multiple suture layers may be necessary to restore adequate support to the anterior rectal wall. Excess vaginal mucosa is carefully trimmed and then reapproximated. A concomitant perineoplasty may be performed by plicat-ing the bulbocavernosus and transverse perineal muscles. This reinforces the perineal body and provides enhanced support to the corrected rectocele.
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