Surgical Technique

The transvaginal approach proceeds to open the posterior vaginal wall, identifying the rectovaginal septum and separating the anterior rectal wall by lateral blunt dissection to expose the levator muscle. The levator muscle is then plicated in the midline by several sutures. Care is taken to avoid perforating the rectum while placing the sutures. To exclude the rectal wall from the suture line, a finger can be introduced into the rectum. The redundant vaginal wall is excised and closed with a running absorbable suture material. In some instances, simultaneous hemorrhoidectomy is undertaken.16,21,22

The most frequent postoperative complications associated with the transvaginal approach include pain and sexual dysfunction.21-23 This surgical option should be considered when a concomitant vaginal hysterectomy is planned or in the presence of an anovaginal fistula.

Comparative results have been summarized in Table 18.2. In Mark's24 experience, the vaginal approach was insufficient to treat symptomatic rectoceles, and he was the first surgeon to note the importance of the rectal side of rectoceles and the need to correct this deficiency. During transanal repair, simple techniques such as the "obliterative suture" described by Block,4 stapling procedures described by Bresler et al,25 such as linear stapling, or the STARR (stapled transanal rectal resection) procedure using a circular stapler, can be utilized.26 Other transanal repair alternatives described by Sarles et al28,29

Table 18.2. Results of various series

Author

n

Technique

Results

%

Complications (%)

Sullivan et al (1968)30

151

Transrectal

Excellent/good

79.5

12.5

Khubchandani et al (1983)31

59

Transrectal

Excellent/good

79.6

35.5

Sehapayak (1985)33

355

Transrectal

Excellent/good

84.5

5.6

Arnold et al (1990)23

35

Transrectal

Excellent/good

80

34.2

Sarles et al (1991)29

39

Transrectal

Excellent/good

95

n/s

Janssen et al (1994)5

76

Transrectal

Excellent/good

92 (87)*

2.6

Khubchandani (1997)32

123

Transrectal

Excellent/good

82

3

Boccasanta (2001)27

90

Transrectal

Excellent/good

90

30

Redding (1964)42

20

Transvaginal

Excellent/good

100

5

Pitchford (1967)21

44

Transvaginal

Excellent/good

n/s

0

Arnold et al (1990)23

29

Transvaginal

Excellent/good

80

31

Mellgren et al (1995)22

25

Transvaginal

Excellent/good

88

20

Watson (1996) (w/Marlex)39

9

Transperineal

Excellent/good

80

n/s

Trompetto (1998)40

102

Transperineal

Excellent/good

85

15

Misici (1998) (w/Marlex)35

44

Transperineal

Excellent/good

n/s

n/s

Rosato (2004)43

52

Transperineal

Excellent/good

96.2

3.8

* After 1 year follow-up; n/s,not stated.

and Sullivan et al30 and variations of this technique have been applied by Khubchandani et al31'32 and Sehapayak.33 All of these techniques tend to plicate the rectal muscle layer on a vertical or transverse fashion, after opening the rectal mucosa, also known as a Delorme's type plication. The redundant rectal mucosa is resected to prevent anterior mucosal prolapse or tenesmus.28-33

Some studies have concluded that the transanal approach would be contraindicated in patients who present with combined fecal incontinence and rectocele due to its deleterious effects on internal sphincter function and resting anal pressures.34 Complications associated with transanal techniques include bleeding, rectovaginal fistula, fecal impaction, delayed healing due to mucosa retraction, and dyspare-unia. Stapled procedures have been followed by stenosis after linear stapling and vaginal tear after the STARR procedure.25,26

The transperineal approach to rectocele repair is another surgical option (Figures 18.3-18.9).35-38 Some surgeons have utilized prosthetic mesh between the rectum and the vagina in order to reinforce the rectovaginal septum,35,39,40 while others41 resect the redundant vaginal wall and reinforce the plasty by plicating the puborectalis muscle (Figs. 18.3 to 18.9).

Preoperative mechanical bowel preparation and prophylactic antibiotics are given to all patients. Patients are placed in the prone jack-knife position with the buttocks taped apart. The

Figure 18.3. Vaginal wall exposed. Figure 18.4. External sphincter (ES),puborectalis (PR),and vaginal wall.
Figure 18.5. Vaginal wall resected.

size and location of the rectovaginal defect is confirmed by manual palpation. An incision at the perineal area (elliptical or U-shape) is created. Electrocautery and blunt dissection allows entry into the rectovaginal space. A high dissection is carried out to the level of the vaginal cupola. If the vaginal wall will be resected, a trapezoid strip of posterior vaginal wall is sectioned. Reconstruction is carried out by plicating the levator muscle using two to three running 3.0 polyglactin sutures. Thorough hemostasis is undertaken prior to completely closing the skin, with no drains left in place. Concomitant sphincter repair can be accomplished as well other procedures such as hemor-rhoidectomy, rectovaginal fistulas, or fissures.

Complications associated with the transper-ineal approach include rectovaginal fistula, dyspareunia, and anterior mucosal prolapse. The

Figure 18.8. Skin incision.

Figure 18.6. Vaginal wall sutured.

Figure 18.8. Skin incision.

Figure 18.9. Wound closure, 1 week postoperatively.

mucosal prolapse, if present, can be successfully treated with rubber banding.

Was this article helpful?

0 0
Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

Get My Free Ebook


Post a comment