Field preparation – O’Connor rectal shield secured with silk sutures and Lone Star® self-retaining retractor for vaginal exposure
Mark out the mucocutaneous junction at the posterior vaginal fourchette for the initial transverse incision, particularly if there are plans to correct a perineal defect at the time of surgery. Dissection of the posterior vaginal wall flap is best performed using primarily sharp dissection, with Allis clamps on the epithelial edge to retract the flap superiorly. Alternatively, a midline incision can be useful if the defect extends more proximally along the posterior wall. Digital manipulation of the rectum using the O’Connor shield can help facilitate this step by allowing the defect to be palpated, guiding further dissection (Fig. 13.2). Be prepared to encounter scar tissue during the initial dissection of the epithelium off the perineal attachments from prior prolapse and/or episiotomy repairs. At this point, an avascular plane should be identifiable between the vaginal epithelium and rectocele sac. The proper plane allows the surgeon to free the rectocele completely using blunt dissection. As the sac is dissected, identify the rectovaginal fascia and follow it laterally until its attachment at the arcus tendineus levator ani. If an isolated defect is encountered, then a “site-specific” fascial repair is indicated. Otherwise, traditional plication of the rectovaginal fascia to reduce the rectocele is most commonly performed; in this situation, we prefer to use an absorbable suture, such as 0 or 2-0 polyglactin (Vicryl®) suture, but a slow-absorbing suture (such as polydiaxonone, PDS) is also an option.
Digital palpation through the O’Connor drape allows manipulation of the rectocele sac. The incision at the mucocutaneous junction is retracted (dotted line), while the vaginal epithelium is retracted upward with Alliss clamps (dashed line)
The plication consists of a series of interrupted sutures from one sulcus to the other, incorporating the rectovaginal fascia. Each suture is left untied and clamped with a mosquito clamp or hemostat. Once all the sutures are placed, they are tied one at a time, starting from proximal (deep) to distal (superficial). We use a DeBakey forceps or a narrow malleable retractor to reduce the sac while tying the sutures. A critical maneuver at this point is to avoid overtightening the plicating sutures, which may potentially introduce de novo dyspareunia. Examination of the vaginal introitus and canal after the sutures are tied to allow two fingerbreadths width easily without any palpable “ridge” to avoid dyspareunia. Once the placating sutures are placed, any redundant or macerated epithelium can be trimmed to permit closure of fresh wound edges. The epithelium is then closed using a running 2-0 absorbable suture.
In cases with an extensive defect, prior failed native tissue repair, and/or a woman who is no longer sexually active, the high midline levator myorrhaphy (Chap. 11) is an intraperitoneal technique that can be useful not only to correct a rectocele, but also for vaginal vault fixation and to prevent enterocele recurrence .
During any posterior wall repair, be mindful for a concomitant enterocele, even if one is not clinically identified on preoperative exam. In the scenario presented in case #2, a patient such as this may present with an enterocele under pressure due to obesity and chronic straining. Once the boundaries of the sac are identified, the next decision is whether to repair it via an intra- or extraperitoneal approach, which is usually based on surgeon preference and the technique used for apical support. We prefer to open the sac and reduce the contents with a moist pack, then close the sac with a purse-string suture using permanent 0 or 2-0 polypropylene suture (Fig. 13.3). After removal of the moist pack, the sac is cinched closed. Cystoscopy is done to assess for efflux from each ureter, as one or both can be kinked by the peritoneal closure. If no efflux is seen, even after intravenous methylene blue administration, one must undo the permanent suture and reassess. If, instead, the sac is left intact and the repair is done via an extraperitoneal approach, then likely a sacrospinous fixation would be an appropriate choice if apical suspension is needed.
(a) Allis clamps are placed on the upper and lower edge of the enterocele sac (red arrow) with a Kerlix gauze reducing the enterocele sac contents (white arrow). (b) The enterocele sac is closed using a purse-string suture (circular arrow)
After completion of the rectocele and/or enterocele repair, evaluate the perineal body for laxity and separation of the superficial transverse perineal muscles by digitally palpating the defect on rectal exam (Fig. 13.4). We will mark out a triangle of thin perineal skin at the mucocutaneous junction for excision. Sharp dissection laterally to the perineal musculature on each side is important to allow for plication of the muscles and recreation of the perineal body. We use an absorbable suture, usually 2-0 PDS, to reapproximate the muscle in a series of interrupted mattress sutures, starting at the deepest aspect of the defect and proceeding superficially towards the vaginal introitus. The vaginal incision is closed transversely at the mucocutaneous junction, with a second closure longitudinally to reapproximate the perineal skin, using an absorbable suture; we prefer either Vicryl or chromic. In addition to a vaginal pack for the posterior repair, we will apply an external cold compress pack in recovery for pain control.
Perineorrhaphy (from Left to Right): Skin marking at mucocutaneous junction for incision, after dissection of bulbocavernosus muscles with three 2-0 PDS sutures in place before tying, and after reapproximation of muscles and perineal skin closure
Traditional posterior colporrhaphy (PC) by midline plication yields excellent results in terms of both anatomic and subjective success. Maher et al, in a prospective study of 38 women, reported an anatomic cure, defined as POP-Q stage I or less, of 79 % at 24 months. 89 % reported “very high satisfaction” on subjective questionnaire, with a significant reduction in dyspareunia and straining to defecate .
In addition to published small cohort studies, there are notable well-designed randomized trials comparing native tissue to graft-augmented repair. Paraiso et al randomized 106 women to either PC, site-specific defect repair (Refer to Video 13.2 Rectocele Plication, Site-Specific Defect Repair, and Perineorrhaphy (De, E)), or porcine dermis graft-augmented repair. At 12 months, there was a significantly higher anatomic failure rate (Bp > −2) in the graft arm of the study (46 %); anatomic failure rates for PC and site specific were similar at 14 % and 22 %, respectively . Similarly, Altman et al reported on 27 women undergoing porcine xenograft and found a 41 % stage II or greater recurrence at 3 year follow-up . Sung et al randomized 160 women to PC alone using absorbable polyglycolic sutures or augmented repair with subintestinal submucosal graft, and found no difference in anatomic failure, bulge symptom failure, or defecatory symptom failure . Unlike the study by Paraiso, in Sung et al, both groups showed improvement in bulge and defecatory symptoms.