Symptoms of rectocele may include vaginal bulge, defecatory dysfunction such as constipation, tenesmus, splinting, or fecal incontinence or dyspareunia. Rectoceles are frequently present with some degree of concomitant apical and/or anterior prolapse. Severity of symptoms does not necessarily correlate with severity of prolapse, and management should be based upon the degree of bother. Consideration should be given to nonoperative management (i.e., pessary placement) prior to proceeding to operative intervention. This chapter reviews the techniques for posterior colporrhaphy and site-specific repair with or without perineorrhaphy. We generally advocate for native tissue repair in the posterior compartment, as existing evidence does not support routine use of either biologic or synthetic graft material. Prior to rectocele repair, it is crucial to determine if there is concomitant apical failure. Simple rectocele repair without resuspension of the vaginal apex in these individuals will increase the patient’s chances of recurrent prolapse.
Preoperative Preparation and Planning
Rectocele repair is often done concurrently with other surgical procedures for pelvic organ prolapse. Bowel preparation is recommended, particularly for patients in whom a difficult dissection is expected, such as those with scarring from prior surgery.
Patient Positioning and Surgical Incision
This repair is performed with the patient in the dorsolithotomy position using candy-cane, yellow-fin, or Allen stirrups. Perform an examination under anesthesia and use an electric razor to clip labial hair that may obscure the surgical field. After completion of the surgical prep, place a Foley catheter under sterile conditions. Suture the labia back to the vulva/groin or use a self-retaining vaginal retractor (e.g., Lone Star or Scott ring) for exposure. If additional exposure of the posterior wall is needed, a Wilson or Deaver retractor can be placed along the anterior wall. We prefer hydrodissection with injectable saline or 0.5% lidocaine with 1 : 200,000 epinephrine prior to incision to facilitate dissection.
The steps of repair are as follows:
Place two Allis clamps at the level of the hymen along the posterior wall to identify the lateral margins of the plication ( Fig. 91.1 ).
Test the degree of vaginal narrowing by bringing the Allis clamps together in one hand and ensuring the introitus accommodates two to three fingerbreadths. Adjust the Allis clamps if necessary and retest.
Grasp the proximal end of the rectocele in the midline using an Allis clamp.
Using a no. 15 blade scalpel, incise a triangle in the posterior vaginal wall epithelium using the three Allis clamps as your triangle corners ( Fig. 91.2 ). If concurrent perineorrhaphy is indicated, instead of making a transverse incision along the posterior fourchette between the distal Allis clamps to form the base of the triangle, create a triangle incision in the skin overlying the perineal body ( Fig. 91.3 ).
Grasp the distal portion of the incision (either the transverse incision forming the base of the triangle or inferior point of the perineal incision) with an Allis clamp and elevate the epithelium. Using a Metzenbaum scissor, dissect the epithelium off of the perineal body muscles (if perineorrhaphy is being performed) and the fibromuscular tissue—also called the perirectal, rectovaginal, endopelvic, or Denonvilliers fascia. Once the edges of the epithelial incision are well-defined and separated from the fibromuscular tissue, further dissection is facilitated by placing an Allis clamp on the epithelial edge with an index finger on the vaginal side and scissor tips pointing away from the rectum. After clearly establishing the surgical plane between the epithelium and fibromuscular tissue, a moist 4 × 8 gauze may be used to gently tease the fibromuscular tissue off of the epithelium. However, this should only be done if the tissue is separating easily. The epithelium should be dissected until the fibromuscular tissue overlying the prolapsed portion of the rectum is fully exposed ( Fig. 91.4 ). Some surgeons prefer to perform this and subsequent steps 7 through 10 with one finger in the rectum to better identify the proximity to the rectal wall. If so, placing the middle finger of the nondominant hand in the rectum can free the index finger and thumb to assist.