Transanal

Sthela M. Murad-Regadas

Rodrigo A. Pinto

Functional evaluation of the pelvic floor helps identify all anatomical defecatory disorders, which facilitate the choice of treatment options. Some studies have shown that the application of a complete functional investigation of the pelvic floor can modify the surgical management in up to 30–40% of cases (1,2). Specific indications for surgical repair of rectoceles depends on the patients’ symptoms, physical examination findings, results of physiological tests as well as failure of medical management including dietary modifications, fiber supplements, laxatives, and biofeedback.

Surgical Techniques

Various preoperative bowel preparation techniques maybe used. While some surgeons advocate sodium phosphate enemas, others recommend bowel cleansing with polyethylene glycol or oral sodium phosphate preparation. Preoperative parenteral antibiotic prophylaxis is frequently used. The transanal approach is preferred by most colorectal surgeons, as they are experienced with transanal surgery. Patients are positioned in the prone jackknife or lithotomy positions depending on the surgeon’s preference.

The transanal repair involves excising the distal redundant anterior rectal mucosa, followed by longitudinal or transverse plication of the muscularis propria layer of the rectum and rectovaginal septum (3,4). While plicating the muscular layer using interrupted or continuous absorbable stitches, special care must be taken to not include the posterior vaginal wall, which could lead to subsequent formation of a rectovaginal fistula (4,5,6,7). All of the hand-sewn methods have some basic principles in common: to excise the rectocele and the excessive anterior mucosa layer; to firmly reapproximate the anterior rectal wall by plication of the submucosa and muscularis; and to induce submucosal fibrosis through surgical manipulation (3,4,6).

Block (5) developed the closed obliterative suture technique in 1986, which consists of a tightly drawn continuous lock-stitch suture that strangulates the mucosa, submucosa, and muscularis layers of the rectocele without opening the rectum, allowing the repair to heal faster. Advantages of this technique include the short operative time that results from not having to dissect all layers of the rectal wall for repair, which also minimizes tissue trauma.

Results and Complications

Patients usually have a short hospital stay after rectocele repair (1 to 2 days). The symptomatic defecatory improvement using the transanal approach ranges from 30–90% (5,6,7,8,9,10,11,12). However, most of the series report unsatisfactory evacuation in 10–30% of patients (13,14). The causes for unsuccessful repairs are usually multifactorial, including inadequate repair, inappropriate patient selection and other coexisting undiagnosed or occult evacuation disorders.

The overall complication rate has been reported as up to 9% (6,8,12,15), and includes bleeding from the dissected mucosa (≤9%) (12,15

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