Transvaginal



Transvaginal


G. Willy Davila



Introduction

Rectocele repair represents one of the most commonly performed gynecologic pelvic reconstructive procedures. Both gynecologists and colorectal surgeons treat rectoceles on a frequent basis by itself or in conjunction with other reconstructive procedures. Dysfunction of the posterior compartment may be very differently managed by different specialists as there is a lack of consensus about indications, surgical techniques, and outcome assessment.

The restoration of normal anatomy to the posterior vaginal wall is referred to as a posterior repair or colporrhaphy. Although frequently used interchangeably with the term “rectocele repair,” the two operations may have vastly different treatment goals. While rectocele repair focuses on repairing a herniation of the anterior rectal wall into the vaginal canal due to a weakness in the rectovaginal septum, a posterior colporrhaphy is designed to correct a rectal bulge, as well as normalize vaginal caliber by restoring structural integrity to the posterior vaginal wall and introitus.

This chapter will cover various aspects of the gynecologic approach to rectocele repair, including symptoms, anatomy, physical examination, indications for repair, surgical techniques, and treatment outcomes.





Preoperative Planning


Anatomy

The anatomy of the posterior vaginal wall cannot be clearly conceptualized apart from the anatomical support of the rest of the vagina. Vaginal support arises from several interactions between pelvic musculature and connective tissue.

Rectoceles result from defects in the integrity of the posterior vaginal wall and rectovaginal septum and subsequent herniation of the posterior vaginal wall and anterior rectal wall into the vaginal lumen through these defects.

The normal posterior vagina is lined by squamous epithelium that overlies the lamina propria, a layer of loose connective tissue. A fibromuscular layer of tissue composed of smooth muscle, collagen, and elastin underlies this lamina propria and is referred to as the rectovaginal fascia. This is an extension of the endopelvic fascia that surrounds and supports the pelvic organs and contains blood vessels, lymphatics, and nerves that supply and innervate the pelvic organs.

The layer of tissue between the vagina and the rectum, or rectovaginal fascia, was felt to be analogous to the rectovesical septum in males and became known as Denonvilliers’ fascia or the rectovaginal septum in the female. Others described the rectovaginal septum as a support mechanism of the pelvic organs, and they were successful in identifying this layer during surgical and autopsy dissections (13,19,21). It is unclear whether this fascial layer extends from the vaginal cuff to the perineum or is only present along the distal vaginal wall from the levator reflection to perineum.

The normal vagina is stabilized and supported on three levels. Superiorly, the vaginal apical endopelvic fascia is attached to the cardinal–uterosacral ligament complex. Laterally, the endopelvic fascia is connected to the arcus tendineus fasciae pelvis, with the lateral posterior vagina attaching to the fascia overlying the levator ani muscles. Inferiorly, the lower posterior vagina connects to the perineal body, comprised of the anterior external anal sphincter, transverse perineum, and bulbous cavernosus muscles. The cervix (or vaginal cuff in the women following hysterectomized woman) is considered to be the superior attachment site or “superior tendon,” and the perineal body the inferior attachment site or “inferior tendon.” The endopelvic fascia extends between these two sites comprising the rectovaginal septum (Fig. 22.1). A rectocele results from a stretching or actual separation or tear of the rectovaginal fascia, leading to a bulging of the posterior vaginal wall noted on examination during a Valsalva maneuver. Trauma from vaginal childbirth commonly leads to transverse defects above the usual location of the connection to the perineal body (Fig. 22.2). In addition, patients may present with lateral, midline, or high transverse fascial defects. Separation of the rectovaginal septum fascia from the vaginal cuff results in the development of an enterocele as a hernia sac without fascial lining and filled with intraperitoneal contents (Fig. 22.2).

Vaginal muscular support is provided by the interrelation among the pelvic diaphragm, the levator ani muscles (puborectalis, pubococcygeus, and ileococcygeus), and the coccygeus muscles. The levator musculature extends from the pubic bone to the coccyx and provides support for the change in vaginal axis from vertical to horizontal along the mid-vagina creating a U-shaped sling. A rectocele typically develops at, or below, the levator plate, along the vertical vagina, weakening the fascial condensation of the attachments of the perineal musculature (Fig. 22.3).


Physical Examination

Pelvic examination allows the surgeon to define the grade of prolapse and determine the integrity of the connective tissue and muscular support of the posterior vaginal wall. The typical finding in a woman with a symptomatic rectocele is a lower posterior
vaginal wall bulge noted on physical examination in a dorsal lithotomy position. It may superiorly extend to weaken the support of the upper, posterior vaginal wall, leading to an enterocele, or to the vaginal apex, leading to vaginal vault prolapse. In an isolated rectocele, the bulge extends from the edge of the levator plate to the perineal body. As the rectocele enlarges, the perineal body may further distend and lose its bulk, leading to an evident perineocele; enteroceles and rectoceles frequently coexist. The physical
examination should include not only a vaginal examination but must also include a rectal examination, as the perineocele may not be evident on vaginal examination. At times, it can be identified only upon digital rectal examination where an absence of fibromuscular tissue in the perineal body anterior to the rectum is confirmed.






Figure 22.1 Diagrammatic representation of the rectovaginal septum including its attachment from vaginal apex to perineal body.






Figure 22.2 Fascial tears of the rectovaginal (RV) septum can occur superiorly or inferiorly at sites of attachment to a central tendon.





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Jun 12, 2016 | Posted by in GENERAL | Comments Off on Transvaginal

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