REPAIR OF RECTOCELE
REASON FOR VISIT:
• Pelvic pressure and pain
• Pain or pressure in the vagina
• Pain during sexual intercourse
• Pain or pressure in the rectum
• Difficult passage of stool
• Needing to apply pressure on vagina to pass stool
• Feelings of incomplete stool passage
• Feeling of tissue bulging out of vagina
RISK ASSESSMENT
• Advanced age
• Obesity
• Bleeding disorders
• Heart problems
• Diabetes
• Hyper tension
• Allergy to medication
• Allergy to anesthesia
anesthesia
PREPARATION OF THE PATIENT:
• Blood tests
• Urine tests
• Chest x-ray
• EKG/ECG
• Urodynamic test
• Barium enema
• Colonoscopy
• Anoscopy
• Proctosigmoidoscopy
• Colonic transit study
• Pelvic floor fluoroscopy
• Anorectal manometry
• Electromyography
• Dynamic magnetic resonance imaging
• Proctography
• Preoperative antibiotics were to be given to the Patients with
diseases of the heart valves
• Aspirin and other blood-thinning medications were stopped for
several days before the surgery
• Laxative was administered to the patient for bowel preparation
• Enema was given
• Patient was in fasting for ____hrs before the procedure
• Part was prepared and draped in sterile fashion
ANESTHESIA:
• General anesthesia
• Spinal anesthesia
POSITION OF THE PATIENT:
•Supine position
•Prone jackknife position
THE PROCEDURE:
METHODS
• Posterior colporrhaphy
• Defect-directed repair
• Posterior fascial replacement
• Transanal repair
• Abdominal approaches
POSTERIOR COLPORRHAPHY
• The skin incised in a V-shaped fashion over the perineum/
transversely along the external margin of the posterior
fourchette.
• The vaginal wall of the posterior fourchette was sharply
dissected from the underlying tissues of the perineal body.
• The rectovaginal space was entered and widely dissected to the
vaginal apex, beyond the top of the rectocele.
• Enterocele was found and enterocele was repaired
• The pararectal fascia was plicated over the rectum with
interrupted, delayed, absorbable, /permanent sutures from the
vaginal apex to the introitus.
• The diameter of the vagina was assessed and no transverse
constriction was occurring
• To relieve any constructions linear, lateral, relaxing incisions
were given
• Redundancy of the posterior vaginal wall flaps was trimmed and
care is taken to preserve the vaginal caliber.
• The cut edges of the upper posterior vaginal wall were
approximated in the midline.
• Defective perineal body was present, so its connective tissue was
plicated in the midline.
• Capsule of the pubis rectalis muscle was plicated
• The remaining cut edges of the posterior vaginal wall and
perineum were approximated.
PERINEORRHAPHY
• Due to attenuation/ laceration/ hypermobility of the perineal
body the perineal deficit was present
• Levator ani plication was done
• _____ Muscles are approximated in the midline
DEFECT-DIRECTED OR SITE-SPECIFIC REPAIR
• Discrete tears or breaks were present in the rectovaginal septum
(transverse separation of the rectovaginal septum) from the
perineal body.
• A midline epithelial incision was given
• The epithelium was separated from the rectovaginal fascia.
• The edges of the fascial defects or tears are identified
• The defect was repaired with interrupted, delayed, absorbable
sutures.
• The sutures were placed from cephalad to caudad.
• The vaginal epithelium was reapproximated
TRANSANAL REPAIR:
Patient was positioned in prone jackknife position
• Rectal side of the rectocele was present.
• A U- or T-shaped incision was made transanally just above the
dentate line.
• A mucosal flap was developed, separated from the rectovaginal
septum, and excised.
• The rectovaginal septum was plicated from the rectal side with
absorbable sutures.
• The plication includes the anterior rectal musculature.
• The rectal mucosa and submucosa were closed in a separate
layer.
POSTERIOR FASCIAL DISPLACEMENT
• Placing a dermal allograft over the repair and securing it to the
rectovaginal fascia cephalad, to the arcus tendineus fascia
rectovaginalis laterally, and to the perineal body distally created
a second layer of support.
ABDOMINAL APPROACH
• The peritoneum overlying the apex and posterior wall of the
vagina was incised to open the rectovaginal space.
• Sutures were placed over the length of the posterior wall, from
the apex to the perineal body.
• The perineal body was elevated by the nondominant hand
• Stitches were placed abdominally into/ as close to, the perineal
body
• The permanent graft was placed abdominally between the
posterior vaginal wall and the rectum.
• The sacrocolpopexy was completed with attachment of the
anterior wall graft and posterior wall graft to the previously
placed sacral sutures.
• The perineal body sutures were placed transvaginally.
• Abdomen was closed layer by layer
FINDINGS:
• Rectocele/rectocele with enterocele/ rectal side of the rectocele
was present.
AFTER PROCEDURE:
• Immediately after surgery the patient will be taken to a recovery
area
• Monitoring the blood pressure/pulse/temperature
• Nothing is taken by mouth for_____hr
DURATION
_______hrs
POSTOPERATIVE CARE
• Take antibiotic treatment as prescribed
• Take pain medications prescribed
• Observe for in discharge from suture site
• Surgical wound dressings will be kept clean and dry
• Take liquid diet for_____days.
COMPLICATIONS
• Allergic reaction to the anaesthetic
• Haemorrhage
• Infection
• Urinary tract infection
• Injury to nearby nerves or blood vessels
• Damage to other pelvic organs, such as the bladder or rectum
• Death (necrosis) of the rectal wall
• Recurrence of the rectal prolapse
• Rectovaginal fistula
INSTRUCTIONS:
• Rest as much as you can.
• Avoid heavy lifting or straining for a few weeks.
• Do not strain on the toilet.
• Take measures to prevent constipation, such as eating high fiber
foods and drinking plenty of water.
FOLLOW UP
______days after surgery.
