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Surgical Technique of Rectocele Repair
Ambulatory Procedure
The following illustrate a sequence of events in the repair of a rectocele
Rectocele identified and skin incised – A bulge is apparent on the bottom (posterior) floor of the vagina. The dotted line represents the skin incision about to be performed in this posterior repair procedure.
Identification of the fascia break –The rectocele exists because of a break in the supportive layer known as the rectovaginal septum (a.k.a. fascia). The defect is readily identified and the rectal wall is found protruding through this break in the rectovaginal fascia.
Figure 2
Figure 3
The rectovaginal fascia defects, seen in Figure 3, are the most common type of tear. Here the supportive floor of the vagina, known as the rectovaginal fascia, has completely detached from the walls on each side or bilaterally. The walls on each side are known as iliococcygeal muscles (aka levator muscles). Despite whether the tear is at the very distal aspect of the vagina (Figure 2) or bilaterally (Figure 3), the surgeon needs to identify the break and repair the break or breaks in the supportive layer through posterior repair surgery.
This illustration demonstrates the rectovaginal fascia weakness from a lateral perspective (ie sideview) with its resulting rectal hernia known as a rectocele.
Figure 5
The surgeon demonstrates repositioning of the rectovaginal fascia as to mimic what the surgical repair will do to the protruding rectum. It is obvious that repositioning the rectovaginal fascia to its normal anatomic position through posterior vaginal repair will result in a reduction of the rectocele. (Figure 5)
Figure 6.1
Figure 6.2
At this point, the site-specific repair is completed. (Figure 6.1,6.2). The rectovaginal fascia is re-attached to the perineal body where the distal defect was located (Figure 6.1) or if there are lateral tears, the rectovaginal fascia is reattached to the iliococcygeal muscles bilaterally with permanent suture (Figure 6.2). This completes the site-specific repair. Based on the studies discussed above, the cure rate utilizing site-specific defect repair alone is approximately 80% at one year. In other words, one out of five patients will have a surgical failure of their rectocele repair within one year of the surgery.
Figure 7
At this point in the posterior repair surgery, the graft is placed atop the repaired rectovaginal fascia and secured laterally at the iliococcygeal muscles (aka levator muscles) and distally at the perineal body. This augmentation or reinforcement increases the cure rate of a rectocele repair.
In certain patients, Drs. Miklos and Moore add the graft in an attempt to increase the cure rate of the rectocele repair. (Figure 7) Realize that they are not changing the operation, only augmenting or reinforcing the repair in an attempt to increase the rate of cure. Preliminary studies done with Brigham & Women Hospital of Harvard University reveal a cure rate of 93% when utilizing a graft to augment the site-specific repair. Several studies have shown that cure rates are over 90% when adding a graft to the repair.
After the skin graft has been placed and sutured into position, the vaginal epithelium or skin is then closed over top of the graft. At the completion of the posterior repair surgery, neither the patient nor the surgeon is capable of seeing the graft.
Figure 8
Figure 8 - Closure of the vaginal epithelium (skin) completes the operation
Figure 9
The lateral view of the completed posterior vaginal repair (Figure 9) shows how the vagina has been reconstructed back to its normal contour. Please note that there is now an extra layer of tissue (ie skin graft) between the rectovaginal fascia and the vaginal epithelium. This extra layer of support increases the rate of cure for a rectocele repair.
Results/Complications
By combining the site-specific repair and mesh graft, Drs. Miklos and Moore have been able to increase their success rate to over 90%. Although these are short-term results, they are confident that the graft-augmented rectocele repair may have the potential to improve long-term success rates. Drs. Miklos and Moore have used biologic grafts for their initial work, however secondary to improvements in mesh technology for vaginal surgery, they primarily use mesh now in their graft augmented repairs. Occasionally, they may still use a biologic graft in certain patients. They have found that graft augmented repairs result in higher cure rates and they have seen very low rate of complications with mesh use in the posterior compartment. Most women have enteroceles associated with rectoceles and the graft allows the enterocele to be repaired at the same time. The new lighter, softer mesh they use is typically not able to be felt by the patient or her partner after healing. Many women with issues such as straining with bowel movements, see an improvement in this as well.
Complications
- Painful Intercourse
- Shortened Vagina
- Vaginal Scar Tissue
- Rejection of Graft
- Vaginal Wound Dehiscence
- Mesh extrusion or erosion
Atlanta Urogynecology Associates Experience
Drs. Miklos and Moore have performed the site-specific posterior repair with graft augmentation over the past 10 years with over a 90% success rate. We believe that this posterior repair surgery technique will greatly reduce the symptoms that affect your lifestyle. You usually go home the next day and experience minimal pain and discomfort. It is our experience that most patients are pain free within 2 weeks after the posterior repair with graft augmentation.