Laparoscopic Enterocele Repair
Enterocele formation (a true hernia of the pelvic floor), which can be reversed through enterocele repair, usually occurs in women who have had a hysterectomy. Most reconstructive surgeons believe this is, in part, due to the removal of the uterus, however enteroceles can also occur in women that have a rectocele with or without prior hysterectomy. To understand an enterocele repair, one must first understand the anatomy of this defect. An enterocele is defined as peritoneum (skin on the inside of the abdominal cavity) in direct contact with vaginal epithelium (skin of the vagina) with no intervening fascia (support structure). Enteroceles typically occur at the top of the vagina where uterus once was (in women with prior hysterectomy) but can also occur at the top of the posterior vaginal wall in conjunction with a rectocele.To repair the enterocele, the supportive structure must be reconstructed. The support structure at the apex of the vagina is the pubocervical fascia (anterior vaginal wall) and the rectovaginal fascia (posterior vaginal wall). The apex of both vaginal walls usually fuses into the uterus. However, in patients where the uterus has been removed through a hysterectomy, sometimes the supportive layers of the anterior and posterior walls have not fused or scarred together, leaving an area lacking support. Therefore a herniation at the apex of vagina allows the peritoneum to come in direct contact with vaginal skin and creates a bulge. This bulge is called an enterocele.
Enterocele repair involves suturing the apex of pubocervical and rectovagina fascia back together. These sutures will only repair the apical defect; it will not support the apex of the vagina to a supporting structure. Usually patients receiving an enterocele repair also require a vaginal apex suspension (vaginal vault suspension).
Above figure shows intestine bulging through the enterocele defect at the top of the vagina. The fascia at the top of the vagina has split and caused a hernia to form which bulges into the top of the vagina. This is just stretched out skin with bowel pushing into it.
A defect in the pubocervical fascia and rectovaginal fascia. The second picture shows the elevation of the defect into the abdominal cavity.
Enterocele Sac Resection
The skin, thus the enterocele, has been removed so one can identify the edges of the supportive layers of the vagina. Those supportive layers are the pubocervical and rectovaginal fascia.
The pubocervical and rectovaginal fascia (supportive layers) are sewn together, repairing the vaginal hernia known as an enterocele. However, enterocele surgery has not addressed supporting the vagina apex... most patients who have done an enterocele repair also need a vaginal vault suspension. In many cases the enterocele is further supported or repaired with the use of mesh. This can be part of the vault suspension or rectocele repair.