Posterior Repair for Rectocele
With a basic rectocele repair, most surgeons perform a posterior colporrhaphy, which is a non-specific midline plication or gathering of the vaginal bulge without any emphasis on the exact area of defect in the fascia. Other surgeons overcompensate and perform a levatorplasty. The lateral muscles that create the sidewalls of the vagina are pulled together and sutured over top of the rectum. This rectocele surgery actually pulls the lateral wall muscles out of their normal anatomic position and creates a floor above the rectum. The muscles are acting in place of the fascia. This operation is quite effective in the treatment of the rectocele but often these patients suffer from dyspareunia (painful intercourse) following surgery. This surgery is not very anatomic and Dr. Miklos and Dr. Moore rarely perform this operation. In fact, Drs. Miklos and Moore have a publication describing levatorplasty release with reconstruction using dermal graft in young, sexually-active women that could not have intercourse without pain after levatorplasty.
Dr. Miklos and Dr. Moore utilize the site-specific posterior repair and add a graft (when necessary). This rectocele repair restores normal anatomy and minimizes the risk of vaginal narrowing or shortening that is common with other traditional posterior repairs. The vaginal skin is incised and the overlying skin is meticulously dissected from the underlying supportive rectovaginal fascia. The defects in the fascia are identified and repaired (site-specific fascia repair) using suture. Upon completion of the fascia defect repair, a graft (typically Dr Moore and Miklos now use a light, soft mesh graft designed for vaginal surgery) is sutured in place after the completion of the site-specific repair in most patients. The skin is then closed using suture. Patients rarely complain postoperatively of painful intercourse or of a narrow vagina.
The following illustrate a sequence of events in the repair of a rectocele - a prolapse between the rectum and the vagina.
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 3 -The rectovaginal fascia defects 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 or bilaterally, the surgeon needs to identify the break and repair the break or breaks in the supportive layer through posterior repair surgery.
Figure 4 - Rectovaginal fascia tear. This illustration demonstrates the rectovaginal fascia weakness from a lateral perspective (i.e. 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 vb .
At this point, the site-specific repair is completed. (Figure 6 and 7). The rectovaginal fascia is re-attached to the perineal body where the distal defect was located (Figure 6) or if there are lateral tears, the rectovaginal fascia is reattached to the iliococcygeal muscles bilaterally with permanent suture (Figure 7). 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.
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 8) 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 10 - 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.