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Laparoscopic Rectocele Repair

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 What is a rectocele?

A rectocele is a bulge of the front wall of the rectum into the vagina.  The rectal wall may become thin and weak and balloons into the vagina on straining (shown on the left), or simply when walking about.

The anatomical defect (the large bulge to the right hand side) is seen vividly in this defecating proctogram.

Other structures that may commonly push into the vagina include the bladder (a cystocele) and or the small intestines (an enterocele) as shown.

Whilst a rectocele may occur in isolation, in many instances a rectocele may be part of a more generalised weakness of pelvic support and may exist along with a rectal prolapse, vaginal/uterine prolapse, cystocele, enterocele and faecal or urinary incontinence.  rectal prolapses are not allways visable ie they are occult and are only seen on a defecating proctogram, or when the patient is anaesthetised (shown here).  Many patients, GPs, gynaecologists and surgeons will attribute the problem to haemorrhoids.

Many will present, not with the rectocele itself but with a mucosal prolpase.  GPs, gynaecologists and surgeons will attribute the problem to haemorrhoids.

What causes a rectocele?
The underlying cause is weakening or disatachment of the pelvic support structures, inparticular the sacrouterine and cardinal ligaments and a thinning of the rectovaginal septum. Certain factors increase the risks of women developing a rectocele. These include; birth trauma (multiple, difficult, prolonged deliveries, forceps, perineal tears), chronic constipation or following a hysterectomy.  In our experience, vaginal hysterectomies are the worst!  Rectoceles are more common with increasing age.

What are the symptoms?
Whilst many women have rectoceles, only a small percentage will have symptoms. Symptoms may be primarily rectal or vaginal. Vaginal symptoms include bulging, the sensation of a mass in the vagina, pain with intercourse, prolapse. Rectal symptoms include difficult evacuation; some women find that pressing against the lower back wall of the vaginal or along the rim of the vagina helps empty the rectum. At times, there will be a rapid return of the urge to have a bowel movement after leaving the toilet.

When should a rectocele be treated?
When it causes significant symptoms. It takes a very experienced Dr to help decide whether your symptoms are caused by a rectocele. If there are multiple abnormalities present it may be best to address them all at once as this will result in the best chance for improvement.

A diet high in fibre and 6-8 glasses of water each day help. Avoid prolonged straining. If you cannot completely empty, stop and try again later. Holding pressure with a finger to support the rectocele and encourage the stool to go in the correct direction is often helpful. Glycerine suppositories sometimes help.

Most gynaecologists 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 surgery actually pulls the lateral wall muscles out of its 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 short term treatment of the rectocele but often these patients then go no to suffer from dyspareunia (painful intercourse) following surgery. This type of surgery is not very anatomic and in our minds does not address the cause which in most patients stems from the anterior aspect of the rectum.

Some gynaecologists utilize what they term a "site-specific" posterior repair and add a dermal graft/mesh (when necessary). This repair restores normal vaginal 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 is sutured in place after the completion of the site-specific repair in most patients. The skin is then closed using a suture. 

Some surgeons perform this repair via the perineum believing that it is minimal access!  Again, we believe that this is only adressing a symptom and not the cause.  The patient is still prone to painful intercourse and more important the risk of mesh erosion through the vagina (can be as high as 20%).  In our series of 68 women with co-existing vault and rectal prolapse,  64% had undergone a failed site specific posterior colporraphy a further 14% had fail an additional anterior colporraphy/cystocele repair. 

Traditionaly colorectal surgeons have approached a rectocele repair (preoperative image) either through the anus or through the perineum i.e., between anus and vagina (shown above).

Data are mixed regarding the impact of rectocele repair on faecal incontinence. A prospective study of 101 women undergoing rectocele repair reported that 63% of those who had incontinence preoperatively reported symptom resolution or improvement at one year. In contrast, in a retrospective series of 231 women who underwent posterior colporrhaphy, the prevalence of faecal incontinence actually increased postoperatively from 4 to 11%.  

A new and we think a much better approch (laparoscopic ventral rectopexy) is to approach the problem from above i.e., through the abdomen. The latter as the name implies can be performed laparoscopicaly.  The great advantage is that No vaginal skin is excised and the chances of mesh erosion is less than 0.5%. More importantly the operation works with Faecal incontinence cured in 95%  As a result there is no vaginal narrowing, shortening or compromise to function.  Dyspareunia (pain with intercourse) is uncommon (2:350). In a series of 68 patients with combined rectal and recurrent vaginal vault prolapse, preoperative dyspareunia reported in 28 women resolved (with one new onset case).  Sexual function improved in 36%, stayed the same in 17%.

The other major advantage is that LVMR demonstrates the deficiencies within the pelvic floor, addresses the primary cause and failures are rare (1 in 68 following mesh dis-attachment from the sacral promontory (managed by re-attachment).  It is particularly useful in ladies who have already had a hysterectomy; restores anatomy and in many instances lengthens the vagina. 

Postoperative appearances following a laparoscopic repair.  the rectal bulge has gone and the perineal body has been pulled up and restored to its position pre-partum or pre-menopause.

In some patients STARR many be an alternative.

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