Overview
Definition:
Transperineal rectocele repair is a surgical approach to correct rectocele, a condition where the anterior rectal wall bulges into the vagina, typically performed through an incision in the perineum and vagina, often involving plication or repair of the rectovaginal septum and levator ani muscles.
Epidemiology:
Rectocele affects a significant percentage of women, particularly post-menopausal women and those who have had multiple vaginal deliveries
prevalence increases with age and parity
While incidence data for the transperineal approach specifically is less defined, it is a recognized technique for moderate to severe rectoceles.
Clinical Significance:
This surgical interface is crucial for restoring pelvic organ support, alleviating debilitating symptoms such as defecatory dysfunction, perineal discomfort, and sexual dysfunction, thereby significantly improving a patient's quality of life
Understanding this procedure is essential for surgical residents preparing for DNB and NEET SS examinations.
Indications
Surgical Indications:
Symptomatic rectocele grade 2 or higher
Failure of conservative management including pelvic floor exercises, dietary modifications, and laxatives
Significant defecatory dysfunction (straining, incomplete evacuation, sensation of blockage)
Associated pelvic organ prolapse requiring surgical intervention.
Patient Selection:
Careful patient selection is paramount, considering overall health, surgical risk, patient's desire for surgical intervention, and realistic expectations regarding outcomes
Preoperative assessment should rule out other causes of defecatory dysfunction.
Contraindications:
Absolute contraindications are rare but may include severe systemic illness, active pelvic infection, or patient's refusal of surgery
Relative contraindications might involve significant rectovaginal fistula or active inflammatory bowel disease affecting the rectum.
Preoperative Preparation
History And Physical:
Detailed history of bowel habits, pelvic symptoms, prior surgeries, and obstetric history
Pelvic examination including assessment of rectocele size, rectal support, and presence of other pelvic organ prolapse
Digital rectal examination to assess rectal tone and integrity of the rectovaginal septum.
Investigations:
Defecography or dynamic MRI pelvis to assess the degree of rectocele and rectal emptying
Anorectal manometry and pudendal nerve terminal motor latency studies may be considered if significant anorectal dysfunction is suspected
Routine pre-operative laboratory tests including CBC, LFTs, KFTs, and coagulation profile.
Counseling:
Informed consent discussing the procedure, potential risks (bleeding, infection, recurrence, injury to adjacent organs, voiding dysfunction, dyspareunia), benefits, and expected recovery
Discussing alternative surgical approaches if applicable.
Procedure Steps Surgical Interface
Anesthesia And Positioning:
General anesthesia or regional anesthesia
Patient placed in lithotomy or exaggerated lithotomy position
Perineal preparation and draping.
Vaginal Incision And Dissection:
A transverse incision is made in the vaginal mucosa anterior to the rectum, extending from the apex of the vagina towards the perineum
The vaginal flaps are dissected superiorly and inferiorly to expose the rectovaginal septum and the rectovaginal fascia.
Rectovaginal Septum Repair:
The rectovaginal septum is carefully dissected free from the rectum
Plication or repair of the rectovaginal fascia using absorbable or non-absorbable sutures is performed to narrow the defect and provide posterior support
The goal is to restore the natural concavity of the anterior rectal wall.
Levator Ani Plication:
In many cases, the pubococcygeus or levator ani muscles are plicated in the midline through the vaginal incision to further enhance posterior vaginal wall support and create an anatomical barrier to rectal prolapse.
Vaginal Closure:
The vaginal mucosa is closed in layers with absorbable sutures, obliterating the dead space and ensuring adequate tension-free closure to prevent dehiscence.
Postoperative Care And Management
Pain Management:
Adequate analgesia, typically multimodal, including oral or IV analgesics
Patient-controlled analgesia may be used in the immediate postoperative period.
Bowel Management:
Laxatives and stool softeners are prescribed to prevent straining and facilitate bowel movements
Early ambulation is encouraged
A clear liquid diet is usually initiated on postoperative day 1, advancing as tolerated.
Urinary Care:
Monitoring for urinary retention
Indwelling catheter may be necessary for 24-48 hours
Prompt recognition and management of any voiding difficulties.
Wound Care:
Perineal hygiene is emphasized
Patients are instructed to keep the perineal area clean and dry
Follow-up appointments are scheduled for wound inspection and suture removal if non-absorbable sutures were used.
Activity Restrictions:
Avoidance of heavy lifting, strenuous activity, and sexual intercourse for 6-8 weeks postoperatively to allow for adequate tissue healing and prevent suture dehiscence or recurrence.
Complications
Early Complications:
Hemorrhage, hematoma formation, infection, urinary retention, wound dehiscence, fecal impaction
Injury to the bladder, urethra, or rectum is rare but possible.
Late Complications:
Recurrence of rectocele, persistent dyspareunia, chronic perineal pain, constipation, or new onset of anterior vaginal wall prolapse
Fistula formation (rectovaginal) is exceptionally rare.
Prevention Strategies:
Meticulous surgical technique, careful dissection, secure closure of the vaginal mucosa, appropriate use of laxatives, early ambulation, and patient education on activity restrictions are key to minimizing complications and recurrence.
Key Points
Exam Focus:
Transperineal approach is favored for its direct visualization and plication of levator muscles
Emphasis on rectovaginal septum plication and levator ani repair as core components
Understanding potential complications like recurrence and dyspareunia is critical for DNB/NEET SS exams.
Clinical Pearls:
Adequate exposure through vaginal incision is key
Avoid excessive tension during suture plication to prevent ischemia and dehiscence
Thorough postoperative bowel regimen is crucial for successful outcome and prevention of straining
Consider defecography for recurrent or complex cases.
Common Mistakes:
Inadequate dissection of the rectovaginal septum
Insufficient plication of the rectovaginal fascia and levator muscles
Overly aggressive dissection leading to injury of adjacent structures
Premature return to strenuous activity leading to dehiscence or recurrence
Failing to address associated pelvic organ prolapse.