Overview
Definition:
Transvaginal rectocele repair is a surgical procedure to correct a rectocele, which is a herniation of the anterior rectal wall into the posterior vaginal wall, accessed through a vaginal approach
This surgery aims to restore normal pelvic anatomy and alleviate associated symptoms
It is a key procedure in the management of pelvic organ prolapse (POP).
Epidemiology:
Rectoceles affect a significant proportion of women, particularly those who have had multiple vaginal deliveries, are postmenopausal, or have undergone hysterectomy
Prevalence increases with age
While exact incidence is difficult to ascertain due to asymptomatic cases, it is a common indication for surgical intervention in urogynecology and general surgery practices.
Clinical Significance:
Symptomatic rectoceles can significantly impact a patient's quality of life, causing defecatory dysfunction such as constipation, straining, incomplete evacuation, sensation of blockage, and the need for manual support (e.g., digitation) to facilitate bowel movements
Understanding the surgical interface is crucial for residents preparing for DNB and NEET SS examinations, as it tests knowledge of surgical anatomy, technique, and complication management.
Indications
Surgical Indications:
Symptomatic rectocele causing significant defecatory dysfunction
Failure of conservative management (e.g., lifestyle modifications, pelvic floor muscle training)
Patient preference for surgical correction after informed consent
Concurrent pelvic organ prolapse requiring repair.
Relative Indications:
Large rectoceles even if mildly symptomatic
Patients seeking simultaneous apical or anterior prolapse repair
Significant anatomical bulge detected on physical examination with patient-reported concerns.
Contraindications:
Active pelvic infection
Uncorrected uterine prolapse if concurrent repair is not planned
Significant comorbidities precluding surgery
Patient unwilling or unable to undergo postoperative care and follow-up.
Preoperative Preparation
History And Physical Exam:
Detailed history including bowel habits, straining, sensation of incomplete evacuation, and use of manual maneuvers
Pelvic examination to assess the grade of rectocele, evaluate for other POP, and assess pelvic floor strength
Proctoscopy or sigmoidoscopy may be considered to rule out rectal pathology.
Diagnostic Imaging:
Defecography or dynamic MRI of the pelvic floor can be useful to assess the severity and extent of the rectocele, identify associated abnormalities like enteroceles or enterocele, and evaluate rectal emptying and perineal descent
However, these are not always mandatory for routine rectocele repair.
Patient Counseling:
Informed consent regarding the procedure, alternatives, potential benefits, risks, and expected recovery
Discussion of sexual function, recurrence rates, and the importance of postoperative pelvic floor exercises
Lifestyle modifications post-surgery, including adequate fiber and fluid intake.
Medical Optimization:
Management of constipation pre-operatively
Review of medications, especially those affecting bowel function or coagulation
Optimization of any comorbid conditions (e.g., diabetes, hypertension)
Bowel preparation as per institutional protocol.
Procedure Steps
Surgical Approach:
Transvaginal approach is standard
Patient positioned in lithotomy position under general or regional anesthesia
Adequate exposure of the vaginal mucosa is essential
Uterine support sutures may be placed if concurrent hysterectomy or uterine prolapse repair is performed.
Vaginal Mucosal Incision:
A transverse or longitudinal incision is made in the posterior vaginal wall, typically at the level of the rectocele or 1-2 cm distal to the hymen, extending cephalad as needed to expose the defect
Care is taken to preserve vaginal length and avoid excessive tension.
Dissection And Rectovaginal Space:
The vaginal mucosa is dissected off the underlying rectovaginal septum, creating a plane to access the herniated rectal tissue
The dissection continues superiorly to define the boundaries of the rectocele sac
Careful sharp and blunt dissection is crucial to avoid rectal perforation.
Rectocele Sac Plication And Repair:
The rectocele sac is reduced and imbricated or plicated laterally to narrow its base and reinforce the posterior vaginal wall
Sutures are typically placed in the rectovaginal septum and adjacent fascial layers to create a strong posterior repair
Mesh or biologic grafts are generally not used for simple rectocele repair but may be considered in complex cases or for recurrent prolapse.
Vaginal Closure:
The vaginal mucosa is closed in layers with absorbable sutures, ensuring good approximation and avoiding tension
If performed concurrently with other prolapse repairs, the closure integrates with those steps
Hemostasis must be meticulously achieved throughout the procedure.
Postoperative Care
Pain Management:
Adequate analgesia is provided, often including opioids for the first 24-48 hours, followed by NSAIDs or acetaminophen
Patient-controlled analgesia (PCA) may be used
Expectation of some discomfort is managed through education.
Bowel Management:
Early ambulation is encouraged
Stool softeners and laxatives are prescribed to prevent straining and constipation
High-fiber diet and adequate fluid intake are reinforced
Avoidance of heavy lifting and strenuous activity for 4-6 weeks.
Wound Care:
Vaginal packing may be used temporarily
Patients are advised to maintain good perineal hygiene
Sitz baths can be helpful for comfort and hygiene
Follow-up instructions regarding vaginal bleeding or discharge are provided.
Monitoring And Follow Up:
Close monitoring for signs of infection, bleeding, or urinary retention
Regular follow-up appointments (e.g., at 2 weeks, 6 weeks, 3 months, and 1 year) are scheduled to assess healing, functional outcomes, and recurrence
Pelvic floor exercises are often encouraged post-recovery.
Complications
Early Complications:
Bleeding, infection (vaginal cuff cellulitis, abscess), urinary retention, fecal incontinence or worsening constipation, injury to adjacent structures (rectal perforation, ureteral injury), vaginal cuff dehiscence.
Late Complications:
Recurrence of rectocele or other POP, dyspareunia (painful intercourse), vaginal stenosis, granulation tissue formation, chronic pain, fistula formation (rare).
Prevention Strategies:
Meticulous surgical technique to avoid injury
Careful hemostasis
Prophylactic antibiotics if indicated
Appropriate bowel management postoperatively
Patient education on activity restrictions and pelvic floor exercises
Adequate follow-up.
Key Points
Exam Focus:
Understanding the layers involved in rectocele repair (vaginal mucosa, rectovaginal septum, rectal muscularis)
Differentiating between rectocele, enterocele, and cystocele
Knowing the indications for transvaginal vs
transabdominal approaches
Recall common complications and their management.
Clinical Pearls:
Adequate exposure is key
don't be afraid to extend the vaginal incision proximally
Dissect carefully in the rectovaginal plane to avoid rectal injury
Over-plication can lead to dyspareunia or obstructive symptoms
aim for appropriate tension
Always assess for and address other POP components.
Common Mistakes:
Incomplete dissection of the rectocele sac
Over-tightening of sutures leading to vaginal stenosis or dyspareunia
Failing to identify and repair associated enterocele or cystocele
Insufficient bowel preparation post-operatively leading to straining and wound dehiscence
Ignoring patient symptoms and focusing solely on anatomical grade.