Managing Posterior Vaginal Wall Prolapse
Once you have determined the size of your dissection, use a dilute vasopressin solution to infiltrate underneath the posterior vaginal wall along the dissection margins (we use vasopressin 20 U in 50 cc of normal saline). An incision along those margins is made with a knife through the mucosa. Metzenbaum scissors or a knife can then be used to excise the vaginal mucosa.
I prefer to keep a finger in the rectum at all times. This helps prevent inadvertent placement of a stitch in the rectum. I generally grasp the edges of the incision with Allis clamps and mobilize the “rectovaginal septum” off the posterior vaginal wall.
Prolonged delayed absorbable sutures are used to plicate the fibromuscularis tissue in the midline in a side-to-side fashion. I generally use a 2-0 polydioxanone (PDS) absorbable suture on a CT-2 needle, oplaced in interrupted horizontal mattress stitches to the level of the hymen. I try to create a ridge of tissue that is directed posterior toward the rectum.
If the rectal ampulla is enlarged, it will often invert as the dense connective tissue is plicated, thus reducing the size of the rectum. Depending on the size of the rectocele and how high I have gone with the rectocele repair, I place two to eight stitches.
Generally, before placing those sutures, I will place a stitch using a 3-0 Vicryl suture at the apex of the incision so that once I finish the deep layer I can easily run a 3-0 Vicryl suture interlocking with about every third stitch to the level of the hymen. I have found interlocking every few stitches prevents shortening of the wall.
When applicable, the perineal body must be addressed next. With the extent of the deficiency taken into account, I mobilize and dissect the mucosa with Metzenbaum scissors so that I can identify or at least attempt to palpate the ends of the retracted bulbocavernosus muscles.
I will grasp these muscles with an Allis clamp and place a horizontal mattress of stitch using a 2-0 PDS suture on a CT-2 needle. The assistant frequently will assist by grabbing the needle with a tonsil clamp. A finger in the rectum can also help stabilize the needle.
Depending on the tissue, I will place one or two layers at this point. I will then close with the 3-0 Vicryl suture that I'd placed above and held, with a deep layer down and a subcuticular layer back up, with the knot just inside of the hymenal ring, similar to an episiotomy closure.
Although not glamorous, repair of a posterior wall defect can often be life changing for a patient. The ability to have bowel movements without manual manipulation, wear a tampon, or just regain confidence as a consequence of improved body image is invaluable.
Often, at the end of a long reconstructive case, the relative importance of a good colpoperineorrhaphy can be hard to appreciate. Yet, for the completion of pelvic floor function and anatomical outcomes, it is often a necessity.
Seventy-five to 95% of women will have good anatomical outcomes with this type of repair with similar improvements in splinting for defecation.
Allis clamps are placed on the hymen at approximately the 5 o'clock and 7 o'clock positions. Clamps are adjusted to desired introital size. Figure 2: Mobilize the “rectovaginal septum” off the posterior vaginal wall. Figure 3: Plicate the fibromuscularis tissue in the midline in a side-to-side fashion. Figure 4: A tonsil clamp is used to invert the enlarged rectal ampulla as the dense connective tissue is plicated. Figure 5: Mobilize and dissect the mucosa of the perineal body to identify or at least attempt to palpate the ends of the retracted bulbocavernosus muscles. Figure 6: Grasp the retracted bulbocavernosus muscles, and place a horizontal mattress stitch. Figure 7: Close the repair with Vicryl suture that was placed above and held, with a deep layer down and a subcuticular layer back up, with the knot just inside of the hymenal ring.
Source Photos courtesy Dr. Dee E. Fenner
Revisiting Symptomatic Rectocele Repair
Concerns have been raised about the use of mesh and subsequent erosion in rectocele repair via posterior colporrhaphy, although many still advocate the use of mesh. Furthermore, it has been noted in several studies that vaginal surgery augmented by mesh did not result in significantly less recurrent prolapse than traditional colporrhaphy. Given this issue, it is pertinent to revisit posterior colporrhaphy and perineorrhaphy for rectocele repair without mesh augmentation.
Approximately 200,000 women undergo surgery for pelvic prolapse each year in the United States. According to the Department of Health and Human Services' Administration on Aging, three-quarters of women with prolapse have a rectocele. It has now been nearly a century since approaches to the posterior compartment to treat symptomatic rectoceles were first described. Through much of this time period, posterior colporrhaphy and perineorrhaphy have proven to be the gold standard. By plicating the posterior vaginal muscularis or medial aspect of the levator ani muscles in the midline, and when prudent performing a perineorrhaphy, cure rates of 76%-96% have been noted.
