VM38 - Transperineal Repair of Recurrent Rectocele

Purpose/Background: Rectocele is defined as an outpouching of the rectum through the rectovaginal septum and the posterior vaginal wall. It is most commonly identified in women after childbirth. Rectocele can present clinically as a component of obstructive defecation syndrome with difficulty in rectal emptying. This can include straining or need for digital splinting of the perineum or vagina to achieve complete evacuation. Surgical treatment of rectocele can include vaginal, perineal and transanal approaches. Transvaginal repair of rectocele has previously been shown to have more significant improvement in constipation and dyspareunia compared to transperineal repair. Studies comparing transperineal repair to transanal repair have shown equivalent rates of success and complications. In this video, we will describe a transperineal approach to rectocele repair for a patient with a recurrent symptomatic rectocele.

The patient is a 51 year old female with a history of a recurrent low left anterior rectocele. She had previously undergone a transperineal repair for a combination of a cystocele, rectocele, and stress urinary incontinence with urogynecology. She now reported needing to splint in the perineum to evacuate her bowels. On examination, a very low left anterior rectocele was observed. This corresponded to the area where the patient applied pressure to splint her bowel movements. She denied chronic constipation or fecal incontinence. Given the position of the rectocele, the decision was made to proceed with a perineal repair.

Methods/Interventions: A transperineal rectocele repair was performed. Full mechanical bowel preparation and general anesthesia were utilized. The patient was placed in prone position. A transverse incision was made over the perineal body anterior to the sphincter complex. The rectovaginal septum was dissected to 3 cm above the apex of the rectal weakness. The posterior vaginal wall was then reinforced with running 2-0 PDS suture. The anterior rectal wall was then examined and the redundancy was reinforced with running 2-0 PDS suture. A digital rectal exam was then performed with no identifiable weakness or depression of the anterior rectal wall. The rectovaginal septum was then reapproximated and the perineal body and skin were closed in multiple layers.

Results/Outcomes: Postoperatively, the patient did well and had normal, formed stools with no recurrent need for splinting.

Conclusion/Discussion: This case highlights the adequacy of a transperineal approach to rectocele repair for symptoms of obstructive defecation, and its utility specifically for distal and off-midline rectoceles.

References:
1 Spencer, C, and F Pakarian. “The role of childbirth in the aetiology of rectocele.” BJOG: an international journal of obstetrics and gynaecology vol. 113,7 (2006): 849; author reply 850. doi:10.1111/j.1471-0528.2006.00979.x
2 Farid, Mohamed et al. “Randomized controlled trial between perineal and anal repairs of rectocele in obstructed defecation.” World journal of surgery vol. 34,4 (2010): 822-9. doi:10.1007/s00268-010-0390-y
3 Balata, Mohammed et al. “Functional Outcome and Sexual-Related Quality of Life After Transperineal Versus Transvaginal Repair of Anterior Rectocele: A Randomized Clinical Trial.” Diseases of the colon and rectum vol. 63,4 (2020): 527-537. doi:10.1097/DCR.0000000000001595
4 Zimmermann, Eleanor F et al. “Transperineal rectocele repair: a systematic review.” ANZ journal of surgery vol. 87,10 (2017): 773-779. doi:10.1111/ans.14068