Site-Specific Posterior Colporrhaphy and Perineorrhaphy for Rectocele

CHAPTER 1

The patient's a young woman who had a longstanding history of pelvic floor dysfunction and constipation, and had over the past several years a couple of vaginal births. Not tremendous perineal tearing, but enough that she noticed that she had increased symptoms. So, symptoms of defecatory dysfunction- constipation, worsening constipation, such that she would splint to have a bowel movement pretty much every day or every time she needed to have a bowel movement with, incomplete evacuation as well. Our surgical approach was to work on her posterior vaginal wall, which is where her symptoms really were. Now in this patient, you could see she had some anterior vaginal wall laxity and something which we call vaginal lappets, which are just vaginal wall redundancy that actually did not incorporate any bladder behind it, or something we would call a cystocele. So our plan was just to revise that, just so that she didn't have that feeling of bulging out of her introitus at the end of her surgery, which would really just represent redundant vagina but not true prolapse. So, that was the minor anterior vaginal wall revision we did. Posteriorly, we did what's called a posterior colporrhaphy and perineorrhaphy where we restored her posterior vaginal wall, reducing what we call a rectocele, and- then also creating a restored perineal body. So you can see at the beginning of this case, she had mostly just perineal skin put together, and that perineal tethering of that skin doesn't provide for any support of the pelvic floor structures that are behind it. And so that's where that rectocele needed to be reduced. Key portions of the posterior colporrhaphy, and I think an important thing, is to make sure that you're restoring what we call the rectovaginal septum, and those tissues that are between where the rectum is and the vagina is- in between that, the supporting structures can be interrupted, and so finding the break, or that interruption, is really important, and so that was something that we were looking for. In this case we did a site-specific posterior colporrhaphy. A site-specific repair is basically looking for the actual break in the rectovaginal septum, and sometimes it's not obvious, and if it's not tremendously obvious, then a plication in the midline has been demonstrated to be of equal value. But certainly when you see a break that's very obvious in the rectovaginal septum, it's prudent to put that together instead. We used a delayed, absorbable suture in that circumstance, and then in the remainder, a Vicryl suture. The reason I use regular suture is just to decrease the risk of what we call dyspareunia, or painful intercourse.

CHAPTER 2

So right now we're draining her bladder. This is a patient with a significant, symptomatic rectocele and perineal laxity. So as you can see, she has a little bit of anterior wall prolapse and some vaginal wall redundancy here, something we refer to as lappets- you can see them. And so we'll probably revise this anterior vaginal wall laxity right here- this is just vaginal wall. And then- based on her prolapse as well as her symptoms, we're probably going to leave that anterior wall as is. This is a patient with a complicated history of pelvic floor dysfunction. I'm going to- just demonstrate her posterior wall examination- which includes- basically since her delivery, she's noted significant gaping and pelvic floor heaviness, and this is just perineal skin essentially that's been put together with very little muscularis here of the perineum, and a very large, gaping- rectocele. She's had constipation since childhood for some pelvic floor dysfunction that she has as a baseline, but this was exacerbated by childbirth, such that every day she's splinting to defecate, and has significant pelvic pressure and pain- posteriorly. So, that's why we are here today.

CHAPTER 3

So let's go ahead, and we'll do the lappets first, just to… With that done, we're going to inject. We're injecting 0.25% with epi. You can see that this is really just vaginal tissue. I'd probably take it at the base of the lappet, but not further. Okay. So I was thinking, if I make an incision here, then we can take it down here and here, remove those, and then close it vertically. Sure. So I'm probably going to have you make a more… Even wider there. Yeah, because then basically we'll essentially do an elliptical incision. I might even have you do it across. Okay. Nice. Let's just make sure we're happy- as happy on this side. I almost feel like the teeniest… Yeah, kind of here? Uh huh. Come in with that blood vessel. So I'm going to kind of come... Yup. Let's see where that goes. Yeah, love it. Go all the way to that corner, yup. That's good, alright. Healthy tissue. 2-0 Vic. Alright. That's just giving you a little bit of exposure, it's not particularly... Nice, big bites too. If you can. Want to get behind that? Yup, I love it. Let me get rid of this. Do you want to do a cysto after this, or...? I don't think we made a cysto for this one. This is such a superficial and not lateral dissection that- literally we're just doing the vaginal wall, but in repairing it here going full-thickness. I love that you're doing full-thickness. You know what I mean, like I feel like sometimes you can lose sight of where mucosa is. Yeah. And, I think that's how we get granulation tissue and impaired healing. As you can see, like when we get our perineal restoration, that just not having that is going to be very comfortable for her.

CHAPTER 4

So now we're placing Allis clamps at the hymenal remnant, trying to ascertain what the limits of our dissection will be laterally. Grab it. I don't- this one I think needs to be up a little bit. Okay. Still could be a little tighter. Okay. Do it. What do you think? It looks good. Do you have water? You don't have any. I hesitate to go any higher than that on a young, premenopausal… You probably could, just the teeniest bit. Yeah, you're pulling it? Yup. So ever so slightly, I would take it. It's like right on the other Allis. Yup. And that one too. Basically bringing your Allises together to inspect what your introital… That's going to feel much better. Diameter will be at the close of the procedure. Okay. Do you have that Marcaine with epi, please?

Alright, so we're injecting Marcaine with epi. Injecting with 0.25% Marcaine with epi- this is used for hydrodissection and also for hemostasis. Sometimes with posterior colporrhaphy in general, you can see areas of scarring and puckering, particularly in the posterior vaginal wall, and and you can oftentimes use, your hydrodissection to even bring out some of that puckering, like right there you'll see sort of brings that area of dissection right out to you and makes it a little bit easier- you can see that that'll bring that vaginal wall out a little bit. Thank you.

CHAPTER 5

So we start by making a linear incision. Sometimes we'll make a V-incision. Notice patients have more perineal pain sometimes from that. It isn't really necessary as you'll see when we close. These Allises- if you put them on a SNaP with a rubber band, it allows for a little bit more subtle movement. If you don't have a- another assistant, they're really quite helpful. These initial cuts can oftentimes be the hardest part because this is where all the perineal scarring from obstetrical tears and episiotomy tend to take place. So oftentimes this is the place you want to get your dissection started. You can see if you buttonhole, you can just take it, and… Teeing up on her- these are Aesculap scissors, basically sharp Mayos, but certainly Metzenbaums work beautifully too. Just make sure that you… I'm going to keep. You want to keep going? So keeping the tips of that- instrument up to avoid- any posterior wall- I think you probably don't even need to advance if you want to… You can see that she goes in and out, and a little bit of spread at the time helps even to do some of that lateral dissection. We're going to take this one. I am? Yeah. I feel like it's easier.

Yeah, absolutely. So you can always take it further up and oftentimes underneath the vaginal mucosa, we will. So now she's taking some of that down. And with a Ray-Tec sponge open a lot of the way, you can allow for some… So you can see this rectovaginal tissue that we're taking down. And some of this we're going to be able to do even bluntly. You can see taking that down just very methodically in that plane, particularly in the areas of scarring is really important. So Ray-Tec sponge opened a lot of the way, provides kind of just the right amount of traction. So counter-traction, you can see this is exactly the plane, and this comes down beautifully without any resistance. Careful here. Yeah. So... It's right there. Yeah. I think actually, it comes down like that. Yeah, I'm seeing it. That's why it's getting so thin. There, that's what we want. So this is all inner, and this is your external. You're going to want to take it right below that, yup. What we're doing is making sure you can see- we call them our Allises that never move, those first two, and that gives you your point of inferior and hymenal tag. Yup, put that right here, and that way we can just release. You... even further than that. I just want these to be down because then we'll be able to- we want to get in there. Okay, on to this one. Okay. Actually, before we go, let's just get a little bit of… That's great. Love it. Good shot.

Alright. Sorry. You can see those fibers, how it allows you to delineate where your plane is, and with this Ray-Tec sponge, you can take it down, but oftentimes if there's any resistance whatsoever, I'll do it sharply just to allow for a very controlled dissection of that area. Holding it out anatomically versus almost inverting it more like this, is sometimes helpful because you can maintain that plane of where you can see, you know how you can see those fibers so much easier. I feel like I prevent buttonholing in that way.

CHAPTER 6

So, site-specific defect repair versus imbricating midline plication has been studied, and generally it's felt that there probably is no specific, advantage of one over the other. I'm finding this to feel… Is it stronger there? This is stronger stuff. This certainly isn't. So let me just show- so you can see that restoring- this is good stuff right here. So this probably to up there is going to be nice. You can see- right here is thin. This stuff... Maybe we can do a site-specific there. Actually- if this- look how nice that is. Oh, yeah. So- grab where I am. Go under like I am, I think it's going to be an easier- what I want to do is demonstrate- this is basically alleviating everything. With the rectal hand, nothing going through. You can see a little bit here- we'll get that fine. But this completely restores the bulge and the rectovaginal septum. Maybe a PDS will last longer though, it's probably a good idea. Alright, you have it? Yeah, the 2-0, not 0.

Okay, so let's grab this first, and then I'll go back and grab that corner and the like. Yeah. This is where oftentimes I'll tack where my sense of that site-specific defect to be. And even if you need to take it in a few, it's fine. I try to minimize the number of knots I have of PDS. So are you thinking that we're going to start here… Into the corner pocket. And then we may stick, you know, something up there, but I would get this one in the corner pocket. So, and I'll let go of this now. Yup. And what I want to do for you now is- yup- is retract that. Basically you're tacking the beginning of your site-specific defect to where you want it to be. Right, so this is where I would think. Yeah. You're fine. I have a hand in the rectum. Okay. So, I actually... I'm just going to check the posterior fascia. Yeah. I tend to leave my hand, my left finger, in the rectum for a lot of this repair just to allow me to access enough rectovaginal tissue and not compromise what I'm using, and yet still know that I'm not in the rectum. Yeah. Important things. You got that knot down tight, good. Yeah, I do- two back-hands... Yup. We're going to do a running PDS on this. I don't tend to use too much PDS, particularly as you get closer to the introitus, because of the delayed absorbable and… Can I get the Browns? Thank you. Alright, so now I'm going to switch back to using the... That's a lot of… Going here first. Sure, so go- I want you to be, yeah, up higher and in there. Okay. For this, this first one I want like, it's basically your… Just- I'm double checking you. It's not- that's not a very good bite. Take it out. You want to be, yeah. Good, and I'll check it. It's good. So you'll feel me if I get near you? I am, so I- I tend to have a finger in the rectum mostly because with each stitch I tend to check because I don't really want to know at the end of the case. Yeah. And so, some people will- I'm not, and then again, we're going to look very smartly at where we're placing this because as we continue along, this will be much more obvious. But as you start it, you can see there's a decent amount of tissue that I actually think is part of the- part of it here. And then we're going to need to bring this stuff up. So I would start with this coming closer here. And I actually feel like- let's just re-find it, I feel like it was- this is also going to come. So I think there's this in between. Are we're trying to cover that, or you want to bring it over? You know, this doesn't look that bad to me. To be honest, she has a lot- she's got a lot of great tissue on this side, which is interesting, right? Because this is where all the scarring was. So I feel like that needs to- I don't want to pull it too much. Right, so we started it with this, right? We want- can you hold that for me? Like what I really want- is… Where did that- Where did that go? Because do you feel how thin this is here? To this we want- cover that. It feels like it gets covered with this- to that. You know what I mean? Like you're bringing that over. So there's going to be- there's going to be 2 different repairs. Like, you're going to put this over here… And then we're going to bring that up.. This is going to be created, but this has to go with it. But I want to just make sure we- we restore that where we want it. Like, do you see how like this is good stuff right here? Do you feel? Yeah. So right here.. Oh. Right, So we were kind of looking at it almost like this. But this is hard, there's not a lot of this. She has some good stuff, like this is all great stuff, and it connects with here. I think it may end up going like this. This stuff here is really good stuff. Okay. So you can see her rectum poking through right here. So her break is like this. Uh huh. So, this is still remnant of good. This has to go up here. Pull your stuff up. My stuff's to there. That's what you want. Okay, so I'm going to grab this. Yup. To start. Right here? Mm hmm. So the problem is if you took this medially, you- we're going to connect nothing to nothing. Mm hmm, well that's why I think that- that data is… So you can see this is going to be glory- like this is a beautiful repair. You can see the break here. It's almost like now like that. Hey, so over here, like you can see- this is an important thing, you can actually see this now, where this goes. So the key is not to restore it like up here, it's to restore it from down here. So this is going to go together nicely without any tension, and then it's going to basically go around. You want me to just kind of come like this then? Yeah. Mm hmm. You okay with one bite? We're now bringing that across. See, this is just staying down It feels really, really good. Just to kind of strengthen it a little bit more. Mm hmm. I'm feeling like, you see how this just totally reduced? You're nowhere near the rectum here. Well, and the appropriate amount- I mean a finger in the rectum right now is allowing us to get the bites we want to really restore this rectovaginal septum. Yup. Let me get a good one here, get around those vessels, and then I'll get- dip down, and... Yup. That's exactly what I want, right, you're going to like get in there somewhere. Yup. This is- yeah, yup, you're just tying this, so get something. I'm not in the rectum. Alright, so the part that I'm questioning is whether we should do something with that left upper quadrant. Yes, like here-ish. Yeah, like with a little running? Of like 2-0 Vicryl? Whatever. Yup, so now we're just going to- finish this off. Let me back in the rectum. Yup, good. Yes, I want- I want you to bring- yeah, I want it to be… Do you want me to go down one here and then go up and around? Because we're going to have to attach all that too. Yeah, so you're going to take- why don't you take that like down here. And then we'll do what we call the rainbow- you know, May's rainbow stitch? So we oftentimes refer to this stitch we're about to do as a rainbow stitch. In general, loaded as a lefty, and then attaching just that proximal area of the rectovaginal septum that we're repairing over to itself. You can see there's- we started in that corner and came down, but I just want to bring that up and restore that. You can see the edge there. So it's going to be kind of along this here. Yup. Happy with that? Yeah. Don't go too far down. Be gentle with your pulls. Alright, I'll put that really- to this. And I feel like this is nice. There's no pooching going on, which is the nice thing. We have a bit of rundown from the part that we're going to excise. You're going to tie that soon? Do you not want to take it all the way across then, or? No, you can. This is good, tough stuff. You're closed, so I would just tie this. Okay. Mm hmm, good. Alright, needle back. Thank you.

CHAPTER 7

So sometimes with a site-specific defect repair, you'll have multiple breaks and multiple different… You okay if I take... Incisions, mm hmm. This one was pretty evident and pretty obvious. But we're going to go ahead now- you want to trim this side first. As you can see when we're trimming this, keeping an eye on what's below- and- kind of making sure we're below all the buttonholes. If you buttonhole low, and you're worried about that, you can always take that in two as well. I'm going to move this a little bit. I almost err on the side of leaving more vagina than less because I find that it's what you're doing underneath that matters the most, and the vagina restores itself, so if it's stretched out, it can un-stretch itself out, but in general we'll just trim those edges, but not too much here. Yeah, that's great. I love it. Just underneath this Allis, and just- bring it upward toward there, yup- you cut- yeah, exactly like, lead toward a non-button- not a dog ear.

CHAPTER 8

Do you wanna do any- do you want to do any more layers or anything? When we get further down? Can we take a...? Yeah, the perineal restoration? Mm hmm, perfect. Taking full-thickness bites. Pull- yeah, down. Good. It's a little bleedy over here. Here, do you want to grab? Mm hmm. I want to bring a little bit of that together, although it's such a nice plic- like I don't want to have a midline plication, especially in a young, you know what I mean? Not menopausal patient. And make sure that we build up this perineum though good. I want you to do this- yep, keep going, nice big bites though, I don't like little. And then we're going to stop soon, right? Probably... I would probably just stop. Yeah, I agree. And now grab your stitches and do your stitches. Okay.

CHAPTER 9

So, I would be methodical though. Do you put some up here first? Or you just? Sometimes, do you want me to put some up there? I do. So now what we're doing is we're doing some restoration of the rectovaginal septum just a little bit more superficially, and I'm going to grab… So higher still. Higher still? Yeah, like you're still in the rectovaginal septum. Then I'd just double- don't move. Wonderful, perfect. So I like to think of this almost as two planes of restoration, this and this. So we'll put some in to allow for that also. I'm gonna take this off if that's alright. I want to come… These are really important to get them wide and separate- yup- like deep and wide, you know? Want a 0 for any of this? I'm going to take a 0. We're thinking about this almost in terms of two planes, so this horizontal plane and this more vertical plane of the perineal body, and so we're still restoring this horizontal plane. Go ahead. And- nice and wide, yeah, good. Yup, and superficial to other bites. Yeah. Yeah. And then again, short. It's perfect. It's important to take these in two bites because you don't want to shortchange that right side. So you can see, we've already essentially re-established a new perineal body. Here. And I think that we probably need to trim this little... Yup, agree. Perfect. Love it- we have it even though, basically restoring this beautiful - I know. Because now we need to do like perineum, right? What I'm wondering is like... Yup, yup. I love it- we'll do a U-stitch here. Yup. We're getting right now the deep and superficial transverse perinei muscles that are coming across like this, and we're now restoring them. Yeah, I want to go more deep maybe, or you got it? We'll see what we think of this. Yeah, I see that. There's a little divot there. If there's going to be a divot here, we're going to take it out. Yup. You think that was from your bite? No, I think it was there, but I want to know if I fixed it. Oh, looks pretty good.

CHAPTER 10

Yes. I know. The vaginal wall will re-accommodate, and… What I want to know is like, is that… Yup. Yes. I love what you're doing. This is exactly what I wanted you to do. Perfect. It's really important to restore the supporting structures underneath the vagina, and the vagina itself will tack itself down and unstretch, if you will, itself. Mm hmm, that's perfect. Okay. That's exactly what I had- take it in two bites, take it in two bites. I don't want that to rip, you know what I mean, I think sometimes we- go ahead, yup. Perfect, that's exactly… So the important thing is to continue with full-thickness mucosa to full-thickness mucosa. Some bites I'll lock, some bites I won't lock. Most of the time I don't lock. But… As we're approaching the introitus, it's also important to line that up. So I would be taking closer bites on this side and further on this, right? Like this on that side? Yeah, so closer on your side- nice, full-thickness… So then this up here is? Mm hmm, yup. You wanted this to come up, right? Yeah, I really want- I want that off, I'm not sure… Yeah it's not- it's not really even part of that, I mean I can bring it up and... It's coming off. Because originally this was what I was planning on bringing. Yes, I want this- like that should probably be to there. This is- I just want to make sure you're deeper here. Do you know what I'm saying? Okay, yup. You see how it's like this a little? But I do want to like come... Yeah. Okay. Alright, I think we're... I think… You think what? Are you going to dunk, drive, and come back. What is your plan right now? So my plan is to bring this here. Yep. And then dunk, go down below. Sure, perfect. Is that...? Yup, I'm sharing it. I was going to treat it like an OB. Yup. Since she's so young. And this we can do... And go very- and then- yup, bring it… This little guy. Up close, yup. So go above, you know what I mean? Above the hymen, and that'll bring it there. And then you're going to dunk under, right? Do you want me to kind of come here? Why don't you go above it a teeny- yup, mm hmm. This is what I would usually do just like... You could just… So whatever is this is now going to go to- yup- I like it. So- do this number. Mm hmm, yup. And then do the same thing on the other side just to- So now we're basically starting it. Take out some of the space, because you- you call that your dunking stitch, right, was that? Kind of- yup. I mean I... Yup. I think we were saying the same thing, and I was just making sure that that- because you see how you brought that up? Yup. And now, just like an obstetric laceration, we're finishing off. That should fill in that space, and then just bring it back up. Mm hmm, yup, I agree. Almost nothing do I do very shallow and superficial on these bites. You know what I mean, because it's...? You want to restore the tissue. One thing that you'll notice is back-handing on that other side makes it much more easy to access enough tissue. You never want to shortchange your tissues so your stitch falls out. Always remaining parallel to the sagittal plane of the patient. So you can see that the stitches we're doing, are going in, out, in, out- almost in this direction as we march forward. And I think that's important because sometimes a transverse incision here can create that step just at the posterior or the distal transverse vaginal ridge. I think I might remove that. It's just hymen. It's just a little hymenal remnant here. So we're marching up again, parallel to the sagittal plane of the patient, past the hymen, and then we'll anchor it and tie it. So then she won't feel the knot. Not too far away. We're going to irrigate a little bit.

CHAPTER 11

As you can see, rectal exam to confirm no sutures in the rectum and beautiful reduction of that rectocele, which is no longer present. Just to demonstrate. There you go. Good. No sutures. Post anatomy.

CHAPTER 12

I think postoperatively what's important is avoidance of constipation. So we tell our patients for sure if they're taking narcotics to make sure they really up the postoperative laxatives and/or stool softeners. So everyone is on a stool softener and a dose of laxative daily. If they're too loose, they can titrate that to their own biology. I think that the biggest complications that we look for are dyspareunia, which is painful intercourse. And- recurrent constipation, recurrent prolapse. So prolapse, or pelvic floor relaxation, or when a patient can feel a vaginal bulge, it can- vary depending on what is the etiology of that vaginal bulge, so whether it's the anterior vaginal wall or the bladder coming through and protruding, something we know as a cystocele, if it's the posterior vaginal wall, such in this case that's a rectocele. And I think that some of the symptoms and some of the etiologies can be similar, so recurrent straining, constipation, anything- heavy lifting or recurrent lifting, patients who, you know, work packing boxes onto trucks- these are people who are more at risk for pelvic floor relaxation and recurrence of this, whether it even not be a recurrence of, in this case, her rectocele, but rather uterine prolapse or her cystocele. So, those are areas for opportunities. So the biggest complication I like to see is the avoidance of constipation. So patients who take narcotics postoperatively are certainly at risk for constipation, and so it's really important to manage that at the outset. The one I think very important thing with a posterior colporrhaphy is related to how much vaginal laxity there is. So the temptation to take a lot of posterior vaginal mucosa, and make the mucosal repair very tight to make the prolapse appear to have disappeared, it's a- it's a pretty tempting, thing to do, but really- almost if you took none of the relaxed vaginal and excess vaginal wall off, the vagina will restore itself when it's not on constant stretch and tension, so a really critical piece to this is to make sure that the repair of the underlying connective tissue and supportive structures is sound, and that's really important.