postheadericon Rectal Intussusception – Traditional Transvaginal Rectocele Repair

Transanal REPAIR & Marks was one of the first to note evacuation difficulties persist after treatment of traditional transvaginal rectocele. He also noted that many women with a symptomatic rectocele had a thinning'''' of the anterior rectal wall, including muscle layers, and an enlarged rectum. Based on these observations, he advocated repair of rectal side of rectocele. Although there are many variations and modifications, the main objective of the procedure is to remove redundant or complicated rectal mucosa and complicate the anterior wall of the rectum. Benefits attributed to the transanal approach are that it is a procedure of lesser magnitude than the gynecologic approach, it offers the opportunity to correct associated anorectal pathology, and there are more direct access to the area suprasphincteric. The disadvantage of this approach is the inability to correct a cystocele simultaneously. For transanal repair, the patient is placed in prone jackknife position. The submucosal plane of the anterior wall is infiltrated with a solution containing epinephrine such as 0.5% lidocaine in 1:200,000 epinephrines. A midline incision is made to a starting point just above the dentate line and is carried upwards into the rectum of about 7 to 8 cm, depending on the size of the rectocele. Alternatively, a rectangular flap of mucosa and submucosa is high. Mucosal flaps are developed on each side. Another option is a simple transverse mucosal incision 1cm above the dentate line. Meticulous hemostasis is achieved with cauterization. Failure musculofascial in the anterior wall is complicated by transversally with interrupted 2-0 absorbable sutures such as Vicryl. If the weakness persists in the anterior wall, another row of similar sutures can be placed. This line may be supplemented by three or four stitches in the same vertical field. The technique adopted by Sullivan et al. consists of longitudinal plication of the circular muscle of the anterior wall of the rectum with five or more slowly absorbed sutures as 2-0 Dexon or Vicryl. For large rectoceles, the authors recommend initial use of three or four stitches cross to take the elevator muscles of the anus within. The affixing cross is then reinforced by longitudinal plication. The authors have completely abandoned the use of transverse sutures for longitudinal plication. This decision was based on a subsequent prospective study of 100 patients, in which the authors noted septicemia and separation of the wound when the combined technique was used, especially in patients who had a large rectocele repair. Sarles et al. using interrupted polyglycolic acid sutures, with bites'''' of the rectal muscle wall socket every 5 mm. Their reasoning is that the anatomical lesion is due to the weakness of the circular muscle, the horizontal fibers of which are open and moderated by progressive stretching of the anterior wall of the rectum. Thus, the vertical plication sutures are more likely to reconstruct the rectovaginal septum. The excess mucosa is excised and the mucosal flaps are closed with absorbable continuous suture.

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