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Re: Recurrent rectocele From: Elrod, Darryl G Maj 48 MDOS/SGOBO (Darryl.elrod@LAKENHEATH.AF.MIL) Thu Nov 30 02:58:33 2006 Messages sorted by: [ date ][ thread ][ subject ][ author ] Next message: Andrew Folley: "Re: Recurrent rectocele" Previous message: Ronald Ainsworth: "Re: Recurrent rectocele" In reply to: Ronald Ainsworth: "Re: Recurrent rectocele" Next in thread: Andrew Folley: "Re: Recurrent rectocele" Reply: Andrew Folley: "Re: Recurrent rectocele" I just plicated the torn 'rectovaginal septum'. It wasn't too long after Karram had published an article that showed histologically that there really is no such thing as a true rectovaginal septum, so it doesn't necessarily surprise me that rectocele repairs fail. I contemplated using a mesh this time, but all the current literature that I can find says that mesh in the posterior vagina should only be used under a research protocol. If I were going to use mesh, I would likely use a Vicryl mesh so that it is absorbable over time and only is there for initial structural support. Anyone else with experience using mesh in the posterior vagina? Glen Rectoceles and the anatomy of the posteriorvaginal wall: Revisited [TRANSACTIONS FROM THE 31st ANNUAL SCIENTIFIC MEETING OF THE SOCIETY OF GYNECOLOGIC SURGEONS] Kleeman, Steven D. MD; Westermann, Cynthia MD; Karram, Mickey M. MD Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Good Samaritan Hospital, Cincinnati, OH Sponsored by a grant from Hatton Research Center, Good Samaritan Hospital, Cincinnati, Ohio. Presented at the 31st Annual Meeting of the Society of Gynecologic Surgeons, April 4-6, 2005, Rancho Mirage, CA. Reprints not available from the authors. Received for publication January 14, 2005; revised July 15, 2005; accepted July 27, 2005 Abstract <http://gateway.ut.ovid.com/gw1/ovidweb.cgi#toc#toc> Objective: The purpose of this study was to histologically evaluate the posterior aspect of the pelvis, specifically, the relationship between the perineum, posterior vagina, anterior rectum, and all other intervening tissue. Study design: The perineum, posterior vaginal wall, and upper part of the rectum were removed en bloc from 4 fresh cadavers without pelvic prolapse. Length of the specimens ranged from 6 to 7.9 cm and width 3 to 4 cm. Seven to 26 serial sections were taken from each cadaver. Sections were stained with hematoxylin and eosin (H&E), Masson trichrome, and Verhoeff Von Gieson elastic stain. Results <http://gateway.ut.ovid.com/gw1/ovidweb.cgi#24#24> : All 4 specimens showed dense connective tissue and no plane of cleavage for 3 to 3.5 cm proximally from the posterior forchette. Proximal to this, all 4 specimens showed space between the muscular wall of the vagina and the muscular wall of the rectum, which was composed of adipose tissue with discontinuous bands of fibrous tissue or loose areolar tissue. This appears to be a natural line of cleavage. Histologically, no evidence of fascia or a rectovaginal septum was identified. Conclusion: Histologically, there is no evidence of a distinct fascial layer between the posterior vaginal wall and anterior wall of the rectum. Clinically, it is the splitting of the adventitia and fibromuscular layers of the vagina that are used in defect-specific rectocele repairs to support the anterior rectal wall. //SIGNED// D. Glen Elrod, Maj., USAF, MC Obstetrician/Gynecologist Chief of Obstetrics 48 MDOS/SGOBO RAF Lakenheath, England Telephone DSN: 314-226-8130 Comm: +44 (0) 1638 52 8130 Notice of Confidentiality Under the Privacy Act of 1974, you must safeguard all information reflected on this e-mail and, if applicable, all attachments. Disclosure of information is IAW AFI 33-119, AFI 33-127, AFI 37-131, AFI 37-132, AFI 33-219, and PL 93-579" This e-mail message including any attachments is for the sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message. Any questions pertaining to disclosure should be directed to the privacy officer. ________________________________ From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Ronald -- ________________________________ Ainsworth Sent: Thursday, November 30, 2006 9:27 AM To: Multiple recipients of list OB-GYN-L Subject: Re: Recurrent rectocele Did you use a graft last time, or just plicate the posterior fascia? "Elrod, Darryl G Maj 48 MDOS/SGOBO" <Darryl.elrod@LAKENHEATH.AF.MIL> wrote: I figured I'd change the tone of the conversation to something along the clinical lines. 35 yo G4P4 with TVH/abdominal paravaginal repair/Burch/McCalls and a posterior repair with perineorrhaphy about a year ago presents back for recurrent rectocele symptoms. Although not as bad as before surgery, she still feels the need to splint with bowel movements and has increased pressure rectally. On exam there is still a significant bulge in the posterior vagina. On rectal exam, the sphincter feels intact, the posterior vaginal wall can be brought nearly to the hymen (better than before her last surgery when I could bring it past the hymen). The anterior vagina and the cuff are well suspended. I don't feel anything that would make me concerned for an enterocele and the upper half of the vagina there feels to be good support. Endoanal ultrasound shows a normal internal and external sphincter. Under normal circumstances I wouldn't be to concerned about either tackling this repair myself or sending her to a urogyn to repair. However, I got one of those turn the head, get red with embarrassment looks from her. I questioned what that was for and got 'do you think this might have something to do with liking anal sex???' Turns out, she likes it enough to not really want to be without it for any lengthy period of time. Oddly enough, I can't seem to find much literature at all on management of recurrent rectocele and none on risk of recurrent rectocele with anal sex. Any thoughts on a) if this would be enough to undo a perfectly good posterior repair (probably) b) if you repaired it again, how long would you prescribe nil per anus (6 months???) c) would you tackle this yourself or refer? Thanks, Glen //SIGNED// D. Glen Elrod, Maj., USAF, MC Obstetrician/Gynecologist Chief of Obstetrics 48 MDOS/SGOBO RAF Lakenheath, England Telephone DSN: 314-226-8130 Comm: +44 (0) 1638 52 8130 Notice of Confidentiality Under the Privacy Act of 1974, you must safeguard all information reflected on this e-mail and, if applicable, all attachments. Disclosure of information is IAW AFI 33-119, AFI 33-127, AFI 37-131, AFI 37-132, AFI 33-219, and PL 93-579" This e-mail message including any attachments is for the sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message. Any questions pertaining to disclosure should be directed to the privacy officer. Next message: Andrew Folley: "Re: Recurrent rectocele" Previous message: Ronald Ainsworth: "Re: Recurrent rectocele" In reply to: Ronald Ainsworth: "Re: Recurrent rectocele" Next in thread: Andrew Folley: "Re: Recurrent rectocele" Reply: Andrew Folley: "Re: Recurrent rectocele"

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