Re: Recurrent rectocele
From: Andrew Folley (agfolley@hotmail.com)
Thu Nov 30 12:14:25 2006
Glenn
I have been using mesh in the posterior repair ofr over one year and
probalby 30 cases.
I do not believe any research protocol is necesssary. American Medicao
Systems has the Apogee and Perigee systems for mesh placement in the anteror
or posterior.
If you are contemplating a repeat rectocoele repair I would strongly suggest
use of mesh for strenght and long term resilience. andrew
>From: "Elrod, Darryl G Maj 48 MDOS/SGOBO" <Darryl.elrod@LAKENHEATH.AF.MIL>
>Reply-To: ob-gyn-l@obgyn.net
>To: Multiple recipients of list OB-GYN-L <ob-gyn-l@dns.obgyn.net>
>Subject: RE: Recurrent rectocele
>Date: Thu, 30 Nov 2006 04:00:55 -0600
>
>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"
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>
>________________________________
>
>________________________________
>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.
>
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