Laparoscopic rectocele repair using polyglactin mesh

May 1997, Vol. 4, No. 3

TheJournal of the American Association of Gynecologic Laparoscopists

Laparoscopic Rectocele Repair Using Polyglactin Mesh Thomas L. Lyons, M.D., and Wendy K. Winer, R.N., B.S.N., C.N.O.R.

Abstract

We assessed the efficacy of laparoscopic treatment of rectocele defect using a polyglactin mesh graft. From May 1, 1995, through September 30, 1995, we prospectively evaluated 20 women (age 38-74 yrs) undergoing pelvic floor reconstruction for symptomatic pelvic floor prolapse, with or without hysterectomy. Morbidity of the procedure was extremely low compared with standard transvaginal and transrectal approaches. Patients were followed at 3-month intervals for I year. Sixteen had resolution of symptoms. Laparoscopic application of polyglactin mesh for the repair of the rectocele defect is a viable option, although long-term follow-up is necessary. (J Am Assoc Gynecol Laparosc 4(3):381-384, 1997.) The history of rectocele repair dates to the early 1900s when approaches to the posterior compartment to treat the defect were described. ~'2 Perineorrhaphy and posterior culporrhaphy became the standard of operative care despite the dearth of data to support them. 3Early in the development of the procedures, prosthetics were described; for example, inverted vaginal mucosa as a sling for the posterior vaginal defect 4 and another graft procedure? These efforts seemed to acknowledge the fact that the defect was a vaginal one, an injury to Denonvilliers fascia, not a rectal one. Still coloproctologists approached the problem transrectally despite the anatomic illogic of this procedure. 6' 7 Due to the fact that structural problems were only one component of the disorder, surgical outcomes were dismal in the few studies that examined clinical outcomes of rectocele repair. This was at least partly because of neurologic deficits associated with pelvic floor injury. Demonstrably good results were reported

in a series of women who underwent rectocele repair in which Marlex mesh was placed transperineally. 8 Postoperative perineal pain was significant, but the need for digital defecation and symptomatic prolapse were reliably resolved. With our experience entering the rectovaginal space laparoscopically, we conducted a trial of this technique to evaluate the efficacy of mesh application by laparoscopy. Materials and Methods Twenty women with symptomatic rectocele (digital defection, constipation, rectocele prolapse) were enrolled in this evaluation of a proved technique using a different mode of access to the rectovaginal space. Patients were interviewed postoperatively at 3-month intervals to assess clinical results. They were asked a series of questions regarding outcome of the procedure

From the Center for Women's Care and Reproductive Surgery, Atlanta, Georgia (both authors). Address reprint requests to Thomas L. Lyons, M.D., Center for Women's Care and Reproductive Surgery, Suite F-6230, 1140 Hammond Drive, Atlanta, GA 30328; fax 770 391 0020.

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RectoceJeRepair with Polyglactin Mesh Lyonsand Winer

and sexual function, including resumption of normal sexual relations, dyspareunia, and orgasm frequency. Interviews were conducted by the same individual, and responses were not available to the authors until all 20 women completed 1-year follow-up.

After the mesh was applied, a high McCall procedure was performed, applying serial purse-string sutures to support the upper third of the posterior vault. These sutures included Denonvilliers fascia anteriorly and the lateral pelvic sidewall on either side. These final sutures were 0 polyester. Finally, remnants of uterosacral ligaments were found superiorly and included in the purse string, and the vault suspension was complete unless a sacral culpopexy was indicated. The anterior compartment was then treated with either Burch (1 or 2 sutures of 0 polyester) or paravaginal repair. Patients were allowed to recover in a 23-hour unit and were discharged as soon as they felt comfortable. Catheterization was limited to that time period. No vaginal packs were used. The women were allowed to resume normal activity depending on discomfort, but were cautioned against lifting (>20 lbs), straining, or intercourse for 6 weeks. After a 2-week postoperative check-up, all contact with the patients was by telephone at 3-month intervals unless complications arose.

Operative Procedure Open laparoscopy was performed in all cases. Concomitant procedures included hysterectomy with or without bilateral salpingo-oophorectomy, and other pelvic floor surgery (paravaginal repair, Burch procedure, sacral culpopexy, high McCall vault suspension). A total laparoscopic approach was used to treat all pathology, although perineorrhaphy was performed due to introital laxity in three women. The rectovaginal septum was opened using the contact neodymium:yttrium-aluminum-garnet laser scalpel, and blunt and shm-p dissection was performed to open the space down to the perineal body. The levator complex was visualized and the lateral limit of the dissection was the lateral pelvic sidewall. A 4 x 12-cm piece of polyglactin mesh was attached to the posterior surface of the perineal body using 0 polyglactin sutures. The mesh was anchored to the posterior surface of the vaginal vault (Denonvilliers fascia) using the same 0 polyglactin sutures with curved-needle suturing techniques, u If the cervix-uterosacral complex was intact, mesh was attached to this structure. If the complex was not intact, the anterior pubocervical fascia was plicated to the posterior rectovaginal fascia and uterosacral complex, and mesh was attached to this complex (Figure 1).

Results

Table 1 gives a clinical summary of the patients. The procedure was associated with strikingly low morbidity (Table 2). The 95% rate of symptom relief was more than comparable with existing data on pelvic floor surgery. The goal of obtaining at least equivalent results while lowering morbidity appears to have been achieved in this small group of subjects. Discussion

~"/'"~'--'~--~"\

Perineal

-\ R9

/• \

~~-~Vagina

~,~Uterosacral

Ugaments

FIGURE 1. Diagram of polyglactinmeshattachedto the posterior rectovaginalfasciaand uterosacra[complex.

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The most common complaint related to the pelvic floor is incontinence. The disorder is most likely associated with stress urinary incontinence, but it may occur with other types of urinary incontinence, fecal incontinence, and constipation or rectal fullness. The defects may be due to anatomic causes, but neuromuscular components also play a major role in the development of disorders of the pelvic floor. Much progress has been made in the medical treatment of these conditions, such as physical therapy, biofeedback, and neural stimulators; however, surgical therapy addresses their anatomic origins. Minimally invasive surgical techniques have been applied, with successful adaptations of the Burch procedure. Clinical outcomes after 3 years and longer appear to be consistent with those of traditional

May 1997, Voi. 4, No. 3

The Journal of the American Association of Gynecologic Laparoscopists

TABLE 1. Patient Demographics

Variable

Result

Age (yrs)

56.4 (range 38-74) 53.6 (range 42-78) 3.0 (range 1-8)

Weight (kg) Parity No. of concomitant operative procedures Laparoscopic supracervical hysterectomy Burch procedure Paravaginal repair McCall culpopexy Sacral culpopexy Rectopexy Perineorraphy Concomitant medical problems Adult-onset diabetes mellitus

Several variables were controlled in our patients, including work by a single surgeon, a dedicated unit, standard materials, and a heterogeneous patient group. However, other than digital defecation or symptomatic prolapse, objective measurements were not made. Perhaps the new standarized method of reporting pelvic floor prolapse developed by a committee of the International Continence Society could be helpful in this regard, but patients would still have to serve as their own controls due to anatomic variations, n The technical requirements of this procedure are not extensive. Anatomic landmarks are easily reached, and laparoscopy provides a relatively bloodless window into the rectovaginal space. In patients in whom an isolated low transverse defect is present, the technique may not be ideal. The rationale for applying minimally invasive surgery to existing procedures seems to fit this group of patients. Further investigation of the technique is warranted with long-term follow-up data.

12 20 16 20 4 3 3 2

TABLE 2. Outcomes

Variable Operating room time (min) Estimated blood loss (ml) Clinical success at 1 yr (%) No. of patients reporting sexual dysfunction Dyspareunia
References

Result

1. Ward GG: Technique of repair of enterocele (posterior vaginal hernia) and rectocele. JAMA 79:709-715, 1922

35 (range 20-48) 5 80

2. Moschcowitz AV: The pathogenesis, anatomy, and cure of prolapse of the rectum. Surg Gynecol Obstet 15:7-15, 1912

0 0

3. Nichols DH, Randall CL: Vaginal Surgery, 3rd ed. Baltimore, Williams & Wilkins, 1989, pp 313-327 4. Zacharin RF: Pelvic Floor Anatomy and Surgery for the Pulsion Enterocele. Vienna, Springer-Verlag, 1985

0 0 0 0 11.5 (range 3-23)

5. Oster S, Astrup A: A new vaginal operation for recurrent and large rectocele using dermis transplant. Acta Obstet Gynecol Scand 60:493-495, 1981

procedures. 9 Currently, attempts to duplicate paravaginal repair laparoscopically are under way, including comparisons of results. Some surgeons described attempts to correct posterior pelvic floor defects by laparoscopy.'~ However, descriptions of both traditional and laparoscopic techniques lack follow-up data, and data that do exist seem more anecdotal than applied. 11 This report is an attempt to clarify existing information on laparoscopic posterior pelvic floor repair and to present a reprise of an old technique to accomplish the repair.

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6. Sommai S: Transrectal repair of rectocele: An extended armamentarium of colorectal surgeons. Dis Colon Rectum 28:422-433, 1985 7. Block [R: Transrectal repair of rectocele using obliterative suture. Dis Col Rectum 29:707-711, 1986 8. Parker MC, Phillips RKS: Repair of rectocele using Marlex mesh. Ann R Coll Surg Eng173:193-194, 1993 9. Liu CY, Paek W: Laparoscopic retropubic culposuspension. J Am Assoc Gynecol Laparosc 1:31-35, 1993 10. Vancaillie TG, Butler DJ: Laparoscopic enterocele repair--A description of a new technique. Gynaecol Endosc 2:217-221, 1993

Rectocele Repair with Polyglactin Mesh Lyonsand Winer

11. Lyons TL: Minimally invasive treatment of urinary stress incontinence and laparoscopically directed repair of pelvic floor defects. Clin Obstet Gyneco138:380-391, 1995

12. Bump RC, Mattiason MD, Bo K, et al: The standardization of terminology of pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 175:10-17, 1996

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