Rectocele Repair Periprocedural Care
- Author: Barbara Samm Frank, MD; Chief Editor: Kris Strohbehn, MD more...
Patient Education & Consent
Informed consent is an integral part of the planning process. The authors believe that it is important to discuss all the risks and benefits that pertain to surgery, including, but not limited to, the risks of bowel injury, dyspareunia, need for reoperation, and defecatory dysfunction.
If the use of mesh is considered, it is imperative to disclose the recent FDA advisory statements. The authors also suggest that the surgeon review the current guidelines put forth by the American Urogynecologic Society pertaining to this matter.
Materials that show diagrams of the anatomy are also very helpful. Pamphlets provided by the American College of Obstetrics and Gynecology for Pelvic Organ Prolapse are well received by patients.
Patients are instructed on a good bowel regimen in order to prevent straining and excessive Valsalva postprocedure. Stool softeners and a dietary instruction sheet are provided.
Elements of Informed Consent
The authors stress that patients are prepared and their expectations addressed prior to surgery (see above for details).
Prior to beginning the procedure, a thorough examination of the patient under anesthesia should be completed. It is important to re-evaluate the defect and to determine the extent of surgery when the patient is at maximum relaxation.
To perform the examination, the surgeon should place two fingers in the vaginal canal and the index finger in the rectum.
Basic equipment for rectocele repair includes a complete vaginal surgery tray and suction.
In some cases, a self-retaining vaginal retractor (eg, Lone Star [Lone Star Medical Products, Stafford, TX], Magrina-Bookwalter vaginal retractor [Codman, Piscataway, NJ]) can be helpful. These retractors can help immensely with exposure without the need for multiple assistants or having to suture the labia to the medial thighs.
Anesthesia is up to the discretion of the surgeon and patient. General, regional, or monitored anesthesia may be used. Many clinicians chose general anesthesia, regardless of the length of the procedure, to ensure adequate relaxation of the legs and pelvic floor.
Gynecologists tend to complete the procedure from a vaginal approach.
The patient should be in the dorsal lithotomy position, preferably in adjustable stirrups to optimize exposure. The Trendelenburg position may be helpful for exposure; however, prolapse may be masked by the patient’s positioning.
Colorectal surgeons tend to prefer prone or jack-knife position for an endoanal approach.
Monitoring & Follow-up
Patients are usually discharged the day of the procedure if it is completed vaginally.
Based on the patient and need for hemostasis, the authors occasionally place a saline-soaked vaginal pack for tamponade overnight. If a pack is placed, it is prudent to have a Foley catheter in place to avoid urinary obstruction. In this case, the patient undergoes a voiding trial prior to discharge from the hospital.
Narcotics and nonsteroidal anti-inflammatory drugs (NSAIDs) may be used for pain control; however, the pain should not be unbearable and should be controllable with oral medications. The authors also recommend liberal use of stool softeners to avoid any bearing down during defecation.
The patient is also instructed pelvic rest for at least 6 weeks after the procedure.
Perioperative complications include temporary urinary retention, pain, and constipation. More serious complications of the procedure include hemorrhage, infection (both at the operative site or urinary tract), injury to the rectum (with rare risk of rectovaginal fistula), and injury to nearby vessels. The authors are also cautious about performing an aggressive repair in a woman who plans to be sexually active, as rectocele repair can result in a foreshortened vagina and/or dyspareunia.
Postoperatively, it is important that the patient decreases certain risk factors may have caused or contributed to the rectocele in the first place. These include cessation of smoking, treatment of chronic pulmonary disease to decrease coughing (which increases intraabdominal pressure), avoidance of constant straining with bowel movements, and avoidance of occupational vocations that include heavy lifting.
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