Rectocele Repair Periprocedural Care

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. Patients should be adequately prepared for surgery and have all questions answered prior to surgery.

If the use of mesh is considered, it is imperative to disclose the recent FDA advisory statements. The surgeon should 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 have general information regarding procedures, frequently asked questions, and helpful drawings.

The patient should undergo a thorough history and in-office physical examination. Assessment should include evaluation of age, body-mass index (BMI), parity, previous pelvic surgery, and preoperative prolapse quantification. Prolapse can be evaluated using the pelvic organ prolapse-quantification system or the Baden-Walker system. Validated quality of life questionnaires such as the Colorectal-Anal Impact questionnaire can aid in addressing bowel symptoms.

An assessment of the anal sphincter should be performed prior to operative planning, as any defect in the sphincter may need additional testing.

If there is any discrepancy between symptoms of the patient and the findings on examination, the surgeon should pursue further work up of the symptom prior to proceeding with surgery.

The risk of shortening the vagina and the patient’s goal for future sexual activity must also be considered in deciding on treatment options. The surgeon must also consider not only the strength of the tissue in the posterior compartment but also the specific defect(s) during the examination and whether they play a role in the patient’s symptoms.

It is important to examine the vaginal tissue for atrophy, with consideration to treat patients with vaginal estrogen cream to help improve tissue health prior to surgery. 

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.

Antibiotic Prophylaxis: Due to the vaginal incision for repair, this procedure is a clean-contaminated procedure and therefore prophylactic antibiotics are recommended. Cefazolin 2gm IV or 3gm for those weighing greater than 120kg is a standard option. ^{[9, 10]}  

Anesthesia: Anesthesia is up to the discretion of the surgeon and patient. General, regional, or sedation anesthesia may be used. Many surgeons choose general anesthesia, regardless of the length of the procedure, to ensure adequate relaxation of the legs and pelvic floor.

Positioning: The patient should be in the dorsal lithotomy position to maximize exposure. The use of adjustable stirrups may help optimize exposure during the surgery. The Trendelenburg position may be helpful for exposure; however, prolapse may be masked with Trendelenburg positioning. Colorectal surgeons tend to prefer prone or jack-knife position for an endoanal approach.

Prior to beginning the procedure, a thorough examination of the patient under anesthesia should be completed. The surgeon should perform a thorough vaginal and rectal exam.  It is important to re-evaluate the defect and to determine the extent of surgery when the patient is at maximum relaxation.

Patients are usually discharged the day of the procedure or the following day if the repair is completed vaginally. Based on the patient and need for hemostasis, a vaginal pack and Foley catheter may be left overnight or removed later in the day.

Pain is usually manageable with oral medications starting on the day of surgery. Low dose narcotics and nonsteroidal anti-inflammatory drugs (NSAIDs) are the mainstay for postoperative pain control.

Patients should be instructed on a good bowel regimen in order to prevent straining and excessive Valsalva post-procedure. Stool softeners and a dietary instruction sheet should be provided prior to discharge, if not done at the preoperative office visit.

Pelvic rest for at least 6 weeks following the procedure is also recommended.

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 the patient reduce certain risk factors that 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.