SURGICAL TECHNIQUES

Defect-directed reconstruction: The common-sense technique for rectocele repair

Thanks to the discovery that tears—not attenuation and disintegration—are the primary reason for connective tissue defects, we can now eliminate rectocele using a simple, standard stitching technique.

Dr. Grody is professor, obstetrics and gynecology, and senior attending consultant, Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Medicine and Dentistry of New Jersey—Robert Wood Johnson Medical School, Cooper University Hospital,  Camden, NJ.

Why did it take us 2 centuries to learn how to do it right? Posterior pelvic repair for the correction of rectocele combined with restoration of the perineal body has been on gynecologic OR schedules since time immemorial, so one would think we knew what we were doing. Yet only in the past 10 years has there been progressive general recognition of the true nature of the anatomic lesions responsible for rectocele formation, thereby finally pointing us in the right direction.

Although it was always assumed, correctly, that the major factor initiating rectoceles is tissue trauma sustained in vaginal birth, traditionally we were taught, and we believed, that the end result was attenuation and deterioration of the rectovaginal septum (RVS) connective tissue. Similar tissue changes also initiated at vaginal delivery were ascribed to the proximal and distal connective tissue attachments of the RVS, respectively; the cardinal-uterosacral ligament complex; and the perineal body—but tears were never entertained in our perceptions. We know, as emphasized by Nichols in the 1960s and 1970s,^1-3 that all of these elements, together with the bilateral RVS connection to levator fascia plus the levator plate of the pelvic floor, constitute the normal vaginal axis when all elements are intact.