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Laparoscopic Enterocele repair

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31/12/2007

What is an enterocele?

Sometimes women develop a hernia through the vagina called an Enterocele.

These hernias are weak areas in the supporting structures that are supposed to surround the vagina. Enteroceles happen when the intestines bulge through these weak areas and press right up against the actual skin of the vagina and the perineum. The skin of the vagina can stretch very much over time, which is why these enteroceles can sometimes be seen protruding well beyond the opening of the vagina.

Here is a picture of what an enterocele looks like from the outside:


 

It may be difficult to distinguish an enterocele from other types of prolapse when looking from the outside. Here is what an enterocele looks like from the inside:

 

Notice that the uterus , bladder and rectum in this picture are in relatively normal positions. The bulge that can be seen from the outside is actually filled with small intestines.  Although the uterus is shown in the above picture, most enteroceles occur after a hysterectomy. Many doctors believe that the area closed at the top of the vagina during a hyterectomy often becomes the "weakest link" allowing an enterocele to develop.

Whilst a rectocele may occur in isolation, in many cases a rectocele may be part of a more generalised weakness of pelvic support and may exist along with a rectal prolapse, vaginal/uterine prolapse, cystocele, enterocele and faecal or urinary incontinence.

A defecating proctogram (seen here) is the best method of defining the extent of an enterocele.

What causes an enterocele?
The underlying cause is weakening of the pelvic support structures and thinning of the rectovaginal septum. Certain factors increase the risks of women developing an enterocele. These include; birth trauma (multiple, difficult, prolonged deliveries, forceps, perineal tears) or following a hysterectomy. They are more common with increasing age.

What are the symptoms?
Whilst many women have enteroceles, only a small percentage will have symptoms. Symptoms may be primarily rectal or vaginal. Vaginal symptoms include bulging, the sensation of a mass in the vagina or perineum, pain with intercourse, prolapse. Rectal symptoms include difficult evacuation; some women find that pressing against the lower back wall of the vaginal or along the rim of the vagina helps empty the rectum. At times, there will be a rapid return of the urge to have a bowel movement after leaving the toilet.

When should an enterocele be treated?
When it causes significant symptoms. It takes a very experienced surgeon to help decide whether your symptoms are caused by an enterocele. If there are multiple abnormalities present it may be best to address them all at once as this will result in the best chance for improvement.

Treatment

The treatment for "enterocele" is to repair and restore the integrity of fascial layer of the vagina.

Most surgeons (gynaecologists) perform a posterior colporrhaphy, which is a non-specific midline plication or gathering of the vaginal bulge without any emphasis on the exact area of defect in the fascia (see below). 

Other surgeons overcompensate and perform a levatorplasty. The lateral muscles that create the sidewalls of the vagina are pulled together and sutured over top of the rectum. This surgery actually pulls the lateral wall muscles out of its normal anatomic position and creates a floor above the rectum. The muscles are acting in place of the fascia. This operation is quite effective in the treatment of the rectocele but often these patients then go no to suffer from dyspareunia (painful intercourse) following surgery. This surgery is not very anatomic and in our minds does not address the cause which in most patients stems from the rectum.

Some gynaecologists utilize what they term a "site-specific" posterior repair and add a dermal graft/mesh (when necessary).
 
This repair restores normal vaginal anatomy and minimizes the risk of vaginal narrowing or shortening that is common with other traditional posterior repairs. The vaginal skin is incised and the overlying skin is meticulously dissected from the underlying supportive rectovaginal fascia. The defects in the fascia are identified and repaired (site-specific fascia repair) using suture. Upon completion of the fascia defect repair, a graft is sutured in place after the completion of the site-specific repair in most patients. The skin is then closed using sutures.  Again, we believe that this is only adressing a symptom and not a cause.  The patient is still prone to painful intercourse and more important the risk of mesh erosion through the vagina. 




In our opinion, enterocele repair is best done by laparoscopic surgery (see above) because the excellent visibility of the pelvic fascial defects afforded by laparoscopy. A newer approch (laparoscopic ventral rectopexy) is from above i.e., through the abdomen. The latter can be performed laparoscopicaly.  No vaginal skin is excised and the chances of mesh erosion is less than 0.5%.  It also addresses the cause and treats the associated occult rectal prolapse, rectocele and uterine prolapse.  


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SPIRE Hospital, Bristol. 
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Contact: Claire Trenberth - 0117 9804051
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