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| 번호 | 제목 | 등록일 | 조회수 |
|---|---|---|---|
| 83 | Combined Perineal and Endorectal Repair of Rectocele by Circular Stapler [2002년 11월 DCR] | 2011-11-17 | 3706 |
|
A Novel Surgical Technique
Donato F. Altomare, M.D., Marcella Rinaldi, M.D., Antonella Veglia, M.D.,Maria Petrolino, M.D., Michele De Fazio, M.D., Pierluca Sallustio, M.D.
From the Department of Emergency and Organ Transplantation, General Surgery and Liver ansplantation Units, University Medical School of Bari, Bari, Italy
PURPOSE: The aim of this study was to present a new technique for treatment of disabling rectocele when associated with internal mucosal prolapse or hemorrhoids using a 33-mm circular stapler.
METHODS: Eight female patients complaining of obstructed defecation because of distention rectocele associated with internal mucosal prolapse or hemorrhoids and perineal descent entered the study. The rectovaginal septum was opened by diathermy up to the end of the rectal wall weakness. The perineal wound and the anus were held open by a self-retractor. Using a transparent anoscope (PPH system™), 2 mucosal pursestrings were prepared 5 and 8 to 9 cm distant from the dentate line. Posteriorly, only the submucosa was included in the pursestring; anteriorly, it included the rectal wall, which was kept separate from the vaginal wall. A transanal 33-mm circular stapler was then used to close the rectocele and treat the mucosal prolapse. Before closing the perineum a levatorplasty was fashioned.
RESULTS: One patient had a vaginal tear during dissection of the septum, which healed spontaneously in one month. No other complications were recorded. Postoperative defecography showed correction
of the rectocele and the posterior rectal prolapse in all patients. In two of them, a small lateral diverticulum could be seen, although this was asymptomatic. After a median follow-up of 12 months, all had significantly improved defecation (chronic constipation score dropped from 14.3 to 5, P <0.04). CONCLUSION: Combined perineal and endorectal stapler repair of rectocele may be a useful new surgical tool for correcting distention rectocele associated with mucosal prolapse or hemorrhoids and perineal descent in selected patients. A longer follow-up on a larger number of patients is needed to confirm these preliminary results.
 DISCUSSION
Surgery for rectocele repair includes several different techniques using different approaches, ranging
from the endorectal to the perineal or vaginal route.This reflects the variety of anatomic and pathophysiologic problems associated with this condition. Although several authors have reported very good results in the treatment of disabling rectocele, the common experience is that only some of these patients benefit from this kind of surgery in the long term. This may be because of poor patient selection and/or to an inadequate surgical approach. For example, patients with a large dislocation rectocele with perineal descent are unlikely to respond favorably to the Sarles or Khubchandani procedures, whereas association with other untreated anorectal abnormalities like anismus or rectal intussusception will invalidate any surgical repair of rectocele. Therefore, the adoption of stringent criteria for selecting the optimal technique for each type of rectocele is essential to ensure a high success rate. In this study we propose a new surgical approach consisting of a combined perineal and endorectal repair of rectocele using a dedicated circular stapler that not only produces strong repair of the defect in the rectovaginal septum but also eliminates the associated mucosal prolapse or hemorrhoids and allows pelvic floor repair with a levatorplasty. In fact, persistence of the associated anorectal abnormalities is one of the most frequent causes of insufficient relief of the symptoms. The only complication recorded in our experience was an accidental vaginal tear during separation of the rectovaginal septum and minor urge fecal incontinence in the same patient. However, the occurrence of minor fecal incontinence after operations for rectocele repair is not uncommon. In fact, Arnold et al. reported fecal incontinence in percent of his series of cases operated on for rectocele by the endoanal approach, and Ho et al. demonstrated a fall in anal pressures after transanal rectocele repair. |
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