Traditionally this compartment is approached vaginally when operated on by the gynaecologist. It is important to remember that the colo-rectal surgeons also operate on the posterior compartment using a transanal approach. The patient should be referred to a colorectal surgeon for assessment if the following are present: concurrent anal or rectal pathology such as hemorrhoids, rectal wall prolapse or rectal mucosal redundancy.
Posterior Colpoperineorrhaphy Procedure
Two allis or littlewood forceps are placed on the perineum at the level of the hymenal remnants, allowing the calibre of the introitus to be estimated. Following infiltration, the perineal scarring is excised and the posterior vaginal wall opened using a longitudinal or triangular incision. The rectocele is mobilized from the vaginal skin by blunt and sharp dissection. The rectovaginal fascia is then plicated using either an interrupted or continuous absorbable suture (Vicryl 3/0), to repair the defect. This is often called the site-specific repair. Care should be taken not to create a constriction ring in the vagina which will result in dyspareunia. The redundant skin edges are then trimmed taking care not to remove too much tissue and thus narrow the vagina. The posterior vaginal wall is closed with a continuous Vicryl 2/0 suture. Many surgeons, in addition to the sitespecific plication, place a number of interrupted lateral sutures that incorporate the Levator Ani muscles. This Levator plication has been shown to be associated with significant dyspareunia and is no longer recommended. Finally a perineorrhaphy is performed by placing deeper absorbable sutures into the perineal muscles and fascia thus building up the perineal body to provide additional support to the posterior vaginal wall and lengthening the vagina. Injury to the rectum is unusual but should be identified at the time of the procedure so that the defect can be closed in layers using an absorbable suture and the patient managed with prophylactic antibiotics, low residue diet and faecal softening agents to avoid constipation.