Enterocele, the missed problem

Enterocele, the missed problem

By By

Dr. Khattab KAEODr. Khattab KAEO

Prof. & Head of Obstetrics and Prof. & Head of Obstetrics and Gynaecology Gynaecology DepartmentDepartment

Faculty of Medicine, Al-Azhar Faculty of Medicine, Al-Azhar University, University, DamiettaDamietta

Vaginal axis

Vaginal axis is 60-70Vaginal axis is 60-70 to the horizontal to the horizontal

Vagina is not a straight tract. Vagina is not a straight tract.

It is angulated, with the perineal body supporting only the lower 3 cm, where the rectum and anal canal turns back sharply.

The upper vagina is almost horizontalThe upper vagina is almost horizontal

andand

the related part of the rectum the related part of the rectum lies on and parallel to the lies on and parallel to the levator plate.levator plate.

The upper fourth of the posterior vaginal wall is directly related to the posterior cul-de-sac.

The vagina is a potential space The vagina is a potential space with its anterior and posterior with its anterior and posterior walls are in contact with each walls are in contact with each

others. others.

As intra-abdominal pressure As intra-abdominal pressure increases, the pelvic diaphrag increases, the pelvic diaphrag contracts & maintains position contracts & maintains position of the levator plate, and the of the levator plate, and the horizontal vaginal axis. horizontal vaginal axis.

As a consequence, uterus, As a consequence, uterus, vagina and rectum are pushed vagina and rectum are pushed against the levator plate and against the levator plate and not through the genital hiatus not through the genital hiatus

Uterovaginal prolapse is attributed to:Uterovaginal prolapse is attributed to:

1- a break in the integrity 1- a break in the integrity of the utero sacral of the utero sacral ligament complex, ligament complex,

2- weakness of the pelvic 2- weakness of the pelvic floor musculature and floor musculature and

3- alteration of the 3- alteration of the normal vaginal axis. normal vaginal axis.

Vault prolapse and recurrent prolapseVault prolapse and recurrent prolapse have common aetiological factors: have common aetiological factors:

- Presence of congenital or Presence of congenital or developmental weakness of the developmental weakness of the supports; supports;

- Omitting precipitating factors like - Omitting precipitating factors like chronic cough or constipation. chronic cough or constipation.

- Inappropriate choice of Inappropriate choice of operation (hysterectomy operation (hysterectomy without repair); without repair);

- Failure to recognise or - Failure to recognise or eradicate enterocele; eradicate enterocele;

- Poor surgical technique, - Poor surgical technique, particularly in the region particularly in the region around the cervix;around the cervix;

It should be emphasised It should be emphasised that repairs are that repairs are compensatory at best compensatory at best and to a great extent and to a great extent empirical. empirical.

Vault prolapse complicates hysterectomy in Vault prolapse complicates hysterectomy in an incidence of 11.6% if hysterectomy an incidence of 11.6% if hysterectomy was performed for prolapse, and 1.8% was performed for prolapse, and 1.8% when it was for other benign diseases. when it was for other benign diseases.

Vault prolapse is a term variously applied to Vault prolapse is a term variously applied to the following conditions:the following conditions:

1- Enterocele. 1- Enterocele.

2- Collapse of the supports around the upper 2- Collapse of the supports around the upper vagina & uterus. This is really represents vagina & uterus. This is really represents what will be 3what will be 3rdrd degree uterovaginal prolapse degree uterovaginal prolapse Nulliparous prolapse is commonly of this type. Nulliparous prolapse is commonly of this type.

3- Prolapse of the vaginal vault after 3- Prolapse of the vaginal vault after hysterectomy. hysterectomy.

Enterocele is hernia of the Douglas Enterocele is hernia of the Douglas pouch. pouch.

The sac may or may not be filled with The sac may or may not be filled with contents. Contents are loops of small contents. Contents are loops of small bowel with elongated mesentery bowel with elongated mesentery (beyond the usual 15 cm; this (beyond the usual 15 cm; this elongation is an important cause of elongation is an important cause of recurrence!)recurrence!)..

Enterocele is usually progressive and Enterocele is usually progressive and can reach as far as the perineal can reach as far as the perineal body. body.

There are at least 4 types of There are at least 4 types of enterocele (identifiable with its enterocele (identifiable with its location within the pelvis), each location within the pelvis), each with a different aetiology). with a different aetiology).

I- Congenital:I- Congenital: The fetal sac of The fetal sac of peritoneum between rectum peritoneum between rectum and vagina fails to fuse, or it and vagina fails to fuse, or it reopens. No associating reopens. No associating rectocele or cystocele. The sac rectocele or cystocele. The sac represents a split layer of the represents a split layer of the rectovaginal septum. rectovaginal septum.

II- Pulsion:II- Pulsion: Increased intra- Increased intra-abdominal pressure creates the abdominal pressure creates the sac and often pushes the vault sac and often pushes the vault down with it. The vault, then, down with it. The vault, then, drags the anterior vaginal wall → drags the anterior vaginal wall → cystocele, but no rectocele. cystocele, but no rectocele.

This type is a sliding hernia along This type is a sliding hernia along the anterior surface of the the anterior surface of the rectum and may eventually rectum and may eventually result in rectal prolapse and result in rectal prolapse and intussuception. intussuception.

III- Traction: III- Traction: A A large rectocele large rectocele and a and a cystocele pull cystocele pull on the vault. on the vault.

IV- Iatrogenic enterocele:IV- Iatrogenic enterocele:

- Enterocele anterior to the vagina: It looks like a - Enterocele anterior to the vagina: It looks like a cystocele. Excess anterior peritoneum is not resected at cystocele. Excess anterior peritoneum is not resected at the time of vaginal hysterectomy when there was the time of vaginal hysterectomy when there was difficulty identifying the vesico-uterine peritoneal fold, difficulty identifying the vesico-uterine peritoneal fold, the peritoneal cavity was entered cranial to the bladder the peritoneal cavity was entered cranial to the bladder and close to the uterine fundus. and close to the uterine fundus.

- Most commonly iatrogenic enterocele results from a - Most commonly iatrogenic enterocele results from a surgically-produced change in the vaginal axis (Burch, surgically-produced change in the vaginal axis (Burch, MMK,..). Ventral suspen-sion or ventrofixation of the MMK,..). Ventral suspen-sion or ventrofixation of the uterus or vagina may render an unprotected cul-de-sac uterus or vagina may render an unprotected cul-de-sac vulner-able to subsequent enterocele. vulner-able to subsequent enterocele.

Lateral pudendal enterocele: This rare Lateral pudendal enterocele: This rare type results from sudden, short, type results from sudden, short, massive increase in intra-abdominal massive increase in intra-abdominal pressure with rupture of the pelvic pressure with rupture of the pelvic diaphragm, often lateral to the diaphragm, often lateral to the vagina. The sac lies lateral to the vagina. The sac lies lateral to the lateral vaginal wall and may extend to lateral vaginal wall and may extend to the vulva. The neck is small and the vulva. The neck is small and intestinal obstruction may occur. intestinal obstruction may occur. During surgery, the hernia defect can During surgery, the hernia defect can be identified by tracing the bowel to be identified by tracing the bowel to its disappearance within the pelvic its disappearance within the pelvic floor. floor.

Abdominal and back pains. These are much more Abdominal and back pains. These are much more likely to be due to primary back problems which likely to be due to primary back problems which may be referable to the abdomen. POP-related may be referable to the abdomen. POP-related backache is diffuse, deep-seated, midline lumbo- backache is diffuse, deep-seated, midline lumbo- sacral or sacral and unaccompanied by tender-sacral or sacral and unaccompanied by tender-ness. It is completely and immediately relieved ness. It is completely and immediately relieved by rest and is never experienced in bed or on by rest and is never experienced in bed or on rising in the morning. It is attributable to traction rising in the morning. It is attributable to traction on the uterosacral & cardinal ligaments. on the uterosacral & cardinal ligaments. Discomfort related to enterocele is caused by: Discomfort related to enterocele is caused by:

Backache due to traction to the long mesentry Backache due to traction to the long mesentry against supports of the vault in the standing against supports of the vault in the standing position. Backache is characteristically minimal position. Backache is characteristically minimal in the morning, worsens as the day goes on, and in the morning, worsens as the day goes on, and peaks by evening. Lying down relieves it. peaks by evening. Lying down relieves it.

Sensation of fullness in the pelvis. Sensation of fullness in the pelvis.

Dysparenia. Dysparenia.

History

Peristalsis may be seen through a thin wall. Peristalsis may be seen through a thin wall.

Diagnosis is suspected when fullness can be Diagnosis is suspected when fullness can be felt in the vault in the lithotomy posi., felt in the vault in the lithotomy posi.,

but most accurate when the patient is standing.but most accurate when the patient is standing.

Rectal examination is essential and shows Rectal examination is essential and shows that the rectum is pushed backwards by that the rectum is pushed backwards by the swelling and not forming a part of it.the swelling and not forming a part of it.

A proctoscope will trans-illuminate a A proctoscope will trans-illuminate a rectocele but not an enterocele.rectocele but not an enterocele.

Examination

The patient is examined systemically and The patient is examined systemically and locally in the supine, standing, squatting and locally in the supine, standing, squatting and straining positionsstraining positions, and some authors , and some authors advocate in addition, the left lateral position advocate in addition, the left lateral position using the Sims' speculum to differentiate a using the Sims' speculum to differentiate a high rectocele from an enterocele (the high rectocele from an enterocele (the speculum blade is held tightly in the speculum blade is held tightly in the posterior cul-de-sac, gently lifting the cervix, posterior cul-de-sac, gently lifting the cervix, a finger in the rectum, then, outlines the a finger in the rectum, then, outlines the upper limits of the rectocele. If an enterocele upper limits of the rectocele. If an enterocele is present, it will be seen to roll down from is present, it will be seen to roll down from the vaginal apex when the patient strains)the vaginal apex when the patient strains)..

High rectocele &enterocele often co-exist. High rectocele &enterocele often co-exist.

Combined PV and PR examination: Combined PV and PR examination: While the patient is in the upright While the patient is in the upright

position, the thumb is placed in the position, the thumb is placed in the vagina & the index in the rectum.vagina & the index in the rectum.

When the patient strains, a bowel-filled sac When the patient strains, a bowel-filled sac in the rectovaginal septum is felt.in the rectovaginal septum is felt.

The thumb establishes whether there is The thumb establishes whether there is a vault prolapse or cystocele.a vault prolapse or cystocele. It It elevates the vault, & the index is elevates the vault, & the index is then introduced through the anus. then introduced through the anus.

Treatment:Treatment: Prophylactic:Prophylactic:

Tightening of the Tightening of the uterosacral and cardinal uterosacral and cardinal ligaments, and their ligaments, and their inclusion in the vault are inclusion in the vault are important steps at important steps at hysterectomy. hysterectomy.

Treatment:Treatment: Prophylactic:Prophylactic: High peritoneal closure during vaginal High peritoneal closure during vaginal hysterectomy is a useful technique. It hysterectomy is a useful technique. It comprises stitching through the surface of comprises stitching through the surface of an uterosacral ligament above the posterior an uterosacral ligament above the posterior cut edge of peritoneum. In a circular cut edge of peritoneum. In a circular direction posterior peritoneum - the other direction posterior peritoneum - the other uterosacral ligament - the round ligament uterosacral ligament - the round ligament anterior to it - anterior peritoneum - the anterior to it - anterior peritoneum - the other round ligament are reefed. other round ligament are reefed.

McCall culdoplasty: It McCall culdoplasty: It comprises approximating comprises approximating the uterosacral ligaments the uterosacral ligaments using continuous sutures, using continuous sutures, so as to obliterate the so as to obliterate the peritoneum of the posterior peritoneum of the posterior cul-de-sac as high as cul-de-sac as high as possible. possible.


Recognizing a potential Recognizing a potential enteroceleenterocele (deep cul-de-sac) (deep cul-de-sac). . An existing enterocele can be An existing enterocele can be recognized with the bent recognized with the bent finger. Packing a suspected finger. Packing a suspected sac with a gauze sponge helps sac with a gauze sponge helps to confirm and identify the to confirm and identify the excess peritoneum. excess peritoneum.


Resecting redundant or excess peri-Resecting redundant or excess peri-toneum. If it is difficult to locate the toneum. If it is difficult to locate the anterior peritoneum, catheterize the anterior peritoneum, catheterize the patient and grasp the bladder wall patient and grasp the bladder wall with successive gentle bites on an with successive gentle bites on an unlocked hemostat (walk-up) until the unlocked hemostat (walk-up) until the cut edge of the peritoneum is reco-cut edge of the peritoneum is reco-gnised and can be grasped with gnised and can be grasped with forceps. A full-length of absorbable 2-forceps. A full-length of absorbable 2-0 suture is used, held in a light hemo-0 suture is used, held in a light hemo-stat for later identification.stat for later identification.

Sacrospinous fixation at Sacrospinous fixation at the time of vaginal the time of vaginal hysterectomy is reco-hysterectomy is reco-mmended when the mmended when the vault descends to the vault descends to the introitus during closure. introitus during closure.

Principles of surgery for genital prolapsePrinciples of surgery for genital prolapse

1- Effective & sustained vault 1- Effective & sustained vault support;support;

2- Approximation of the utero-2- Approximation of the utero-sacral ligaments (obliteration of sacral ligaments (obliteration of the enterocele sac); the enterocele sac);

3- Repair of associating cystocele 3- Repair of associating cystocele & rectocele. & rectocele.

4- Correction/prevention of 4- Correction/prevention of urinary incontinence.urinary incontinence.

Active treatmentActive treatmentThe sac is dissected to a point where The sac is dissected to a point where

excision of excess peritoneum extends excision of excess peritoneum extends across the anterior surface of the rectum.across the anterior surface of the rectum.

Any fat belongs on the rectal side of dis-Any fat belongs on the rectal side of dis-section. The characteristic condensation section. The characteristic condensation of fat or the longitudinal muscle fibres in- of fat or the longitudinal muscle fibres in- dicate that the rectum has been reached.dicate that the rectum has been reached.

The anterior peritoneum is inspected and The anterior peritoneum is inspected and the redundant peritoneum is excised. The the redundant peritoneum is excised. The sac is closed purse-string by size 0 non-sac is closed purse-string by size 0 non-absorbable suture material in > one layerabsorbable suture material in > one layer

A coincident eversion of the vault is treated A coincident eversion of the vault is treated by colpopexy. by colpopexy.

Vaginal repair of enteroceleVaginal repair of enteroceleLocation of the ureter is critical. Location of the ureter is critical.

When the enterocele dissects its When the enterocele dissects its way down the rectovaginal way down the rectovaginal septum and leaves the vaginal septum and leaves the vaginal apex in its normal position, the apex in its normal position, the ureters also remain in their ureters also remain in their usual post-hysterectomy usual post-hysterectomy location. location.

But, when the vagina inverts, But, when the vagina inverts, the ureters are brought down. the ureters are brought down.

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Enterocele, the missed problem