A sigmoidocele, similar to an enterocele, is a true hernia with a break in the fascial supports of the upper vagina-uterosacral-cardinal ligament complex and the rectovagi-nal septum. With increased abdominal pressure, the sigmoid herniates into the cul-de-sac, through the defect, and abuts the vaginal mucosa. This requires a significant redundancy in the sigmoid and a deep cul-de-sac to allow herniation to occur.
Sigmoidoceles are believed to cause constipation by obstructing defecation. Diagnosis is made by defecogra-phy. The herniating sigmoid colon full of firm barium paste or stool is observed compressing or obstructing the rectum. The obstructed rectum does not completely empty and may lead to prolonged straining and a sense of incomplete emptying. Increased straining may cause further damage to the pelvic floor supports. Patients complain of pelvic or lower abdominal fullness and frequently need to apply manual pressure to the perineum, posterior vaginal wall, or lower pelvis to defecate. In addition, associated abnormalities such as rectoanal intussusception, rectocele, and paradoxical contraction of the puborectalis frequently contribute to the symptomatology.
Sigmoidoceles are rare and occur in 4% to 5% of all patients undergoing defecograms.12,13 Clinical examination may reveal pelvic floor prolapse and apical or posterior support defects but the presence of a sigmoid hernia is indiscernible. Fenner12 indicated that none of the nine patients with vaginal vault or uterine prolapse with posterior compartment defects diagnosed as rectocele were diagnosed on physical examination alone. She concluded that the possibility of a sigmoidocele should be considered in all patients with a posterior compartment defect and symptoms of constipation.
Jorge and colleagues13 suggested a sigmoidocele classification according to the position of the lower loop please see Chapter 3.4, Figure 3-4). Although sigmoidoce-les are found on defegrams of asymptomatic patients, a nonemptying sigmoidocele can be the cause of a sensation of incomplete evacuation.
Optimal treatment of sigmoidoceles is controversial. Studies are few, retrospective, and involve small numbers. In addition, the clinical presentation is prolapse and constipation, which is not unique to sigmoidoceles particularly because they are often found in association with a variety of other clinical entities involving defects in the pelvic floor. Consequently, outcomes of differing therapy are difficult to assess. Choice of repair is based on the few published studies and clinical experience. Little is known about the functional relationship between rectoceles, ente-roceles, sigmoidoceles, and defecation. A large, multicenter, randomized controlled trial is needed to evaluate the various surgical options and their long-term outcome of sigmoidocele repair.
At Cleveland Clinic Florida, patients with constipation and a first or second degree sigmoidocele are approached with conservative measures or biofeedback therapy with the expectation of success in approximately 50%. Third degree sigmoidoceles are usually managed by sigmoid resection with a successful outcome achieved in the majority. This procedure is ideally suited to the laparoscopic approach with the expectation of shorter hospital stay and less disability. Coexisting intussusception can be treated with rectopexy at the time of surgery. If nonrelaxing pub-orectalis syndrome is coexistent, this entity should be addressed preoperatively with biofeedback therapy.
If defects in the posterior vaginal wall and pelvic organ prolapse coexist with the sigmoidocele, repair may require a multidisciplinary approach. Fenner12 reported on seven patients with vaginal or uterine prolapse or rectocele in addition to sigmoidocele. All patients underwent pelvic reconstructive surgery to address the prolapse and posterior wall defects followed by one of three procedures to address the redundant sigmoid based on the severity of the constipation, degree of prolapse, and degree of sigmoid redundancy. Two patients underwent sigmoid resection with sigmoidopexy, one patient had sigmoidopexy alone, and four had Halban obliteration of the cul-de-sac. Follow-up at 2 years showed no recurrence of the posterior vaginal defect and all patients had resolution of constipation except two in whom the Halban procedure was performed. In summary, the choice of the surgical procedure should primarily address repair of the posterior compartment hernia. In addition, resection or sigmoidopexy performed for large hernias in addition to the pelvic reconstructive surgery.
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