Vaginal Enterocele Repair

Enterocele usually exists with other support defects, and concurrent vaginal vault suspension, cystocele, and recto-cele repair are often necessary.

The technique is as follows (Figure 8-4.1):

1. The patient is placed in dorsal lithotomy position, and the bladder is drained before incision. Prophylactic antibiotics are given routinely before the operation.

2. The vaginal epithelium at the apex is grasped with Allis clamps and a vasoconstricting solution is submucos-ally injected. The vaginal epithelium is incised with a scalpel vertically or in a diamond shape, the enterocele is

Figure 8-4.1. Vaginal enterocele repair. a, Isolation and entry of the enterocele sac in the rectovaginal space. b, Pursestring sutures are placed closed to the neck of the enterocele sac. (Reprinted from Walters MD, Karram MM.Urogynecology and Reconstructive Pelvic Surgery. 2nd ed., p 223, Copyright 1999 Mosby,with permission from Elsevier.)

Figure 8-4.1. Vaginal enterocele repair. a, Isolation and entry of the enterocele sac in the rectovaginal space. b, Pursestring sutures are placed closed to the neck of the enterocele sac. (Reprinted from Walters MD, Karram MM.Urogynecology and Reconstructive Pelvic Surgery. 2nd ed., p 223, Copyright 1999 Mosby,with permission from Elsevier.)

identified, and the edges of the vaginal epithelium are dissected sharply away from the enterocele sac.

3. The enterocele sac should be mobilized from the vaginal walls and rectum. When the enterocele sac is difficult to distinguish from the rectum, differentiation is aided by a rectal examination with simultaneous dissection of the enterocele sac from the rectal wall. At times, distinguishing the enterocele sac from a large cystocele may prove difficult. When this occurs, placement of a curved uterine sound into the bladder or transillumination with a cystoscope may be helpful.

4. After the enterocele sac has been dissected from the vagina and rectum, traction is placed on it with two Allis clamps and the sac is entered sharply. The enterocele sac is digitally explored and adhesions of the small bowel and omentum are dissected to the level of its neck.

5. Under direct visualization, two or three circumferential, nonabsorbable, pursestring sutures are used to close the enterocele sac. The cardinal-uterosacral ligaments are incorporated as well. Once placed, the sutures are sequentially tied. Care should be taken to avoid kinking the ureters.

6. Posterior colporrhaphy and vaginal vault suspension are performed as indicated.

7. Cystoscopy is performed to ensure ureteral patency after intravenous indigo carmine is given.

Figure 8-4.2. McCall culdoplasty technique. Note that the lowest suture incorporates the posterior vaginal wall,thus providing additional support. (Reprinted from Walters MD, Karram MM.Urogynecology and Reconstructive Pelvic Surgery.2nd ed.,p 224,Copyright 1999 Mosby, with permission from Elsevier.)

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