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Figures in review by RICHARD REID
Pelviperineology Issue: Vol. 26 N.2 June 2007

Recto-enterocoele repair: past problems and new horizons

(Fig. 3 )

how the primary fascial injury occurs

Fig. 3. Is a diagram from William’s Textbook on Obstetrics, showing how the primary fascial injury occurs as the fetal head passes through the mid pelvis. In other words, endopelvic fascia is like canvas it does not stretch, but will tear at points of extreme stress.

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(Figs. 4)

typical posterior bulge

rectocoele component of the bulge

Figs. 4. – Shows the clinical effects of a recto-enterocoele avulsing the rectovaginal septum below the pericervical ring.

4a: The typical posterior bulge, caused by “partition failure” in the postero-apical compartment. Whether the rectocoele or the enterocoele component assumes greater relative prominence is largely a matter of random variation.
4b: An assistant’s finger in the rectum, highlighting the rectocoele component of the bulge. A “bowel pocket” (causing symptoms of obstructive defaecation) is well demonstrated.
dissection on the cranial side of the rectovaginal septum
completing the dissection
4c: A careful dissection on the cranial side of the rectovaginal septum, using Lone Star retractor hooks to aid the dissection. A line of avulsion can be seen between the dense white fascia of the rectovaginal septum (below) and the yellow pre-peritoneal fat of the cul de sac (upper areas).
4d: On completing the dissection shown in the previous photo, the cul de sac can be seen to be projecting downwards and forwards as a large enterocoele. The futility of “repairing” this bulge by plicating this pre-peritoneal fat is obvious.

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(Fig. 5 )

The pelvic organ support mechanisms used by Nature are similar to the maneuvers that one would use to prevent an invaginated finger of a surgical glove

Fig. 5. – The pelvic organ support mechanisms used by Nature are similar to the maneuvers that one would use to prevent an invaginated finger of a surgical glove (A) from being everted under pressure (B). To prevent such eversion, the finger apex could be suspended to the top of the glove by connective tissue (C), the base of the finger could be constricted by postural tone from the pelvic floor muscles (D) or Valsalva forces could be dissipated against the ‘flap valve’ mechanism of an intact levator plate (E).

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(Figs. 6 )

fig. 6a

fig. 6b

fig. 6c
Figs. 6. – A diagram showing the dynamic interaction between the pelvic floor muscles and the endopelvic fascia.

6a: The slow twitch fibres maintain constant postural tone, thus narrowing the urogenital hiatus and elevating the levator plate into a convex, dome-like configuration. The former action directly opposes any tendency for the pelvic viscera to exteriorize, and the latter action creates a dynamic backstop that acts as a flap valve to neutralize passive intra-abdominal forces.
6b: Loss of postural tone in the pubococcygeus and puborectalis section of levator ani allows the introitus to gape, while loss of postural tone in the iliococcygeus portion would allow the levator plate to sag (thus destroying the flap valve effect). 6c: When levator ani weakness is combined with fascial defects, the pelvic organs tend to move forwards and sit over a widened genital hiatus. As such, the combination of muscular and fascial injury has a synergistic effect in predisposing to pelvic organ descensus.

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(Fig. 7 )

Fig. 7. – Fascia of postero-apical plane, seen in the coronal plane. It takes origin from uterosacral ligaments (centrally) and lower edge of sacrospinous ligaments (laterally), then running down the arcus tendineus fascia pelvis (upper half of vagina), before dipping backwards on the arcus tendineus fascia rectovaginalis, to insert into perineal body.

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