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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. 1a & 1b)

prolapse repair

prolapse repair fig. b

Figs. 1a & 1b. – Depict the reparative concepts of pre WWII surgeons, based on the belief that the uterus was basically “propped up” by the
walls of a stiff vaginal tube. As shown in this diagram, modified from Wilfred Shaw’s textbook of 1935, prolapse repair in this era concentrated on constricting the genital hiatus and creating a rigid perineal shelf. The belief that this anatomically inappropriate technique was an effective means of supporting upper tract was entirely illusory. In reality, the prolapsing uterus and/or enterocoele simply dangled ‘out of sight’, in an artificial pocket that formed above the perineal shelf. What was not illusory, however, is the severe dyspareunia that high transverse levator- plasty caused.

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(Fig. 2a )

sagittal section of female pelvis

Fig. 2a. – A sagittal section of female pelvis, showing how the vagi- nal suspensory axis and the anterior vaginal hammock intersect like
a flag, at half mast on a flagpole. Obstetric forces tear the fascia in the mid-pelvis (ie, where the “flag” joins the “flagpole”).

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(Fig. 2b )

fig. 2b

Fig. 2b. – The connective tissues of the postero-superior axis (“flag- pole”) form a continuous strong band that runs from the sacral periosteum, through the uterosacral ligaments, into the pericervi- cal ring, and down through the rectovaginal septum, to insert into the perineal body. When this is intact, bowel motions are guided smoothly through the pelvis and easily out the anus. However, when it is torn, pelvic dragging discomfort and obstructive defeca- tion become a problem.

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(Fig. 2c )

diagram shows the anatomic consequences of damage to the vaginal suspensory axis

Fig. 2c. – This diagram shows the anatomic consequences of damage to the vaginal suspensory axis. Laceration of the uterosacral ligaments above the pericervical ring creates uterine descensus, while avulsion of the rectovaginal septum below the pericervical ring leads to herniation of ileum, sigmoid or rectum into the vaginal lumen.

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