FIGURE 1 Lower transverse tear
FIGURE 2 Upper transverse tear
U-shaped tears
Another not uncommon type of defect can be U-shaped, either at the bottom, as depicted in FIGURE 3, or at the top of the posterior pelvic compartment. Similarly linear (longitudinal) tears near one side or the other directly adjacent to the pelvic sidewalls, rarely in the midline, are not unusual and can be repaired in the same manner.
FIGURE 3 U-shaped tear
Hockey-stick tears
Occasionally, a hockey-stick lesion, combining a longitudinal tear and a transverse tear in continuity, as shown in FIGURE 4, is discovered.
FIGURE 4 Hockey-stick tear
Double defect
A more uncommon type of combined or double defect, in which the Denonvilliers fascia (RVS) has been torn both adjacent to the vault and in the perineal area but retains strong attachments bilaterally, is shown in FIGURE 5.
FIGURE 5 Double defect
A contented vaginal environment
The major breakthrough is the concept that tears in the Denonvilliers fascia, not attenuation, are the cause of rectoceles. These tears—transverse, longitudinal, U-shaped, multidirectional, even stellate—can be identified almost always without difficulty with the aid of a rectal examining finger and edge-grasping clamps at surgery. The repair itself is not only anatomically logical but also much easier and more confidence-inspiring than the traditional, now archaic, method of fishing around for scraps of levator fascia and muscle to approximate, under tension, in the midline.
This defect-directed repair, born of common sense (ie, comprehension and application of normal anatomy), is structurally nonconstrictive and functionally nonrestrictive—truly a contented vaginal environment.
All sketches from TeLinde’s Operative Gynecology, 9th edition, with permission from Lippincott, Williams, and Wilkins, Publishers.
Dr. Grody reports no financial relationship with any companies whose products are mentioned in this article.