Middle and Anterior Compartment: Issues for the Colorectal Surgeon
Multi-compartment pelvic floor disorders are common and require a multi-disciplinary team approach to evaluation and management. It is imperative for specialists to recognize when consultation with the one another is indicated, as joint management may sig
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Key Concepts • Multi-compartment pelvic floor disorders are common and require a multi-disciplinary team approach to evaluation and management. • The levator ani muscles and connective tissue structures of the pelvis provide the main supports to the pelvic floor and pelvic organs. • Transvaginal repair of pelvic organ prolapse is commonly performed at the time of transperineal repair of rectal intussusception or prolapse. • The most commonly performed abdominal procedure for pelvic organ prolapse is the sacral colpopexy, which can be performed concomitantly with ventral or other types of rectopexy. • A transvaginal or transanal approach can be taken to repair a rectocele, but the transvaginal approach is more common and seems to have better outcomes with less morbidity.
Introduction Many patients who complain of descensus in a single pelvic compartment may be affected by prolapse in multiple pelvic compartments [1] and several publications have described coexistence of rectal and pelvic organ prolapse [2–9]. In addition, there is a high incidence of anorectal dysfunction in women with genital prolapse. As a result, multi-compartment pelvic floor disorders are now increasingly being evaluated and managed together by female pelvic medicine and reconstructive surgery (FPMRS) surgeons and colorectal surgeons [10, 11]. It is imperative for specialists to recognize when consultation with the one another is indicated, as joint management may significantly improve patient outcomes. For instance, defecatory symptoms may not improve with transvaginal rectocele repair alone [12], as obstructive symptoms may be related to more extensive posterior compartment dysfunction.
For example, studies have shown that an enterocele is not an uncommon finding in patients presenting with a rectocele, and may occur in up to 42 % of patients [13], and rectal intussusception may occur in up to 68 % of patients undergoing defecography for symptomatic rectocele [14]. The other posterior compartment conditions that may occur with anterior and middle compartment prolapse include sigmoidocele, anismus, perineal descent, and/or rectal prolapse. Peters et al. [15] showed that in 55 patients evaluated with rectal prolapse, 52 of the patients had other pelvic floor defects, and 39 were found to have occult rectal prolapse that simulated a rectocele or enterocele. Patients with the above-mentioned posterior defects often require radiographic evaluation for accurate diagnosis, as well as a multi-disciplinary team approach to management [16, 17]. In this chapter, we review the anatomy of the pelvic floor and the important relationships between its compartments, we describe the FPMRS surgeon’s approach to the evaluation and management of pelvic organ prolapse, we provide an overview of the transvaginal and abdominal approaches to apical prolapse procedures that can be performed concomitantly with colorectal procedures, and we describe and compare the different approaches to the rectocele repair.
Anatomy of the Pelvic Floor The levator ani muscles (puborectali
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