Robert E Zacharin

Pelvic Floor Anatomy and the Surgery of Pulsion Enterocoele

With a Foreword by

Richard E. Symmonds Mayo Clinic

Springer-Verlag Wien GmbH

Robert F. Zacharin, M.G.O. (Melb.), F.R.C.S. (Eng.), F.R.C.O.G., F.R.A.C.S., F.R.A.C.O.G. Gynecologist in Charge, Department of Gynecology, Alfred Hospital, Melbourne, Australia

The use of registered names, trademarks, etc. in the publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regula­tions and therefore free for general use.

Product Liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting pharmaceutical literature.

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© 1985 by Springer-Verlag Wien Originally published by Springer- Verlag Wien New York in 1985 Sof'tcover reprint of the hardcover 18t edition 1985

With 75 partly coloured Figures

Cover design: Joachim Boning, Vienna, Austria Frontispiece: Routes of dispersion of intraabdominal pressure in the erect human. The key role of the lumbo-sacral joint is emphasized, and also that of the bony pelvis and sacrum. Levator ani is indicated by the darkened triangular area in the pelvic floor.

Library of Congress Cataloging in Publication Data: Zacharin, Robert Fyfe. Pelvic floor anatomy and the surgery of pulsion enterocoele. l. Uterus-Prolapse-Surgery. 2. Generative organs, Female-Anatomy. 3. Gynecology, Operative. I. Title. [DNLM: l. Genitalia, Female-anatomy & histology. 2. Hernia-surgery. 3. Uterine Prolapse-surgery. 3. Uterine Prolapse-surgery. WP 250 ZI6pJ RG36l.Z33 1985.618.1'44.85-17268

ISBN 978-3-7091-4077-2 ISBN 978-3-7091-4075-8 (eBook) DOI 10.1007/978-3-7091-4075-8

To Tricia

"Have you guessed the riddle yet?" the Hatter said, turning to Alice again. "No, 1 give it up," Alice replied: "what's the answer?" "I haven't the slightest idea, " said the Hatter. "Nor I, " said the Hare. Alice sighed wearily. "I think you might do something better with the time," she said, "than waste it asking riddles with no answers. "

Alice's Adventures in Wonderland, Lewis Carroll, 1865

Foreword

It is in the surgical aspect of their specialty that the gynecologists' work may be most frequently judged by their peers or by the litigious society that currently exists. Great and commendable progress has been made over the past 30 years in the basic scientific, endocrinologic and obstetric aspects of the specialty, but this has occurred with a commen­surate de-emphasis of surgical procedures and surgical training, a decline in devotion to technical detail and perfection, and a tendency to take surgery for granted.

Obstetric and gynecologic residency programs provide increasing numbers of specialists with average competence in the performance of the common, rather standardized gynecologic operations. In general, technical skill in the extirpative operations can be acquired far more readily than proficiency in the art of reconstructive surgery.

At present, for a number of reasons, gynecologic surgical training is most deficient in regard to the surgical correction of severe forms of obstetrically damaged genital tract supports. The operations for pro­lapse defy standardization and require great technical individualization; this must be based on the surgeon's judgment developed through expe­rience, a thorough understanding of normal pelvic anatomy, and recog­nition of the deficiency responsible for the prolapse in individual cases.

Unfortunately, mere technical competence in the accomplishment of abdominal and vaginal hysterectomy does not ensure the recognition of these deficiencies; when they are recognized, the surgical correction of them may be inadequate. More than 700,000 hysterectomies are accom­plished in the United States each year. It has been estimated that I per 250 to 300 of these patients subsequently will have some degree of vaginal vault prolapse and enterocoele. In my experience and that of others, the number of patients referred with recurrent prolapse has been increasing each year, which serves to emphasize the importance of this new book, Pelvic Floor Anatomy and the Surgery of Pulsion Enterocoele. To my knowledge, thisrepresents the first volume devoted exclusively to this topic.

X Foreword

Over a period of many years, the author of this book, a man of experience, insight, and recognized surgical talents, has reported detailed studies of comparative pelvic anatomy in the female. An understanding of this anatomy is of the utmost importance in any con­sideration of the etiologic and therapeutic aspects of prolapse, enter­ocoele, urinary incontinence, and other gynecologic conditions that require reconstructive efforts. Included in the monograph is an infor­mative and remarkably complete historic review of the diverse operative procedures, largely empirically developed, that have been devised for the correction of prolapse.

Careful study and thoughtful consideration of the anatomic con­cepts proposed and the operative techniques suggested and beautifully illustrated in this unique volume will be invaluable not only for the res­ident physician but also for the specialist-practitioner who performs "routine" operations for prolapse but may infrequently encounter or not feel qualified to perform the complex operative procedures required for the correction of the unusual, massive and recurrent forms of pelvic herniations.

Richard E. Symmonds, M. D. Emeritus Chairman, Division of Gynecologic Surgery, Mayo Clinic and Mayo Foundation; Emeritus Professor of Gynecologic Surgery, Mayo Medical School, Rochester, Minnesota, U.S.A.

Preface

Pulsion enterocoele is a most distressing and serious complication of pelvic surgery and may follow vaginal hysterectomy, abdominal hyster­ectomy or the Manchester operation. It appears to be most common after vaginal hysterectomy and certainly this procedure is associated with the largest examples of the problem, despite many surgical precau­tions advocated to prevent its appearance. It has become clear that poor quality genital tract supports are to blame rather than the surgeon.

Once a large vaginal inversion has developed it cannot be managed conservatively, for the inherent risk of rupture is great, since the peri­toneal cavity and outside world are separated only by vaginal wall and the peritoneum. A multitude of measures to correct the situation by surgery have been advocated over many years, so clearly no one tech­nique has emerged which can supply all the answers.

Management depends on several important considerations which include, the age of the patient and her ability to tolerate surgery and whether or not vaginal function is to be preserved. Available surgical techniques include the vaginal approach, an abdominal approach or a combination, and just what procedure a gynecologist chooses depends upon his belief regarding the supportive anatomy of the genital tract and accordingly either an entirely empirical or attempted specific attack will be made.

In many facets of surgical therapy in different parts of the body, for reasons difficult to discern, an empirical approach unrelated to the anatomy concerned is most popular and this has certainly been the case with pUlsion enterocoele. Convinced that the correct approach to the surgical correction of large pulsion enterocoele must lie in a specific attempt to reconstruct the normal supporting anatomy of the upper genital tract, abdominoperineal correction was commenced in 1968.

The publications of Berglas and Rubin on levator myography indi­cated with clarity just how the levator complex and pelvic cellular tissue support functioned, and was the basis upon which the procedure

XII Preface

was designed. There has been a great deal of controversy about genital tract supports since the tum of the century but gradually the situation has cleared and presently a combined role for the pelvic cellular tissues and levator complex is accepted.

This monograph discusses the anatomy of the pelvic floor in detail beginning with its evolutionary development, through normal, compar­ative and functional anatomy since such a view is necessary to appre­ciate fully the vital functional roles of the two components of upper genital tract support. Following the clinical picture of pulsion entero­coele the various methods of correction which have been proposed are examined, and finally a detailed explanation of abdominoperineal repair is given.

Large pulsion enterocoele supposedly is a rare condition, yet since 1968, 122 women have been accepted for surgical correction. If vaginal function is no longer required, total colpocleisis is the least traumatic procedure which will control the situation, and in this series was per­formed 25 times. A majority of the patients wished to retain vaginal function and the longterm results of abdominoperineal repair are pre­sented in 97 women, showing clearly the excellent functional result attainable. Major surgery is required for any major surgical problem and of course there will be attendant risks and complications; but in this series they have been few. Whilst most patients come from Mel­bourne, a significant number have been referred from many parts of Australia, as the benefits of the technique have become known.

I am indebted to my colleague Nicholas Hamilton for his ready help and advice and particularly his surgical skill as my abdominal col­laborator, to the Audiovisual Department at the Alfred Hospital (Cam Harvey, Michael Cardamone, and Angela Leaman) for the excellent photographic prints and line drawings, to Enid Meldrum, Chief Librarian in the Medical Library at the Alfred Hospital, for her expert help with references and the bibliography, to both Norman Beischer and Robert Marshall who read the initial manuscript and offered extremely helpful criticism and corrections and finally to my secretary Rosemary Stewart who has cheerfully typed the manuscript so many times.

Robert F. Zacharin Melbourne, July 1985

Contents

Introduction 1

Anatomy of the Genital Tract Supports 7 Evolutionary Anatomy 7 Human Anatomy 18

i) Pelvic Cellular Tissues 18 ii) Levator Ani 31

iii) Pouch of Douglas 38 Comparative Anatomy 45

i) Human 45 ii) Ruminant Animals 49 Functional Anatomy 52 Conclusions 63

Aetiology 65 Local Factors 65

i) Congenital 65 ii) Acquired 68

General Factors 72 Conclusions 74

The Clinical Features of Enterocoele 77 Classification 77 Genital Prolapse 79 Pulsion Enterocoele 80 Pudendal or Perineal Hernia 81 Clinical Picture 83 Diagnosis 84 Differential Diagnosis 85 Complications of Large Pulsion Enterocoele 94 Management 96

i) Traction Enterocoele 96

XIV Contents

ii) Pulsion Enterocoele 96 a) Conservative Management 98 b) Prophylaxis 98

The Surgical Correction of Pulsion Enterocoele 102 i) Small Pulsion Enterocoele 102

ii) Medium Pulsion Enterocoele 105 iii) Large Enterocoele 106 Surgical Choices 106

Repair by Vaginal Approach Alone 107 Repair by Abdominal Approach Alone 119 Colpocleisis 126

The Place of Colpocleisis in the Correction of Large Pulsion Enterocoele 128 Technique 128

Repair by Combined Abdominal and Vaginal Approach 132

Abdomino-Perineal Repair of Large Pulsion Enterocoele (A.P.R.E.) 134

Selection of Patients 135 Operative Principles 135 Operative Technique 136 Results 148 Complications 154 Conclusions 155

Bibliography 156

Subject Index 167

Acknowledgements

(i) Figures 6 and 7: reprinted with permission of American Journal of Obstetrics & Gynecology, "Man's assumption of the erect posture." J. W. Davies. 70, 1012 (1955).

(ii) Figures 8 and 9: by permission of Surgery, Gynecology & Obstetrics.

(iii) Figure 10: reprinted with permission of American Journal of Obstetrics & Gynecology, "Surgical significance of the recto­vaginal septum." D. H. Nicholls and P. S. Milley. J08, 215 (1970).

(iv) Figure 11: reprinted with permission of the Annals of the Royal College of Surgeons of England.

(v) Figures 12, 13, 31: reprinted with permission of the Journal of Investigative Urology 13, 175 (1975).

(vi) Figure 14: reprinted with permission of the Journal of Anatomy (S.F. Ayoub, The anterior fibres of levator ani in Man. Cambridge University Press.)

(vii) Figures 15, 16, 18, 20a: reprinted with permission from the American College of Obstetricians and Gynecologists. Obstetrics & Gynecology 55, 135 (1980).

(viii) Figures 21, 22, 23, 24b, 69c, 71 b, 72: reprinted with permission of the Australian and New Zealand Journal of Obstetrics and Gynaecology.

(ix) Figures 29, 30: reprinted by permission of Surgery, Gynecology & Obstetrics.

(x) Figures 32, 33: reprinted with permission from the American College of Obstetricians and Gynecologists. Obstetrics & Gyne­cology 15,711 (1960), 29,450 (1967).

(xi) Figures 39, 40: reprinted by permission of Annals of Surgery 133, 255 (1951).

(xii) Figure 42: reprinted with permission from the American College of Obstetricians and Gynecologists. Obstetrics & Gynecology 32, 802 (1968).

XVI Acknowledgements

(xiii) Figures 53 a & b, 54, 55 a, b, c: reprinted with permission from the American College of Obstetricians and Gynecologists. Obstetrics & Gynecology 10, 595 (1957).

(xiv) Figures 56, 57, 58, 59, 60: reprinted with permission from the American Journal of Obstetrics & Gynecology, "Vaginal prolapse following hysterectomy." R. E. Symmonds & J. E. Pratt. 79, 899 (1960).

(xv) Figures 46, 65,66,68, 69b, 75: reprinted with permission from the American College of Obstetricians and Gynecologists. Obstetrics & Gynecology 55, 141 (1980).

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